Kirkley Mill Surgery

Updated 18 August 2021

• The name of the registered provider is Rosedale Surgery. The provider started providing services at the Kirkley Mill Surgery location at the beginning of November 2020 and have another registered location, Rosedale Surgery.
• The practice has an alternative primary medical services (APMS) contract with the Norfolk and Waveney Clinical Commissioning Group (CCG).
• The practice provides services to approximately 6435 patients registered at the practice.
• The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury.
• Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one of 10). The lower the decile, the more deprived the practice population is relative to others.
• According to the latest available data, the ethnic make-up of the practice area is 96.9% White, 1.1% Asian, 1.4% Mixed, 0.4% Black, and 0.2% Other.
• The provider is a partnership of eight GP partners. At the Kirkley Mill Surgery location there are three GP partners, one salaried GP, one advanced nurse practitioner, one nurse who is training to become an advanced nurse practitioner, two practice nurses, two health care assistants, who undertake phlebotomy, and one clinical pharmacist. There is a pharmacy technician who is employed by the primary care network and there are two advanced nurse practitioners who work across both locations. There is a practice manager who leads the non-clinical team of two secretaries, one workflow/summariser, one information technology lead, four receptionists and one administrator. However, staff do work across both locations according to patient need.
• The practice is part of Lowestoft primary care network. (Primary care networks are groups of practices who work together to improve primary care services).
• The practice’s opening times are from 8am until 6.30pm Monday to Friday. The practice was open until 7pm on a Tuesday for pre-bookable appointments. Appointments were also available on Saturday and Sunday morning at another practice in the primary care network.
• Out-of-hours GP services are provided by IC24, via the NHS111 service.

Updated 18 August 2021

We carried out an announced desk-based review of Kirkley Mill Surgery on 10 August 2021. Overall, the practice is rated as good.

When this service registered with us, it inherited the regulatory history and ratings of its predecessor.

Following our previous inspection of the predecessor, published on 24 September 2019, the practice was rated good overall and for providing safe, caring, responsive and well led services. The population groups of people with long term conditions and working age people were rated requires improvement in the effective domain. Due to our ratings principles, the effective domain was rated requires improvement. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kirkley Mill Surgery on our website at www.cqc.org.uk

This desk-based review was to follow up on the areas for improvement and where the provider ‘should’ take action identified at our previous inspection. We found the required improvements had been made.

The practice is now rated as good for providing effective services and for the population groups people with long term conditions and working age people.

We found that:

• Improvements had been made to outcomes for patients with long term conditions in the most recent published Quality and Outcomes (QOF) data. The practice performance was in line with the Clinical Commissioning Group (CCG) and England averages.
• Work had been undertaken to significantly improve the review of patients diagnosed with cancer and improve cervical screening rates.
• The practice had continued to work to improve prescribing of hypnotic medicines. The practice performance had improved from 1.68 in 2018 to 2019, to 1.33 in 2020 to 2021, compared to the Clinical Commissioning Group average of 0.99 and the England average of 0.66. The practice had an action plan and due to expanding the pharmacy team, quarterly meetings were in place to discuss strategies to further reduce prescribing of these medicines safely.
• The practice continued to make improvements to summarise patient notes in a timely manner. This had improved from 858 notes awaiting summarising in July 2019 to 167 notes in August 2021. These notes were patients who had registered within the previous six to eight weeks. Due to the retirement of a dedicated summarising clerk, the practice had deployed two experienced staff to support with summarising and were in the process of training another two staff to summarise and work at both practice locations. The summarising training was supervised by a GP and a summarising protocol was in place. Alerts were added to the patient’s computer record to inform staff that the notes had not yet been summarised. Notes identified as a priority for summarising were completed first. A risk assessment and action plan for summarising was in place and was monitored.

Whilst we found no breaches of regulations, the provider should:

• Continue to work to improve the uptake of cervical screening.
• Continue to review and reduce prescribing of hypnotic medicines where appropriate.
• Continue to complete the action plan relating to summarising patient notes to ensure this is completed in a timely manner.

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

Updated 18 August 2021

Updated 24 September 2019

Updated 24 September 2019

Updated 18 August 2021

Updated 24 September 2019

Updated 24 September 2019