We carried out a review of the data available to us about Kirkby Health Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Kirkby Health Centre, you can give feedback on this service.
This practice is rated as Good overall. (Previous rating April 2017 – Good)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We undertook a comprehensive inspection of Kirkby Health Centre on 29 September 2016 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as requires improvement.
We undertook a follow up desk-based focused inspection of Kirkby Health Centre on 01 March 2017. This inspection was carried out to review in detail the actions taken by the
practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.
We carried out an announced comprehensive inspection at Kirkby Health Centre on 28 August 2018 as part of our inspection programme.
At this inspection we found:
The areas where the provider should make improvements are:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
We carried out an announced comprehensive inspection at Kirkby Health Centre on 29 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Kirkby Health Centre on our website at www.cqc.org.uk.
This inspection was a desk-based review carried out on 01 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 29 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
The practice had implemented a set agenda for monthly practice meetings which was attended by all staff groups, which discussed alerts, significant events and training.
Appropriate recruitment checks were carried out before staff commenced employment.
All staff had received safeguarding children and safeguarding adult training to a level appropriate to their role. Staff had also completed infection control training.
The practice had taken steps to strengthen their governance systems and monthly practice meetings had a set agenda which included specific governance issues, including alerts, significant events and complaints.
A schedule was put into place to review all policies and procedures.
A training schedule was also in place to monitor when staff were due to carry out refresher training for statutory and mandatory training, as well as training relevant to their role.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Kirkby Health Centre on 29 September 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
There was an effective system in place for reporting and recording significant events however the actions and lessons learned recorded were brief.
The practice offered extended hours Tuesday morning from 7am for working patients who could not attend during normal opening hours this was for GP and nurse appointments
Safety alerts and alerts from Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and cascaded to the appropriate persons. However, we saw no evidence the practice carried out reviews and completed searches on the patient record system to ensure action was taken against the alerts.
The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. However training records did not provide assurance that mandatory training for all staff was up to date.
There was evidence of appraisals and personal development plans for all staff however staff had not had an appraisal within the last 12 months.
The practice did not hold governance meetings, and governance was not an item on the practice meeting agenda.
Clinical meetings were informal and not always minuted.
The areas where the provider must make improvement are:
Ensure clinical meetings with the nurse, GP and long term locums take place.
Ensure governance issues such as significant events, complaints and safety alerts are discussed at practice meetings.
Ensure training records are maintained that provide assurance that training for all staff is up to date.
Ensure staff receive an appraisal every 12 months.
The areas where the provider should make improvement are
Review all policies, protocols and procedures to ensure they are up to date.
Document action taken in relation to safety alerts received.
Chief Inspector of General Practice