The Care Quality Commission
  • Doctor
  • GP practice

Archived: Sir John Kirk Close Surgery

Overall: Good read more about inspection ratings

3 Sir John Kirk Close, London, SE5 0BB (020) 7358 4080

Provided and run by:
Nexus Health Group

All Inspections

31 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at Sir John Kirk Close Surgery on 31 May 2019 as part of our inspection programme.

At the last inspection in May 2018 we rated the practice as inadequate for providing safe services, and requires improvement for providing well-led services because:

  • The practice had not sufficiently mitigated risks associated with infection control, legionella or fire.
  • The practice’s triage appointment system used by reception staff posed potential risks to patients which had not been adequately considered or addressed.
  • There was a lack of clarity among staff about what amounted to a significant event and who assumed responsibility for patient safety alerts.
  • Some aspects of medicines management and arrangements to ensure equipment was safe to use were not satisfactory.
  • Not all staff had received a DBS check and not all clinical staff had been vaccinated against common communicable diseases.

We issued a warning notice to the provider after our inspection in respect of the concerns identified.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We have rated this practice as good overall and good for all population groups.

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 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

  • Maintain improved uptake of childhood immunisations.
  • Take action to improve uptake of 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

9 May 2018

During a routine inspection

This practice is rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced Sir John Kirk Close on 9 May 2018 as part of our inspection programme.

At this inspection we found:

A number of concerns regarding the provision of safe services and that governance systems were unclear in some places.

For example:

  • The practice had not sufficiently mitigated risks associated with infection control, legionella or fire. The practice’s practice triage appointment system that reception worked to posed potential risks to patients which had not been adequately considered or addressed. There was a lack of clarity among staff about what amounted to a significant event and who assumed responsibility for patient safety alerts. Some aspects of medicines management and arrangements to ensure equipment was safe to use were not satisfactory. We were provided evidence after our inspection that the practice had taken action to address most of these issues.
  • Not all staff had received a DBS check and not all clinical staff had been vaccinated against common communicable diseases. We were provided with evidence on inspection that DBS checks had been requested for staff who did not currently have these on file.
  • Most patients found the appointment system easy to use and reported that they were able to access care when they needed it; though some said they occasionally had difficulty accessing routine appointments. The practice had changed their appointment system in response to patient feedback but the new system presented potential risks which had not been assessed or addressed.
  • There was a focus on continuous learning and improvement though we were only provided with one two cycle audit from the last two years which demonstrated quality improvement.

However, we did see some areas of good practice. For example:

  • We saw that the practice had systems in place to enable care and treatment to be delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.

The areas where the provider must make improvements are:

  • 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 improvements are:

  • Consider the way it engages with Patient Participation Group members to ensure that all members are able to participate in meetings.
  • Consider ways to improve patient satisfaction with the nursing service provided by the practice.

We issued a warning notice to the provider after our inspection in respect of the concerns identified.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice