Kingsmead Healthcare

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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported in raising concerns and described staff as compassionate and understanding. Managers promoted openness, and staff felt confident speaking up when things went wrong. Clinical issues were discussed during team meetings, encouraging shared learning and continuous improvement.

Safety was consistently treated as a top priority, supported by clear processes for reporting incidents, near misses, and safety events which included a significant event log and protocol. Complaints were systematically recorded and investigated, and when things went wrong, staff offered apologies and support.

The service worked collaboratively with people and healthcare partners to establish and maintain safe systems of care, where safety was actively managed and monitored. Systems were in place to process information for new patients, and the service worked effectively with other providers to support shared care and smooth transitions between services. Referrals and test results were handled in a timely manner.

Leaders and staff reported that a designated team was responsible for managing referrals through the NHS e-Referral Service. Staff monitored the system to ensure referrals to specialist services were accurately documented, included the correct information, and were processed without delay. Safety netting procedures were in place to ensure all patients were appropriately followed up. Routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated.

Leaders also explained that they maintained oversight of workflow tasks to ensure timely responses. A system was in place to summarise patient records effectively.

The service showed a strong commitment to safeguarding, taking prompt action to protect individuals from abuse and neglect through effective collaboration with partners. Monthly internal meetings were held to discuss safeguarding issues, and children who missed appointments were actively monitored. Non-clinical staff understood how to report concerns appropriately.Robust systems and processes were in place to keep people safe, with a clear focus on improving lives while upholding the right to live free from harm, discrimination, and abuse. Safeguarding concerns were consistently shared in a timely and appropriate manner, and patient records confirmed that vulnerable individuals were flagged for staff attention.Staff were well-trained in safeguarding procedures, and policies were clearly understood and effectively implemented.

Staff worked with individuals to understand and manage risks holistically. They delivered care that was safe, supportive, and tailored to meet people’s needs.

Emergency equipment was available and properly maintained. Staff were able to recognise when a patient’s condition was deteriorating and understood the appropriate actions to take. Patients were advised about risks related to their condition and were given guidance on what to do if their condition worsened.The service had a comprehensive suite of policies which addressed various risks, including fire, flooding, loss of computer or telephone systems, and staff shortages.

During our on-site assessment, we observed that the premises were clean, well-maintained, and conducive to safe care. The service had effective systems in place to monitor and comply with mandatory risk assessments, including fire safety and legionella testing, helping to ensure the safety of both patients and staff. Records confirmed that medical equipment was regularly maintained, calibrated, and tested.

A business continuity plan was in place and subject to regular review to ensure preparedness for potential disruptions.

Patients confirmed the service was always maintained well; however, it was mentioned that the seating areas could be expanded to accommodate more patients.

The national GP Patient Survey, carried out from December 2024 to April 2025, received 88 responses. It found that 92% of patients had confidence and trust in the healthcare professional they saw or spoke to during their last appointment, compared to 92% locally and 93% nationally.The service had ensured that there were sufficient qualified and experienced staff who received effective support and supervision. Staff had worked well together to deliver safe care that met people’s individual needs, and the team had reported feeling supported by the leadership team, with their views being listened to. Staff were equipped with the necessary knowledge and skills to deliver safe, effective, and person-centred care, and the provider maintained oversight to ensure training remained up to date and relevant.

The service assessed and managed the risk of infection effectively. Risks were identified, controlled, and processes were in place to share concerns promptly with relevant agencies. Cleaning schedules were in place and followed.

Risk assessments and audits were completed, with actions taken to mitigate identified risks. People we spoke with told us they found the premises clean and tidy and had no concerns relating to infection prevention and control.

Leaders described the service's processes to ensure appropriate clinical oversight and told us how they monitored patients' health, including their use of high-risk medicines (such as warfarin, methotrexate, and lithium). We found that staff had good knowledge of current and relevant best practice and professional guidance.

There was an effective system to evidence the competence of non-medical prescribers, including clinical supervision. The service had appropriate policies and procedures to govern prescribing effectively. The provider held regular GP clinical meetings to discuss patient cases, share knowledge about new medical information, review clinical practices, identify areas for improvement, and ultimately enhance the quality and safety of patient care within the service.

Staff received training in medicines management and reported feeling confident in handling the storage, administration, and documentation of medicines. They held the necessary authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Medicines-related stationery was managed securely, and staff followed established protocols to ensure safe prescribing practices.

The service ensured that medicines and treatments were safe, person-centred, and aligned with individuals’ needs, capacities, and preferences. People were actively involved in planning their care, including when changes to their medicines occurred. Staff supported patients in understanding and managing their medicines safely and knew who to contact if their condition worsened or unexpected symptoms arose.

Staff were regularly trained and assessed for competency in medicines optimisation. Prescription stationery was stored securely, and medicines were kept at appropriate temperatures. Stock levels and expiry dates were routinely checked.

