Kirkley Mill Surgery

We carried out an announced desk-based review of Kirkley Mill Surgery on 10 August 2021. Overall, the practice is rated as good.

When this service registered with us, it inherited the regulatory history and ratings of its predecessor.

Following our previous inspection of the predecessor, published on 24 September 2019, the practice was rated good overall and for providing safe, caring, responsive and well led services. The population groups of people with long term conditions and working age people were rated requires improvement in the effective domain. Due to our ratings principles, the effective domain was rated requires improvement. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kirkley Mill Surgery on our website at www.cqc.org.uk

This desk-based review was to follow up on the areas for improvement and where the provider ‘should’ take action identified at our previous inspection. We found the required improvements had been made.

The practice is now rated as good for providing effective services and for the population groups people with long term conditions and working age people.

We found that:

• Improvements had been made to outcomes for patients with long term conditions in the most recent published Quality and Outcomes (QOF) data. The practice performance was in line with the Clinical Commissioning Group (CCG) and England averages.
• Work had been undertaken to significantly improve the review of patients diagnosed with cancer and improve cervical screening rates.
• The practice had continued to work to improve prescribing of hypnotic medicines. The practice performance had improved from 1.68 in 2018 to 2019, to 1.33 in 2020 to 2021, compared to the Clinical Commissioning Group average of 0.99 and the England average of 0.66. The practice had an action plan and due to expanding the pharmacy team, quarterly meetings were in place to discuss strategies to further reduce prescribing of these medicines safely.
• The practice continued to make improvements to summarise patient notes in a timely manner. This had improved from 858 notes awaiting summarising in July 2019 to 167 notes in August 2021. These notes were patients who had registered within the previous six to eight weeks. Due to the retirement of a dedicated summarising clerk, the practice had deployed two experienced staff to support with summarising and were in the process of training another two staff to summarise and work at both practice locations. The summarising training was supervised by a GP and a summarising protocol was in place. Alerts were added to the patient’s computer record to inform staff that the notes had not yet been summarised. Notes identified as a priority for summarising were completed first. A risk assessment and action plan for summarising was in place and was monitored.

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

• Continue to work to improve the uptake of cervical screening.
• Continue to review and reduce prescribing of hypnotic medicines where appropriate.
• Continue to complete the action plan relating to summarising patient notes to ensure this is completed in a timely manner.

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