Kirby Road Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service had improved. Patients presenting with symptoms which could indicate serious illness were now followed up in a timely and appropriate way. More patients were now being screened for cervical cancer and more children had been immunised against various infectious diseases. Most patients with long-term conditions now had appropriate monitoring and reviews, in line with national guidance. However, the practice could continue to focus on improving care for patients with asthma. Thirty-six out of 37 patients with a learning disability had had a health check in the last year. However, the practice could act on the improvements they have identified to make sure patients who were eligible for NHS health checks were offered complete and clearly recorded checks.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care home representatives feedback was generally positive about their experience on behalf of their residents in respect of assessing patients’ needs. The practice provided routine assessments as well as those for acute need, with people involved in the assessment of their needs, and support provided where needed to maximise their involvement. Positive feedback from patients in respect of their experiences with the clinical teams meeting the assessment of their needs was also shared by the practice. About 38% of patients registered with the practice had 1 or more long-term conditions, such as asthma, chronic kidney disease (CKD), diabetes or hypothyroidism.

Patients with long-term conditions usually had the appropriate monitoring and reviews, in line with national guidance, to check their health and medicines needs were being met. Where patients had not been reviewed in line with guidance, the practice were aware and had processes in place to manage risks, including keeping a register of ‘high risk’ cases and limiting the amount of medicine the patient could request without having a review. Our search of the practice’s clinical records system found 36 patients with asthma who had been prescribed 2 or more ‘rescue packs’ in the last year. These packs contain medicines used to treat flare ups of asthma. Repeated use of these medicines can indicate the patient’s asthma could be better controlled. We looked at the patient records for 4 of these patients. We found all 4 patients had not always had an appropriate assessment before the rescue pack was prescribed. The patients were not always followed-up by the practice after a flare-up of their asthma to make sure their immediate and ongoing needs were fully addressed. However, the practice were aware of the patients and their situations, and had completed asthma reviews in the last year with 3 of the patients, which included an asthma care plan. The other patient had not attended appointments or responded to invitations for a review. Some of the patients were under the care of, and had been followed-up by, hospital specialists. The practice had identified this could be made clearer in patients’ records. The practice had identified that for one of the 4 patients, the rescue packs had been prescribed by another service, and as a result had missed being followed-up by the practice. In response to this, the practice had made changes to the searches they ran weekly to include these patients in the search, to help make sure other patients were not missed. Following our feedback, the practice reviewed the records for all 36 patients we identified on our search.

Patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Our searches of the practice’s clinical records system found 1 patient whose test results suggested they may have diabetes but for whom the diagnosis had not been recorded on the patient’s record. We looked at the record for this patient and saw the blood tests had been completed recently and the patient had an appointment already arranged with the practice to discuss the results and ongoing management.

We did not receive specific examples from people about the planning and delivery of evidence-based care and treatment. However, the practice shared with us examples of positive feedback from patients in respect of their experiences with the clinical teams planning and delivering people’s care and treatment that was evidence-based and in line with good practice.

Staff we spoke with said that people were told about current good practice that is relevant to their care and they were involved in how this is reflected in their care plan. They also said that leaders encouraged and supported them to learn about new and innovative approaches that evidence shows can improve the way their service delivers care.

The practice had systems and processes to ensure that staff were up to date with national legislation, evidence-based good practice and required standards. For example, clinical staff we spoke with told us that regular meetings were held among clinicians to discuss cases, new guidelines and share learning. The practice also facilitated a range of staff meetings which included multi-disciplinary clinical meetings and involved clinicians from other health services. Positive feedback about practice meetings was also included by non-clinical staff in their questionnaires. Staff also told us that they were able to attend updates and learning events and had access to evidenced-based guidance, such as those from the National Institute for Health and Care Excellence (NICE). These were used to support audits of clinical care. Additionally, the practice made use of clinical system templates to support the management of patient care and treatment.

We did not receive specific examples from patients about how staff, teams and services worked together. However, the practice shared with us examples of how they worked effectively across teams and services to support people, including patient’s feedback.

Staff we spoke with described how they were proud of the cohesive team working relationships they had to ensure all patients received high quality care and treatment. They told us they were engaged and supported by leaders to be innovative and to meet patients’ needs. This positive feedback about working together as a team was also fed back by staff in their questionnaires.

The practice worked with other organisations to deliver effective care and treatment. For example, positive feedback provided by care home representatives that the practice provided services to, highlighted the development of good working relations with residents, their relatives, and care home staff.

Staff had the information they needed to deliver safe care and treatment. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Staff regularly liaised with community teams such as community nurses and mental health practitioners. There were clear policies and procedures in place, which were easily available for staff to use. There were appropriate referral pathways to make sure that patients’ needs were addressed. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

We did not receive specific examples from patients about how the practice supported them to live healthier lives. However, the practice shared with us examples of how they supported people to manage their health and wellbeing so they could maximise their independence, choice and control and to live healthier lives and where possible, reduce their future needs for care and support. This included patient’s feedback.

Staff we spoke with told us how they encouraged and supported people to live healthier lives to help improve and maintain their health and wellbeing. Staff told us how they worked with a social prescriber, including referring patients to them. Social prescribers work with other professionals to connect people to a variety of services to meet their social, emotional and practical needs. Social prescribers can support a patient or carer to access the right services to help with issues which are affecting their health and wellbeing, for example stress, unemployment, education, debt, loneliness and housing issues, for example by helping people to access food banks. The practice had organised a Health and Wellness Day for patients which had included guest speakers from other organisations as well as practice staff and health screening opportunities. Leaders told us that feedback from this event by patients had been positive and they were now planning their next Health and Wellness Day for August 2024.

