Kirby Road Surgery

On this page

• 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

The service had improved. There was now a culture of thoroughly investigating events, incidents and complaints. The practice acted on and shared the learning identified from them to make improvements. There were now safe recruitment practices and systems to make sure staff were protected against infectious diseases. The practice had systems for the appropriate and safe use of medicines, including the use of Patient Group Directions (PGDs). There was a strong understanding of safeguarding and there were comprehensive systems to help protect people from abuse and neglect. The practice supported the development of all staff, and staff told us how much they had appreciated being encouraged to acquire new skills and develop their existing skills. However, improvements in the management of risks relating to fire safety, infection prevention and control, and medicines that need storing in a fridge could be improved.

This service scored 81 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were supported to raise concerns and staff treated them with compassion and understanding. We spoke with a representative from the practice’s Patient Participation Group (PPG) who said that the provider took concerns seriously and proactively made improvements to the service.

Staff knew how to identify and report concerns, safety incidents and near misses, and leaders understood how to raise concerns and report incidents both internally and externally. For example, the practice informed the Care Quality Commission (CQC) about events when there was a legal requirement to do so. The practice thoroughly investigated and analysed significant events, incidents and feedback from staff, and acted on the learning identified from them to make improvements. Staff throughout the practice were involved in identifying the learning and agreeing the actions required. The practice shared their learning with other services and involved other services to help maximise the learning and improvements. For example, the learning and changes the practice made in response to the death of a patient where certain medicines had been a contributing factor.

There was a system for recording, investigating and acting on significant events. The practice had recorded 3 significant events in the 15 months leading up to this inspection. The practice kept thorough records of the actions taken and advice received from others, for example advice from the Data Protection Officer the practice contacted when the practice had accidentally sent a form to a patient that contained the details of a different patient. The practice had a system for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). Safety alerts were reviewed by the practice’s pharmacist, who recorded the details on a spreadsheet, along with comments of the actions taken and when. The practice logged all safety alerts received and recorded the practice’s initial assessment of them, including if the alert was not relevant to the service and no further action was needed. However, the practice responded to our feedback about how the system could be improved to evidence staff had received and acted on information. Staff understood how to deal with alerts and we found the actions needed were embedded into everyday practice. We ran 4 different searches of the practice’s clinical records system to identify patients who were prescribed medicines for which safety alerts had been issued. We found the practice had responded to protect all patients affected by them.

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 care and support was planned and organised with people, together with partners and communities in ways that ensured continuity, including patient’s feedback. The views of people who used the service, partners and staff were listened to and considered.

Staff had the information they needed to deliver safe care and treatment. There was a system for processing information relating to new patients including the summarising of new patient notes. Leaders were aware, however, there was a backlog in summarising historic patient records. They told us they had investigated ways to help complete this work. The records awaiting summarising were kept in an organised and secure way.

Feedback we received from care home representatives were positive about their experience on behalf of their residents with regards to systems in place for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals. Our search of the practice’s clinical records system showed referrals were sent in a timely way and letters coming into the practice were processed in a timely way. Test results were managed in a timely manner and with appropriate clinical oversight. The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services.

Safeguarding systems and processes were developed, implemented and communicated to staff. Staff knew who the clinical lead for safeguarding was and knew how to access practice policies and information for safeguarding. One of the GP Partners had an interest in safeguarding and told us how they had worked to make safeguarding an integral part of the day-to-day running of the practice. We saw areas of outstanding practice, such as: • The practice held meetings weekly to review known safeguarding concerns and to discuss and introduce new concerns, for example reports from the ambulance service about a homeless person. Actions were agreed in these meetings, including who would take them, for example to offer homeless people support and referral to appropriate support services. • Staff discussed changes in the service and updates to national guidance in these meetings. Staff also raised issues, for example concerns about the impact for victims of domestic abuse who viewed their full medical records. The practice proactively sought current advice and legislation to make sure the practice’s procedures were up-to-date. • Some staff had attended ‘Domestic Abuse Responder Training’. This meant these staff were more able to help if someone attended the practice wanting information. One of these members of staff was also a ‘Domestic Abuse Champion’ and had links with local charities. • The practice was a registered ‘Safe Space’, and there was a ‘Domestic Abuse Support Hub Space’ where people could access information and online services with support from staff with knowledge of local safeguarding processes and an interest in supporting those experiencing domestic abuse. The practice had recently relocated this space to offer patients a quieter and more private space.

• The practice worked with other agencies such as the Bedfordshire Domestic Abuse Partnership and local government, for example to have a directory of local and national services for both patients and staff to use. • In addition to information on noticeboards in all rooms in the practice, the practice had made shortcut links to documents such as policies, procedures and resources on computers in every room in the practice, to help staff access them easily. • There was a noticeboard in the waiting area at the practice dedicated to sharing information about various safeguarding matters. Information leaflets were also available, as well as posters in the practice and information on the practice’s website, including information for specific groups of people and what people could do if they had a concern. Feedback from partners referred to how the practice worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. This included, working relations between the practice and care home residents, their families and staff.

All practice staff, clinical and non-clinical, had completed training in both safeguarding children and in safeguarding adults to level 3 within the last 3 years. This was beyond the level of training set out in national guidance. A programme of workshops to explore areas of safeguarding in more detail and for staff to share their experiences and discuss the complexities of each area. These workshops were additional to the mandatory training staff were required to complete and were available for all practice staff, in response to interest from non-clinical members of staff to attend them. The practice took a proactive approach to engagement in local safeguarding processes and sharing information with other services, such as out-of-hours services. There were discussions with other health and social care professionals when needed, such as health visitors and social workers, to support and protect adults and children at risk of significant harm. There were named staff who were trained to do initial assessments of victims of domestic abuse and processes in place to make sure at least one of these members of staff was available whenever the practice was open. The practice used a standardised system to identify people who are or may be made vulnerable on record, and certain administrative staff were responsible for keeping registers up-to-date. Appropriate Disclosure and Barring Service (DBS) checks were undertaken where required. DBS checks identify whether a person has a criminal record or is on an official list of people that should not work in roles where they can have contact with children or adults that can be made vulnerable. These checks help to protect other staff and people that use the service from abuse. Enhanced checks were completed for all clinical staff and non-clinical staff who acted as chaperones.

We did not receive specific examples from patients about how people were involved to manage risks. However, the practice shared with us examples of how they worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that is safe and supportive and enabled them to do the things that matter to them, including patient’s feedback. People were informed about any risks and how to keep themselves safe, including what to do and who to contact if their condition did not improve or if they experienced any unexpected symptoms.

The practice was equipped to respond to medical emergencies and staff were mostly suitably trained in emergency procedures. Training records the practice gave us for this inspection showed all clinical staff had completed training in child and adult basic life support and anaphylaxis in the last year. Three of the 17 members of non-clinical staff were overdue this training, although all had completed relevant training within the 16 months leading up to this inspection. The practice required all staff to complete training in sepsis awareness every year, and was included in the above training package. Sepsis, sometimes called blood poisoning, happens when your body overreacts to an infection and starts to damage itself. Symptoms can be difficult to spot and sepsis can be life-threatening. Therefore, it is important that staff can recognise and act on symptoms. Although 3 members of non-clinical staff were overdue this training, as above all 3 had completed the training within the 16 months leading up to this inspection. Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient. There were posters about the signs of sepsis throughout the practice, including in reception, for both patients and staff.

The practice held appropriate emergency medicines and had risk assessments in place that explained why medicines were, or were not, kept in the practice. There was a system was in place to monitor the expiry dates of emergency medicines and equipment. During our site visit, we found all the expected emergency medicines to be available and in date. The practice kept medical oxygen and a defibrillator on site, and there were systems to ensure these were regularly checked and fit for use. However, these systems, and systems for making sure other emergency equipment such as consumables for administering medicines were available and safe for use, could be strengthened.

Staff were aware of the procedure for emergency evacuation, for example in the event of fire. Disabled staff had personal emergency evacuation plans. These were easily accessible and other staff members knew what support might be needed.

The practice’s most recent fire risk assessment had been completed by practice staff in April 2024. Some of the actions identified had been taken and others were in progress, such as alterations to the fire exits to make sure they were suitable. During our site visit, we saw various fire extinguishers throughout the building, which had been serviced appropriately, and clear signs directing people to fire exits, explaining the fire procedure and saying who the fire wardens were. Fire wardens had completed additional training to enable them to do this role safely. There were systems to ensure that electrical equipment was regularly tested and medical equipment regularly calibrated. This is important to ensure that it provides correct readings to ensure patients receive appropriate treatment. During our site visit, we saw equipment had been tested in August 2023. The practice had carried out various other health and safety risk assessments, including for Legionella. The practice had taken the actions identified in the risk assessments, such as monthly tests of the water system. These tests are important to identify if there is an increased risk of legionella bacteria growing in the water system so that the required actions can be taken. This is important because if these bacteria are breathed in, it can lead to Legionnaire’s disease, a serious type of lung infection which can be fatal. The practice also carried out risk assessments for the control of substances hazardous to health (COSHH), for example chemicals used for cleaning, oxygen and medical devices used as an alternative to liquid nitrogen.