For the year ending March 2025, the service’s cancer detection rate was 24%, which was significantly lower than the local average of 54%. We discussed this with the provider, who told us that performance had improved in the following year. Leaders explained that clinicians maintained a low threshold for referral and automatically referred patients presenting with certain symptoms of concern, such as breast lumps. They also used non-urgent referral pathways where appropriate, which enabled patients to be seen within two weeks.

The provider had robust systems in place to manage safety alerts and medicine recalls. Staff took proactive steps to ensure prescribing was appropriate and aimed at optimising care outcomes, including the responsible use of antibiotics. Prescribing data reviewed during the assessment supported this, showing that the provider issued fewer antibiotics compared to local and national averages.

A programme of regular clinical audits focused on prescribing practices, aiming to continuously improve care and treatment. For example, the provider had undertaken a comprehensive audit of antibiotic prescribing patterns across three periods during 2025 and assessed compliance with prescribing guidance, the use of broad-spectrum antibiotics, and overall prescribing trends. Audit findings showed sustained improvements in prescribing practices, including a reduction in the number of antibiotic courses exceeding the recommended five-day duration, particularly for Amoxicillin, and gradual improvements in compliance for Penicillin V. The provider had also maintained good control of broad-spectrum antibiotic prescribing and used audit data to identify areas requiring further improvement, such as Flucloxacillin and Cefalexin prescribing.

Leaders told us that findings were regularly reviewed through clinical meetings to support reflective practice, shared learning and accountability. The provider had implemented a range of measures to support improvement, including electronic prescribing prompts, standardised prescribing templates, ongoing clinician education, routine audit cycles and multidisciplinary discussions of prescribing data. Staff also promoted patient understanding of antibiotic use through clear communication, self-care advice and safety-netting information.

As part of the assessment, a series of clinical record searches were carried out by a CQC GP Specialist Advisor, with the provider’s consent. These searches aimed to assess whether the service was delivering care and treatment in line with current legislation, standards and evidence-based guidance.

We reviewed patients who had received a medication review within the previous 12 months. The search identified 745 patients, and we examined five records. All five patients had received a medication review; however, two were unstructured.

A further search identified 21 patients on the asthma register who had been prescribed two or more courses of rescue steroids, from a total register of 364 patients. We reviewed five records and found that four patients had not received a follow-up review after their rescue steroid course.

Another search reviewed patients who had received a medication review within the previous three months. The search identified 745 patients, and we examined five records. One patient had received a structured medication review and four had received unstructured reviews. No prescribing concerns were identified.

We reviewed patients identified as having a potential misdiagnosis of diabetes. The search identified 13 patients, and we examined five records. Four patients had diabetes but were incorrectly coded. All patients had been informed of their diagnosis. Four patients had received annual reviews, and one patient had been contacted but had not responded.

We also reviewed patients prescribed citalopram 40mg or escitalopram 20mg, in line with MHRA guidance regarding dose reduction in patients aged over 65 years. Three patients were identified. Two records did not contain documented evidence that the risks associated with higher-dose citalopram had been discussed. One record demonstrated that the risks and benefits had been discussed and understood.

A further medicines optimisation search identified 20 patients prescribed an ACE inhibitor or angiotensin II receptor blocker who had not received the required monitoring. We reviewed five records. Four patients had received reminders to attend for monitoring. One patient had not received a reminder and no blood test form had been generated.

We reviewed the practice's prescribing of short-acting beta-agonist (SABA) inhalers using a search which identified seven patients with potentially high SABA use. We examined five records and found that all five patients had overdue medication reviews. Two of these patients had received reminders to attend for review.

Additionally, we identified a coding and documentation issue affecting the recording of asthma management activity. In one case, asthma monitoring had been undertaken, including an Asthma Control Test score, peak flow measurement, inhaler technique assessment, self-management advice and confirmation of no recent exacerbations. However, these activities had been recorded within a flu vaccination consultation and were not coded as an asthma review. Consequently, the system continued to indicate that no asthma review had been completed and that the medication review was overdue.

The lack of appropriate coding limited the practice's ability to demonstrate that patients with high SABA use had received asthma reviews and optimisation of therapy. While relevant clinical activity had taken place, it had not been recorded in a way that supported effective monitoring, recall systems or prescribing oversight. This represented a clinical governance, coding and documentation weakness rather than evidence of unsafe care.

Overall, the issues identified related primarily to documentation, coding accuracy, monitoring processes and the recording of appropriate review types. While we identified some gaps in follow-up and monitoring, there was limited evidence of direct risks to patient safety. The concerns identified were principally associated with governance, record-keeping and assurance processes. Following the assessment the provider confirmed that all patients were followed up as required and that appropriate action was taken.