The practice identified patients who may need extra support and directed them to relevant services. This included unpaid or family carers. An unpaid or family carer is anyone who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, mental health needs or drug or alcohol problem and cannot cope without their support. The care they give is unpaid. The practice supported unpaid or family carers through hosting carers coffee mornings. These were well attended and participants shared support, for example about money issues and bereavement. Issues raised about individuals during the coffee mornings could be resolved, for example by triggering input from a social prescriber. Partner organisations also attended these meetings and provided advice. The practice shared with us positive feedback they had received about the coffee mornings. The practice also provided information on a carers’ noticeboard, offered health checks and support from a care coordinator, which could include a referral to social prescribing services. At the time of this inspection, the practice had 54 unpaid or family carers on the register. The practice had a ‘Carers Champion’. Staff encouraged and supported patients to be involved in monitoring, managing and improving their own health. Information was available on the practice’s website, for example about maternity care, child health, mental health and bereavement. In addition to information about local services, such as community support groups and support for patients who have diabetes, the practice supported national priorities and initiatives, including information on the practice’s website about support available to help people to stop smoking, advice about weight management and encouraging people to ‘get active for mental health’. Patients were able to discretely collect testing kits for sexually transmitted diseases.

We did not receive specific examples from people about monitoring and improving outcomes. However, the practice shared with us examples of how they routinely monitored people’s care and treatment to continuously improve it, including patient’s feedback.

The practice offered patients with a learning disability an annual health check. The practice told us they had completed reviews with 36 of the 37 patients registered with the practice for whom a learning disability had been recorded. The practice assessed and monitored the physical health of people with mental ill-health. Patients aged 75 and over are also eligible for a NHS health check. Although information the practice gave us showed various aspects of this health check had been completed for some patients as part of reviews of their medicines or long-term conditions, the practice had identified improvements that could be made. The practice shared with us their plans to introduce dedicated clinics to complete these health checks to make sure all eligible patients are offered a complete check, which could be completed during one appointment. Information provided by the practice showed although 80% of the patients registered with the practice in this age group had had a blood pressure check, a body mass index calculation had been recorded for only 44% of the patients, and 61% of the patients had had cholesterol and blood sugar screening.

Patients aged between 40 and 74 are eligible for a NHS health check. The practice had identified that health checks for these patients were not recorded accurately on the practice’s clinical records system. Information provided by the practice showed various different aspects of this health check had been recorded for some patients registered with the practice. For example, a blood pressure check had been recorded for 52% of the patients in this age group, a body mass index calculation for 31% of the patients, cholesterol screening for 43% and blood sugar screening for 45%. The practice gave us a plan of the actions they intended to take to improve the recording of health checks for this group of patients, including implementing an IT system to make sure checks completed as part of a different review were also recorded as a health check, and to establish communication channels with local pharmacies and other services where patients may have had a health check.

The practice met national targets for the number of children immunised against various infectious diseases, such as Diphtheria, Tetanus, Polio, Measles, Mumps and Rubella. The practice identified children who had missed appointments for childhood immunisations. The practice contacted these families and rebooked appointments, including at evenings and on Saturdays to help improve attendance. The practice identified that some of those who had missed appointments were from families who do not speak English as their first language. The practice therefore created a letter that was translated into the appropriate languages and sent to each family. Cervical screening (a smear test) is one of the best ways to help protect against and prevent cervical cancer by early detection. The latest information from the UK Health Security Agency (UKHSA) showed that on 30 June 2023, 79% of patients registered with the practice who were eligible for this screening had been screened adequately within the recommended time period. This period is 3 years 6 months for people aged between 25 and 49, and of 5 years 6 months for people aged between 50 and 64. The national target is 80%. We saw the coverage of patients being screened was consistently increasing since 2020. The practice aimed to improve the numbers of women and transgender people who were attending appointments for cervical screening as well as create a place where patients could go for their screening and feel safe and empowered. Feedback the practice had collected from patients who had used the practice’s ‘Smear Saturdays’ service was positive about the availability of weekend appointments and their experiences. There was a noticeboard in the practice’s waiting area with up-to-date information and encouraging eligible patients to book an appointment for a smear test. This included information inclusive of transgender people.

We did not receive any concerns from patients we had feedback from with regarding consent. Care home representatives were positive in their feedback. They told us staff always spoke with the patient, relatives and carers and obtained informed consent and considered the patients’ choices and decisions.

Staff told us they always obtained consent from patients or if appropriate their guardian and offered a chaperone where appropriate. This was recorded under the patient’s records on the clinical system.

Consent to care and treatment was obtained in line with legislation and guidance. Clinicians understood these requirements when considering consent and decision making. Staff supported patients to make decisions, and where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. There were processes for requesting support from an Independent Mental Capacity Advocate when needed and for verifying and recording details if there were arrangements in place to allow someone to make decisions on behalf of a patient, for example through a Power of Attorney. Staff were aware of the importance of making sure a patient had given their consent before sharing information with others and there was a system to record if the patient had given their consent.