The practice had reviewed their Fire Safety Policy in May 2024. The practice provided evidence of regular fire drills and of actions taken in response to learning identified from them. The practice provided records showing weekly checks of the fire alarm system and emergency lighting were carried out. All staff had completed training in fire safety in the last 2 years, in line with the practice’s policies.

While there was some negative feedback about the approach of some staff members, feedback from people, their family carers and professionals who worked closely with the service was mostly positive with regards to staffing. This included current comments posted on the NHS reviews website. The practice also shared with us feedback they had collected from a patient survey with regards to cervical screening Saturday clinics. This was noted as overwhelmingly positive and talked about safe and effective staffing, in particular about the supportive environment and attitude from clinicians.

There were enough staff to provide appointments and prevent staff from working excessive hours. There was an effective approach to managing staff absences and busy periods. For example, the practice had identified more appointments for minor illnesses were needed on Friday afternoons. Staff had the skills, knowledge and experience to deliver effective care, support and treatment. The practice had a comprehensive training programme, and staff had protected time for learning and development. The practice supported the development of all staff, and staff were positive about the learning and development opportunities available at the practice. This included day-to-day support for all staff, including those who were new to general practice nursing or who were physician associates. Staff told us how much they had appreciated being encouraged to acquire new skills and develop their existing skills, for example by supporting them to become a healthcare assistant, nurse associate or non-medical prescriber.

We looked at the staff files for 2 clinical and 2 non-clinical members of staff who had started working at the practice in the 18 months leading up to this inspection. Recruitment checks were completed in line with regulations and the practice’s Recruitment Procedure. The practice used a tracker to make sure professional registrations were kept up-to-date for staff for whom professional registration was required. The practice also carried out yearly audits to help make sure appropriate DBS checks had been completed for all staff. Staff had access to regular appraisals, one to ones, coaching and mentoring, and clinical supervision. Records the practice provided for this inspection showed all staff had had an appraisal within the year leading up to this inspection, in line with the practice’s Staff Appraisal Policy. The practice could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, pharmacists and physician associates. The practice demonstrated the prescribing competence of non-medical prescribers through regular review of their prescribing practice, supported by clinical supervision and a systematic process. A non-medical prescriber is a registered healthcare professional who has completed training to be able to prescribe certain medicines without needing to ask a doctor. A lead GP carried out monthly audits of the prescribing practices, consultations and clinical records completed by staff who were non-medical prescribers. The practice had developed a tool, based on tools available from the Royal College of Nursing, to help make sure the audits were completed in a structured way and that they were thorough, consistent, and recorded clearly.

We did not receive any feedback from people who use the service about infection prevention and control (IPC).

IPC audits were carried out, and the practice had acted on most issues identified in them. The practice carried out the most recent audit in March 2024. Generally, staff and leaders were aware the practice required some redecoration and updating, for example to make sure all clinical handwashing facilities met the expected standards. The practice regularly liaised with cleaning staff to address any concerns noted, and the practice carried out ‘spot checks’ to ensure cleaning met the expectations of the practice staff.

We observed the practice to be clean and tidy. The arrangements for managing waste and clinical specimens kept people safe.

The practice kept a tracker to make sure all staff, clinical and non-clinical, had adequate immunity against infectious diseases, in line with guidance from the UK Health and Security Agency (UKHSA). We found all staff had received all the recommended vaccinations. Training records provided for this inspection showed all staff, clinical and non-clinical, had completed appropriate training in infection prevention and control. All staff were up-to-date with this training, in line with the practice’s policies.

Feedback we received from care home representatives were positive about their experience on behalf of their residents in respect of managing medicines. They told us the practice was proactive in regular reviews of patients’ medicines.. The practice also shared with us examples on how staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely, including patient’s feedback. The practice had started work in August 2023 to lower the number of patients prescribed benzodiazepine and ‘Z drugs’ or reduce the doses of these medicines prescribed. These medicines need to be used carefully because people can become dependent on or addicted to them. Between August 2023 and the time of this inspection, these medicines were no longer prescribed for 9% of the patients, and smaller doses of the medicines were prescribed for a further 56% of patients. Eight patients continued to be prescribed high doses of these medicines. However, the doses prescribed for 5 of these patients had been reduced. Data from NHS Business Services Authority (NHSBSA) showed the practice’s prescribing of hypnotic medicines such as benzodiazepines, gabapentin and pregabalin were in line with the local and national averages. The practice was also in line with local and national averages for prescribing multiple psychotropic medicines for a patient.

