The Care Quality Commission
  • Doctor
  • GP practice

Bridgemary Medical Centre

Overall: Good read more about inspection ratings

The Bridgemary Medical Centre, 2 Gregson Avenue, Bridgemary, Gosport, Hampshire, PO13 0HR (01329) 232446

Provided and run by:
Bridgemary Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Bridgemary Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Bridgemary Medical Centre, you can give feedback on this service.

02 December 2020

During a routine inspection

We undertook an announced comprehensive inspection on 2 December 2020 including virtual inspection activity from 30 November to 2 December 2020.

At our previous inspection in January 2020, we found significant concerns, some of which we had also found during our previous inspection visit in June 2019. This led to a rating of inadequate and the practice being placed into special measures.

This inspection was a comprehensive follow up inspection. Due to the COVID 19 pandemic, we amended our methodology to undertake the inspection partially onsite, and wherever possible, virtually. We also changed our methodology to reduce the burden on General Practice, and as such we did not obtain evidence where we had evidence from alternative sources, where no risk was identified at a previous inspection and it was proportionate not to obtain new evidence.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall. Specifically, we found the practice to be good for safe, caring, responsive and well led services, and requires improvement for effective. The long-term conditions, working age patients and vulnerable people population groups have been rated as requires improvement, with all the other population groups rated as good.

We rated the practice as good for providing safe, caring, responsive and well led services because:

  • Improvements to risk identification and management had been made.
  • The premises were clean and risks associated with the premises had been identified and managed.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • There had been an improvement to the culture and leadership within the practice enabling better strategic planning and governance.
  • Patients found staff and services were provided in a caring way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We rated the practice as requires improvement for providing effective services because:

  • Quality and outcome framework (QOF) deductions (known as personal care adjustments - PCAs) had improved for most QOF indicators. However, there was still a high number of PCAs for several of the diabetes indicators for the period April 2019 to March 2020.
  • Patient uptake rates for cervical screening were 69.5% in June 2020, which was worse than the national target of 80% and lower than the practice’s previous uptake data.
  • Not all the patients on the learning disability register had received an annual health check, although there had been some improvement in the number of these carried out since the last inspection.
  • However, the practice had commenced a programme of quality improvement activity and had focused on areas of practice that required improvement.

Whilst we found no breaches of the regulations, the provider should:

  • Review the overarching fire risk assessment.
  • Review employment checks to ensure consistency for non-clinical and clinical staff.
  • Improve the clinical outcomes for patients on the diabetes register, including the decisions to exclude them under a personalised care adjustment.
  • Continue to encourage patients on the learning disability register to attend for their annual health check and improve uptake rates.
  • Review recall processes and engagement with eligible patients, to improve the uptake of cervical screening rates.
  • Develop a protocol for the prioritisation and assessment of patients through the total triage system, including a list of red flags requiring urgent treatment. Include staff training and updates for changes, where appropriate.
  • Offer training to staff so they understand the importance of using translation services for patients who speak limited English, rather than a family member or carer.
  • Develop a process for identifying the needs of your local population, recognising the diversity of need for various vulnerable groups.
  • Review the information staff offer patients when raising a complaint to ensure ‘formal complaints’ can also be taken verbally, in line with the practice policy.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

30 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Bridgemary Medical Centre on 30 January 2020. We previously inspected the practice on 24 June 2019 and rated Bridgemary Medical Centre as inadequate overall. The practice was placed into special measures. This inspection was within six months of the previous inspection and was to determine whether the practice had made sufficient improvements to come out of special measures or whether further action was needed by CQC to close the practice.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall. During our previous inspection we rated the practice as inadequate overall. During this inspection we rated safe as requires improvement, effective and well led as inadequate and caring and responsive as good.

We rated the practice as Inadequate for providing effective and well led services because:

  • Systems and processes were not in place to address issues identified at our June 2019 inspection.
  • There were gaps in systems and processes which meant that new issues were identified at this inspection.
  • The practice continued to have no programme of clinical audit designed to improve outcomes for patients (other than medicines management audits carried out by the clinical pharmacist).
  • New systems and processes were not embedded for long term sustainable improvement.
  • There continued to be significant gaps in care planning for patients with a learning disability or dementia.
  • The practice had failed to take action to reduce exception reporting.

We rated the practice as Requires Improvement for providing safe care because:

  • The practice did not have systems and processes in place to prevent and control infection.

We rated the practice as Good for providing caring and responsive care because:

  • Staff treated patients with kindness, respect and compassion.
  • Complaints were listened and responded to and used to improve the quality of care.

