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Kirby Road Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 July 2021

We carried out an announced inspection at Kirby Road Surgery on 24 to 26 May 2021. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 25 September 2019, the practice was rated requires improvement overall, for the key questions safe and effective and the population groups. They were rated inadequate for providing well-led services. We carried out an announced focused inspection of Kirby Road Surgery on 29 January 2020, which was undertaken to follow up on a warning notice we issued to the provider in relation to Regulation 17 Good Governance.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kirby Road Surgery on our website at

Why we carried out this inspection

This was a focused inspection to follow up on:

  • The safe, effective and well-led key questions
  • Any breaches of regulations or ‘shoulds’ identified in the previous inspection.

How we carried out the inspection/review

Throughout the COVID-19 pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing and telephone calls.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Asking patients to submit online feedback.

Our findings

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 have rated this practice as Requires Improvement overall and for the population groups Long-term conditions, Working age people (including those recently retired and students) and People experiencing poor mental health (including people with dementia). We have rated the population groups Older people, Families, children and young people and People whose circumstances make them vulnerable as good.

We rated the practice as requires improvement for providing safe services because:

  • Nursing staff were not trained to the appropriate level for safeguarding children and young people.
  • There was not a process for the ongoing checks of the registration status of clinical staff.
  • The system in place for high-risk medicines monitoring was not effective. We found some patients were overdue a review.
  • Actions from a safety alert had not been followed. We found patients were prescribed a combination of two medicines that was not recommended.

We rated the practice as requires improvement for providing effective services because:

  • The practice had not taken sufficient measures to improve the uptake of cervical screening which meant they remained below the 80% target set by Public Health England.
  • The Personalised Care Adjustment (PCA) rate, which replaced exception reporting, was high in some areas of Quality and Outcomes Framework (QOF) and the practice were unable to provide an explanation for this.
  • The percentage of patients diagnosed with chronic obstructive pulmonary disease (COPD) who had received a review was lower than local and national averages.
  • Some patients diagnosed with dementia did not have a care plan in place.

We rated the practice as requires improvement for providing well-led services because:

  • The provider had made improvements to the leadership of the practice. There was a new GP partnership formed. However, changes to governance structures particularly relating to policies and procedures were not fully embedded which led to the concerns with the provision of safe services.
  • The practice had not fully considered the needs of patients with a hearing impairment in relation to access during the COVID-19 pandemic.
  • There had not been sufficient actions implemented in response to available data, to improve the practice performance from the previous inspection in September 2019.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report.)

The areas where the provider should make improvements are:

  • Seek ways to encourage eligible patients to have cervical cancer screening.
  • Make improvements to the Personalised Care Adjustment rates in the Quality and Outcomes Framework.
  • Improve ways for people with a hearing impairment to access services.

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






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)

Requires improvement

People whose circumstances may make them vulnerable