The practice ensured medicines were stored safely and securely with access restricted to authorised staff. Staff had the appropriate authorisations to administer medicines, including Patient Group Directions (PGDs) and Patient Specific Directions (PSDs). A PGD provides a legal framework that allows specific registered health professionals to give a named medicine to certain groups of patients, without the need for an appropriate clinician to issue individual prescriptions. Staff told us how they used PSDs safely and effectively. Prescribing clinicians can use PSDs to instruct non-prescribing staff, such as healthcare assistants, to give a named medicine to certain individual patients who the prescriber has assessed need the medicine.

Some medicines, for example vaccines, need to be stored in a fridge to make sure they remain safe and effective to use. We saw medicines were stored in fridges appropriately. The practice recorded the temperatures of the fridges daily, in line with national guidance. It is important to monitor the temperatures of the fridges to identify if the temperatures fall outside the acceptable range so that actions can be taken to make sure the medicines remain safe and effective to use. However, there were no systems, such as the use of a second thermometer or a data logger, to identify if the in-built thermometers on the fridges stopped working accurately and to be able to carry on monitoring the fridge temperatures should there be a fault. The practice could also strengthen their systems for reducing the risks of fridges being accidentally turned off. Blank prescriptions were kept securely, and their use monitored in line with national guidance.

There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Our search of the practice’s clinical records system showed the practice had recorded medicines reviews: • in the 3 months leading up to our inspection for 820 patients prescribed repeat medicines. We looked at the records for 3 of these patients and found the reviews to be of good quality, included all repeat medicines, and included a check any required monitoring was up-to-date. When appropriate, patients were supported when changes to their medicines were recommended • in the last 18 months for all patients prescribed 10 or more medicines • for all patients who had been prescribed Gabapentin or Pregabalin. These medicines need to be used carefully because a person’s body can change to tolerate them, creating a dependency on the medicine, and are known to be widely used illegally as a drug of abuse. However, we found 49 patients who had been prescribed benzodiazepine medicines or ‘Z drugs’ more than 10 times in the last year. We looked at the records for 4 of these patients, and found the medicines had been reviewed and prescribed appropriately for 2 of the patients, with evidence attempts had been made to wean the patients off the medicines. We did not see evidence attempts had been made to help the other 2 patients reduce their use of these medicines. The practice told us one of these patients had declined medicine reduction but was aware of the risks of taking the medicine. This patient was under the care of a specialist hospital doctor who had recently reviewed the patient and advised to continue with the current medicine and dosage. The other patient had not had a review of their medicine in the last year. The practice told us this patient was one of 3 patients who had not yet had an initial review of their medicines with the specialist pharmacist.

There was a process for monitoring patients’ health in relation to the use of medicines that require monitoring. The practice carried out regular searches of the clinical system to make sure patients prescribed high-risk medicines were up-to-date with the required monitoring and take actions when needed. Our searches showed patients prescribed high-risk medicines had received the necessary monitoring to make sure it was safe to continue to prescribe the medicine and the dose prescribed was suitable. This specific and regular monitoring is needed because of the risks associated with taking the medicines. We found: • All patients prescribed Methotrexate or Azathioprine, medicines used to calm and control the body’s immune system, to stop or slow the disease process in inflammatory conditions, such as rheumatoid arthritis, had been monitored in line with national guidance. • All patients prescribed an angiotensin receptor blocker (ARB) or angiotensin converting enzyme (ACE) inhibitor medicine had received the recommended monitoring in line with national guidance. These are medicines used to treat high blood pressure and heart failure. • Of the 186 patients registered at the practice who were prescribed a direct acting oral anticoagulant (DOAC) medicine, 7 patients had not been monitored in line with guidance. These medicines are used to help prevent blood clots forming in people who are at high risk of developing them. Blood clots can lead to serious conditions such as strokes and heart attacks. We looked at the records for 3 of the 7 patients. We did not identify any concerns other than the monitoring for 1 of the patients should have been completed every 6 months but the patient had been advised to have monitoring yearly. This patient already had an appointment arranged to have the necessary monitoring, and the practice responded immediately to our feedback and updated the patients’ record.