The Care Quality Commission
  • Doctor
  • GP practice

Kirby Road Surgery

Overall: Requires improvement read more about inspection ratings

58 Kirby Road, Dunstable, Bedfordshire, LU6 3JH (01582) 609121

Provided and run by:
Kirby Road Surgery

All Inspections

30 June 2022

During an inspection looking at part of the service

We carried out an announced inspection at Kirby Road Surgery on 30 June 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

Safe – requires improvement

Effective – requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 26 May 2021, the practice was rated requires improvement overall and for the key questions are services safe, effective and well-led.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • All key questions.
  • Any breaches of regulations or should do actions identified in the previous inspection.

How we carried out the inspection

Throughout the 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.
  • Staff questionnaires.
  • 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.

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

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

  • There were gaps in the recruitment checks of new staff.
  • Patient Group Directions (PGDs) for staff to administer medicines were not authorised correctly and did not contain the name of the practice.
  • The practice had issued a higher than average number of anti-microbial prescriptions for the treatment of urinary tract infection. There had been an increased trend for prescribing these medicines over the past year and there was no evaluation to ensure prescribing was appropriate and in line with good antimicrobial stewardship guidelines.
  • Medical oxygen was available on site in the treatment room. However, oxygen masks and tubing were stored in a separate cupboard and not together with the oxygen cylinders and the practice had not assessed the risk of a delay in providing emergency care and treatment.
  • The practice did not have an effective system to learn and make improvements when things went wrong.

However, actions had been taken to address the concerns found at the previous inspection under the key question; are services safe?

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

  • A review of the patient clinical system found that patients who have had an exacerbation of asthma and those diagnosed with hypothyroidism were not always monitored appropriately. Patients with chronic kidney disease did not have a code indicating the diagnosis on their clinical record and allowing them to be identified for appropriate care and treatment.
  • The uptake for cervical screening had improved but remained below the 80% target.

We rated the practice as good for providing caring services because:

  • Patient feedback was positive regarding the care they received.
  • The practice had identified 107 patients who were carers. This was approximately 1% of the practice population.
  • There was a carers lead and support information for carers.

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

  • Patients reported they did not have timely access to the practice.
  • The practice had installed a new telephone system. However, there had been no analysis of data to evaluate its effectiveness.
  • Complaints were not handled in a consistent way and were not used to improve the quality of care.
  • The latest national GP Patient Survey data showed a significant decline in patient satisfaction.

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

  • The practice had responded to concerns raised at previous inspections.
  • Staff reported they felt supported by the GPs and practice management.
  • The GP partnership did not reflect the CQC registration.
  • The provider was registered as a data controller with the Information Commissioner’s Office. However, this was not with the current name of the practice or partnership.
  • We found that significant events and complaints were not handled in a satisfactory way to identify learning and drive improvements.

We found breaches of regulations. The provider must:

  • 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:

  • Continue to take actions to improve the uptake of cervical screening for all eligible patients.
  • Update the major incident plan following learning from the COVID-19 Pandemic.

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

26 May 2021

During an inspection looking at part of the service

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 www.cqc.org.uk

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

29 January 2020

During an inspection looking at part of the service

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

25 September 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Kirby Road Surgery on 25 September 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well-led

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 requires improvement for all population groups.

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

  • Identified actions from infection prevention and control (IPC) audits had not been completed. We noted the work surfaces in the treatment room were cluttered allowing for the potential collection of dust and there were no foot operated pedal bins in the staff and patient toilets to ensure safe disposal of hand towels and waste without cross contamination.
  • Emergency medicines were not easily accessible. Some staff did not know where to locate emergency medicines and equipment. Some recommended emergency medicines were not held in the practice and there was no risk assessment in place to mitigate this.
  • A log had not been kept to demonstrate that fire drills had been completed. Fire alarm checks were only completed every two months.
  • There were lapses in security in the premises. NHS smartcards were left in keyboards when staff were away from desks. The reception office was unlocked and easily accessible to patients.
  • There were concerns with health and safety in the practice. The practice had not identified trip hazards. There was a mercury sphygmomanometer used for taking blood pressure readings. However, staff were unaware of the actions to take in the event of a mercury spillage.
  • Blood test results for patients prescribed Warfarin were not recorded in the patient computer record. We checked the hospital system and were assured that all patients prescribed Warfarin had received appropriate blood monitoring.
  • The temperature of the fridges used to store vaccines was checked each day. The thermometers were integral to the fridges. A second independent thermometer was not used to cross-check the accuracy of the temperature and to monitor the temperature if the electricity supply to the vaccine fridge was interrupted.

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

  • Exception reporting was high in some areas of the Quality and Outcomes Framework monitoring.
  • The uptake for cervical screening was below the 80% target set by Public Health England.
  • Some single-cycle audits had been undertaken by individual GPs. However, these were not shared with other clinicians and two-cycles and not been completed to demonstrate quality improvement. There was no other quality improvement activity demonstrated in the practice.
  • Staff development was not supported by the use of appraisals.

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

  • There were flaws in the leadership and governance of the practice.
  • Staff were not supported fully by the GP partners.
  • Systems and processes in place were not adequately followed.
  • A fire risk assessment had not been completed to support decisions made in relation to fire alarm checks.
  • Essential risk assessments had not been completed in relation to security and, health and safety.
  • There was a lack of staff meetings and formal communications with staff. Outcomes and learning from significant events and complaints were not shared with practice staff.

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.

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

The areas where the provider should make improvements are:

  • Keep a log of fire drills.
  • Review the use of mercury sphygmomanometers and ensure staff are aware of actions to take in the event of a mercury spillage.
  • Consider the use of a second independent thermometer to monitor the temperatures of the fridges used to store vaccines.
  • Encourage eligible female patients to have cervical cancer 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

28 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kirby Road Surgery on 28 September 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff were aware of their responsibilities in helping to safeguard and protect patients.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. The practice had introduced a different way of working to manage the practice.
  • The practice matron employed by the practice supported frail elderly and vulnerable patients.
  • They worked well with multidisciplinary teams, including community and social services to plan and implement care for their patients.
  • The practice held regular staff and clinical meetings where learning was shared from significant events and complaints.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 248 patients as carers (approximately 2.7% of the practice list).
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice offered extended hours appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

However there were two areas of practice where the provider should make improvements:

  • The practice should continue to complete staff apprasials and ensure that they are undertaken annually.
  • Continue to support and develop the patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice.