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Kirby Road Surgery Requires improvement


Inspection carried out on 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

Inspection carried out on 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

Inspection carried out on 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.