Kirby Road Surgery

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