We have rated the population groups as follows:

We rated the population groups for people with long term conditions, older people and people whose circumstances make them vulnerable as Inadequate because:

  • There was high exception reporting for diabetes indicators in the Quality and Outcomes Framework (QOF) and actions had not been taken to reduce the number of exceptions.
  • The practice did not use a clinical tool to identify older patients who were living with moderate or severe frailty and then carry out an assessment of their physical, mental and social needs.
  • There were gaps in care planning for patients with a learning disability.
  • The practice did not have advanced care plans in place for patients who were vulnerable or nearing the end of their life.

We rated working age people and people experiencing poor mental health as Requires Improvement because:

  • The practice had not met cervical screening targets and did not have actions in place to address these.
  • There were gaps in care planning for patients with dementia.

We rated families, children and young people as good because:

  • The practice has met the minimum 90% target for four of four childhood immunisation uptake indicators.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Develop advanced care plans for patients who are vulnerable or nearing the end of their life.
  • Improve the number of clinical audits, especially those in relation to the improvement of clinical care.
  • Improve cervical screening uptake.
  • Improve availability of information leaflets in respect of long term conditions in other languages to support patients.

I am returning this service to special measures. Services placed in special measures will be inspected again within six months of publication of the report. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. 

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. 

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice

22 August 2019

During an inspection looking at part of the service

Previously, we carried out an announced focused inspection at Bridgemary Medical Centre on 24 June 2019. We inspected the effective and well led key questions only and rated these as inadequate The practice was rated as inadequate overall.

We served a warning notice to the provider following a breach of regulation 17:Good Governance, of the Health and Social Care Act 2008. We also issues a requirement notice in relation to regulation 12, Safe Care and Treatment.

We carried out an announced focused follow up inspection at Bridgemary Medical Centre on 22 August 2019 to confirm that the practice had met the legal requirements in relation to the warning notice served after our previous inspection in June 2019. This report covers our findings in relation to the warning notice only. This means the ratings from our previous inspection remain the same.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

At this inspection we found that that the requirements of the warning notice had been partially met. We therefore served a requirement notice in relation to regulation 17: Good Governance, of the Health and Social Care Act 2008.

We found that:

  • Patients were receiving care in line with evidence-based guidance.
  • The practice had taken steps to improve clinical governance, but policies and processes still need further development and embedding.
  • Plans had been put in place to improve and develop Quality and Outcome Framework (QOF) monitoring, but these were in their infancy.
  • Significant events were appropriately reported, investigated and monitored.
  • Care planning was being developed but was still in the early stages.

However, we found that:

  • There remained a lack of oversight and monitoring in relation to staff training.
  • There remained a lack of clinical audits and quality improvement activity to review effectiveness.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The full report published on 7 August 2019 should be read in conjunction with this report. The practice remains rated inadequate until a full comprehensive inspection is carried out by the Care Quality Commission.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice

24 June 2019

During an inspection looking at part of the service

We undertook an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: Effective and Well led. We did not inspect safe, caring or responsive key questions as part of this inspection.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall. During our previous inspection we rated safe, responsive and caring as Good. During this inspection we rated effective and well led as Inadequate.

We rated the practice as Inadequate for providing effective and well led services because:

  • Patients’ needs were not assessed, and care and treatment was not delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • The overall governance arrangements were ineffective.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.

We rated all population groups as Inadequate because:

  • Care and treatment was not delivered in line with current legislations, standards and evidence based guidance and this affected all population groups.
  • The practice was unable to demonstrate that staff had the appropriate skills to carry out their roles and this affected all populations groups.
  • There was high exception reporting for diabetes indicators in the Quality and Outcomes Framework (QOF) and actions had not been taken to reduce the number of exceptions.
  • The practice did not have advanced care plans in place.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Review the system for monitoring oversight of staff training records.
  • Determine systems to monitor and follow up patients with poor mental health or dementia who failed to collect their repeat prescriptions.
  • Create advanced care plans for patients who are vulnerable or nearing the end of their life.
  • Increase the number of two cycle clinical audits, especially those in relation to the improvement of clinical care.
  • Improve cervical screening uptake.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months of publication of the report. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. 

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. 

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of General Practice

9 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Bridgemary Medical Centre, 2 Gregson, Avenue, Gosport, Hampshire, PO13 0HR on 9 December 2014. Overall the practice is rated as good.

We found that Bridgemary Medical Centre is a good practice overall with a strategy and track record of continuous improvement for the care and responding to the needs of patients living in the area.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the population groups we looked at.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand.

• Patients said they were satisfied with the appointments systems and that there was continuity of care, with urgent appointments available the same day.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The practice was a training practice and the practice leaflet explained that medical students spent part of their training from Southampton.

Last year’s performance for all immunisations was above average for the CCG, and again there was a clear policy for following up non-attenders by the practice nurse.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice