Kirkgate Surgery

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

We found some systems and processes to ensure people were protected from avoidable harm were not operating effectively. This included shortcomings in the management of environmental risks, infection prevention and control arrangements, and oversight of staff records and compliance requirements. Leaders had not always maintained effective oversight of risks or ensured appropriate records were available to demonstrate safe care and treatment.

The practice was in breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

Records reviewed demonstrated servicing and testing had been undertaken for a range of equipment and systems, including fire extinguishers, fire alarms, PAT testing, medical equipment calibration and emergency lighting. However, systems to monitor and maintain the safety of the premises were not always effective. An Electrical Installation Condition Report (EICR) was not available during the assessment. A new EICR was completed on 26 July 2026, after the onsite visit and after the assessment process had commenced. Following the inspection, the provider also located an EICR dated 2019 We found the requirement for an up-to-date EICR had previously been identified within an external fire risk assessment completed in May 2024 but had not been addressed until after the assessment process had commenced. In addition, the provider was unable to provide evidence of an asbestos survey and advised arrangements were being made for a survey to be completed. During the inspection, we observed that the emergency pull cord was not in place in the accessible toilet, despite patients having access to and using the facility. Managers later informed us that the cord had been found, it had not been reinstalled following building works completed in approximately July or August 2025.

The practice had completed some risk assessments to support the management of environmental risks; however, systems for monitoring and acting on identified risks were not always effective. An internal fire risk assessment was dated 18 July 2026, which was after the inspection had been announced. An external fire risk assessment was completed by an accredited provider in May 2024; the assessment identified actions requiring completion which were overdue for review at the time of inspection. The practice could not demonstrate these actions had been completed,. An external health and safety compliance audit completed in 2023 also identified actions requiring completion; however, not all actions had been addressed. The most recent legionella risk assessment was dated November 2021 and there was no evidence to demonstrate all recommended actions had been completed. Leaders told us a further assessment had been scheduled for August 2026. COSHH safety data sheets were available; however, a COSHH risk assessment had not been completed. Leaders could not always demonstrate which historical premises-related records were held by the practice, limiting effective oversight and management of the premises.

The practice did not always make sure staff records and employment checks were complete and up to date. However, they had sufficient numbers of qualified, skilled and experienced staff who worked together to provide safe care that met people's needs.

The practice employed a range of clinical and non-clinical staff and had recruitment and onboarding procedures in place. Disclosure and Barring Service (DBS) checks had been completed before staff commenced employment. Inductions included both role-specific and practice-specific elements, such as fire safety training and shadowing opportunities. Rotas were planned to ensure a suitable mix of skilled staff were available across the practice. The practice was also a training practice for medical students and foundation year doctors, with plans to support GP registrars.

Effective arrangements were in place for clinical supervision. The practice had a clinical supervision policy, and we reviewed examples demonstrating that supervision sessions were being undertaken and recorded. The practice also maintained a comprehensive locum pack to support safe working arrangements.

However, staff records were not always complete. The provider had only limited assurance of staff immunisation status in line with current guidance. Of the four staff records reviewed, only one contained evidence of immunisation status. Following a further check by the provider, immunisation records were identified for an additional member of staff. However, leaders were unable to confirm whether this information was available for all staff members. Two staff files did not contain proof of identification and 2 did not contain interview records. The practice was also unable to demonstrate an effective process for completing and recording annual professional registration checks. Following the assessment, leaders provided evidence that professional registrations were current and advised a formal annual checking process would be implemented going forward. We identified further gaps in employment records, with no confidentiality clause included within contracts. Most staff files lacked a signed confidentiality agreement. A staff training matrix requested following the onsite assessment was not provided, limiting the practice's ability to demonstrate effective oversight of staff training compliance.

The service did not effectively assess or manage the risk of infection.

The practice had an identified infection prevention and control (IPC) lead, who had completed additional training for the role. Staff completed IPC training appropriate to their role and the premises appeared visibly clean and tidy during the assessment. Although some areas of the building required cosmetic repair, leaders advised that plans were in place for building improvement works. Used sharps were stored safely and appropriately labelled.

However, systems to assess, monitor and manage IPC risks were not fully effective. The practice advised us that work to review and strengthen IPC arrangements was underway prior to the assessment being announced and that an IPC audit was in progress at that time. The practice subsequently provided a completed audit dated 17 July 2026 following the onsite visit. The practice was unable to provide evidence of any previous IPC audits. The audit identified several actions relating to environmental cleanliness, waste management, staff training and audit processes. The practice was unable to demonstrate effective oversight of cleaning arrangements. There were no documented cleaning schedules detailing required cleaning activities and no daily or weekly cleaning records available to evidence when cleaning had been completed. Weekly environmental spot checks were undertaken; however, although these records were dated, they were not signed to demonstrate review and accountability. Records relating to the cleaning of carpeted areas could not be provided during the assessment. Following the onsite inspection, the practice advised that no carpet cleaning records had been located and that carpet cleaning had been booked, with arrangements made for this to be undertaken on a regular basis. Of the 4 staff records reviewed, only 1 contained evidence of immunisation status in line with current guidance. Sharps injury guidance directed staff to seek support from an occupational health service; however, the practice did not have arrangements in place to access occupational health services.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.