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Archived: Kirkley Mill Surgery Inadequate

The provider of this service changed - see new profile


Other CQC inspections of services

Community & mental health inspection reports for Kirkley Mill Surgery can be found at East Coast Community Healthcare C.I.C..

Inspection carried out on 1 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kirkley Mill Surgery on 1 June 2017. Overall the practice is rated as inadequate. Our key findings across all the areas we inspected were as follows:

  • There was a system in place for the recording and reporting of significant events. However, learning from significant events was not always shared with staff.
  • There was no effective system in place for receiving, sharing and actioning patient safety alerts.
  • Policies and procedures for safeguarding children and vulnerable adults were in place, and staff were aware of these. Not all staff had received safeguarding training appropriate to their role, and not all GPs had the correct permissions in place on the computer system to ensure they were aware of patients with current safeguarding needs.
  • Health and safety risks to patients and staff were assessed and monitored, however there was no evidence that fire drills had been undertaken.
  • We found the practice was clean and tidy and procedures were in place for infection prevention and control. However, the infection control lead had not completed any specific training to undertake this role. The record of staff hepatitis B immunity was incomplete and the lock on one of the external clinical waste bins was broken.
  • We reviewed patients who were prescribed high risk medicines. They had not all been reviewed in a timely manner before their medicines had been reissued.
  • There was no effective system in place for dealing with clinical pathology results in a timely manner and the practice did not use an agreed and consistent coding system for patient’s medical records.
  • Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment to patients; however evidence based guidance was not always being followed.
  • The arrangements for triaging requests for home visits were undertaken by non-clinical staff, without written guidance or clinical oversight.
  • There was limited evidence of quality improvement including clinical audit.
  • The practice did not hold regular multi disciplinary meetings and did not ensure that relevant information was shared with other services. The practice planned to hold multi disciplinary meetings, however these had not commenced at the time of the inspection.
  • Some areas of the practice performance were insufficiently understood and supported to ensure safe and effective care and treatment for patients.
  • A process was in place for receiving, investigating and responding to complaints. Information on how to escalate a complaint was not provided to complainants in response letters; however the practice had included this in their new information leaflet, which was being printed. Improvements were made to the quality of the service provided as a result of complaints and concerns; however actions taken were not shared with all staff to encourage learning.
  • A healthy lifestyle behavioural coach worked at the practice and feedback from patients on this service was very positive.
  • Most patients reported being treated with compassion, dignity and respect and involved in decisions about their care and treatment. Patients were able to make an appointment with a GP although there was not always continuity of care.
  • The results from the national GP patient survey showed the practice was generally performing below CCG and national averages. The practice did not have a Patient Participation Group (PPG).
  • We found there was a lack of overall clinical leadership and oversight at the practice.

The areas where the provider must make improvement:

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

The areas where the provider should make improvement are:

  • Offer health reviews to patients with a learning disability.
  • Ensure that information about the complaints policy is available for patients and includes information about how to take action if a complainant is dissatisfied with the response.
  • Continue with plans to start a Patient Participation Group in order to obtain patient feedback and engagement with the practice and act on this feedback to improve patient satisfaction.

Since our inspection Great Yarmouth and Waveney Clinical Commissioning Group (CCG) and East Coast Community Healthcare Community interest Company (ECCH) have taken significant action in response to our findings. We have been provided with evidence to demonstrate that immediate actions have been undertaken and assurance from the CCG that all identified actions will be completed to minimise the risk to patients.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. 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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice