You are here

Kirby Road Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 March 2020

We carried out an announced focused inspection of Kirby Road Surgery on 29 January 2020. This inspection was undertaken to follow up on a warning notice we issued to the provider in relation to Regulation 17 Good Governance.

The practice received an overall rating of requires improvement, with inadequate for providing well-led services, at our inspection on 25 September 2019. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full comprehensive report from the September 2019 inspection can be found by selecting the ‘all reports’ link for Kirby Road Surgery on our website at

Our key findings were as follows:

  • The practice had taken the action needed to comply with the legal requirements of the warning notice we issued.
  • An action plan had been put in place to make improvements to the practice.
  • Communications and knowledge was shared between the two practice managers. Practice meetings and communication channels had been put in place to support staff.
  • Policies and procedures had been reviewed, particularly in relation to the monitoring of patients who were prescribed high risk medicines.
  • A programme of appraisals was in place. There were no plans in place for the practice manager appraisals.
  • Clinical audits had been shared at clinical meetings.
  • Risk assessments had been completed for health and safety, security and fire safety.

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

  • Complete appraisals for the practice managers to support their performance and development.

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


Requires improvement






Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement