Letter from the Chief Inspector of General Practice

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the 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.

• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Patient survey figures were consistently above average when compared with CCG and national averages.
• Comments about the practice and staff were wholly positive.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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. We saw this to be the case on the day of inspection.
• 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.

• 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

• The practice operated a walk in service daily 9am to 11am for phlebotomy or a review with one of the nursing team for dressings, advice or monitoring.

• 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

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:

• Patients found the appointment system easy to use, were able to get through to the practice by telephone when they needed to and were able to access care when they needed it.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. We saw evidence that when incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines. Medical staff used quality improvement tools to improve patient safety and outcomes.
• Staff involved and treated patients with compassion, kindness, dignity and respect. Patients we spoke with told us practice staff were friendly, caring and understanding.
• There was a strong focus on continuous learning and improvement at all levels of the organisation with a strong patient focus.

The areas where the provider should make improvements are:

• Continue to embed the system to improve oversight of staff training.
• Take action to annotate vulnerable patient records when patients fail to attend hospital appointments.

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.