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Inspection Summary

Overall summary & rating


Updated 24 September 2019

The practice is rated as Good overall. The practice was previously inspected in August 2018 and rated as requires improvement overall and requires improvement for providing safe, effective and well-led services.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Kirkley Mill Surgery on 15 August 2019 (referred to in this report as ‘the Practice’) as part of our inspection of Suffolk GP Federation C.I.C., the registered provider of this service. Suffolk GP Federation C.I.C is a community interest company and is the registered provider of three other locations and services are provided from various sites across Suffolk. Our judgement of the quality of care at this service is based 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:

  • Patients were supported, treated with dignity and respect and were involved in decisions about their care and treatment.
  • Results from the national GP patient survey published in July 2018 were in line with local and national averages. Results for access were above local and national averages.
  • Patients’ needs were met by the way in which services were organised and delivered. For example, Suffolk GP Federation C.I.C. had worked with two other local practices and had access to two full time mental health nurses and a paramedic. The three practices worked together to deliver an ‘on the day’ service from 3pm to 6.30pm to offer urgent appointments for patients.
  • Feedback from patients on the day of inspection, including CQC comment cards, was positive about the care received by the practice.
  • We spoke to the practice about their hypnotic prescribing and found the provider and practice were actively monitoring and trying to reduce their prescribing. We saw a small reduction in hypnotic prescribing since January 2019, however it was still above average.

At this inspection, we rated the practice as requires improvement for the population groups of people with long term conditions and working age people in the effective domain because:

  • We reviewed unverified QOF data from 2018/19 and found some improvements had been made to outcomes for patients. The practice and provider had an improvement plan in place and data for 2019/20 showed the practice had achieved more reviews than in the same time period for the previous year. Exception reporting could only be completed by the clinical primary care lead to ensure the exceptions were appropriate. Although there was improvement in all the indicators noted, further work was required to improve outcomes to meet national and local averages.
  • The practice were aware that their cancer screening rates were lower than average. In response to this, the practice held a joint meeting with the local hospital screening lead and representatives from the cancer prevention team to help assist them in promoting screening and prevention of cancer; however, at the time of our inspection the practice was unable to demonstrate improvement in the Public Health England data.

We rated the other population groups as good for providing effective care.

The areas where the provider must make improvements are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

The areas where the provider should make improvements are:

  • 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

Inspection areas




Requires improvement






Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people


Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable