The Care Quality Commission
  • Doctor
  • GP practice

Bilborough Medical Centre

Overall: Good read more about inspection ratings

48 Bracebridge Drive, Nottingham, Nottinghamshire, NG8 4PN (0115) 929 2354

Provided and run by:
Nottingham City GP Alliance Limited

Important: The provider of this service changed. See old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Bilborough 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 Bilborough Medical Centre, you can give feedback on this service.

11 November 2021

During a routine inspection

We carried out an announced inspection at Bilborough Medical Centre on 11 November 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 16 January 2020, the practice was not rated for effective and responsive services, and rated good for safe, caring and well led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bilborough Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • All key questions in order to give the practice an overall rating
  • Areas identified as ‘shoulds’ at the previous inspection

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit.

Our findings

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.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care.
  • Leaders had an inspiring shared purpose and strived to deliver and motivate staff to succeed. They actively promoted a culture of innovation and continuous improvement. For example, the practice piloted an automatic booking system for booking appointments for specific clinics such as cervical screening. They sent text messages containing a link to the appointment slots available. This enabled patients to choose convenient times for them and book the appointment instantly without having to telephone the practice first. The booking system was further used to invite patients to COVID-19 vaccinations. This resulted in increased uptake of cervical screening and vaccinations and reduced non-attendance drastically.
  • The strategy and supporting objectives were stretching, challenging and innovative, while remaining achievable. The vision and values of the provider organisation were mirrored and embedded in the practice.

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

  • Establish a patient participation group to enhance engagement with patients.
  • Continue their work to improve uptake of childhood immunisations and cervical screening.

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

16 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Bilborough Medical Centre on 16 January 2020 as part of our inspection programme.

The previous provider ceased providing services at the location on 31 March 2019. The new provider, Nottingham City GP Alliance Limited, started providing services at the location on 1 April 2019.

At our previous comprehensive inspection on 18 April 2018 we rated the practice inadequate overall with ratings of inadequate for safe, effective, caring, responsive and well-led services. These areas affected all population groups within the effective key question, so we rated all population groups overall as inadequate. We took urgent action in line with our enforcement procedures to impose conditions on the provider’s registration.

We carried out a subsequent unannounced inspection on 24 May 2018 in response to continuing concerns about the service being provided. We did not rate that inspection. The overall rating for the service remained as inadequate.

We decided to undertake this inspection of the service following a change in the provider of the service. This inspection looked at the following key questions: Safe, Effective, Caring, Responsive and Well led.

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 not given an overall rating for this practice.

We rated the practice as good for providing safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing well led services because:

  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We were unable to rate the practice for providing effective and responsive services because whilst improvements had been made by the new providers since the last inspection, there was no published data available as yet to support our findings.

These areas affected all population groups, therefore we were unable to rate the population groups.

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

  • Improve the premises/security risk assessment with regards to security of doors when rooms are not in use.
  • Improve systems for checking that results have been received for all samples taken for cervical cancer screening.

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service. The service will be inspected again within 12 months.

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