Updated 19 June 2025
Date of Assessment: 23 September to 25 September 2025.
Kingswood Surgery is a GP practice that delivers services to 6815 patients under a contract held with NHS England. The list size has remained relatively static since 2016.
The surgery is situated in a 3-storey building which it shares with other services. It has consulting rooms on the entry level and a lift is used to access first-floor nurse consulting rooms. There is a car park for patients immediately behind the surgery and disabled bays to the front. The surgery has good wheelchair access and a hearing loop.
The surgery is registered with CQC to provide: diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder, or injury.
It was previously assessed in August 2017 and was rated ‘Good’ overall.
The National General Practice Profiles states that the ethnic make-up of the patients is 94.3% white, 2.4% Asian, and 3.3% Black, Mixed Race or other. The age distribution of the patient population is above the national average for older people (22.2% v 17.7%) and below the national average for young people (18.2% v 19.5%).
Information published by Office for Health Improvement and Disparities shows that deprivation within the patient population group is in the ninth decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others.
This assessment considered the demographics of the people using the service, the context it was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences, however.
The service did not always plan and deliver evidence-based care and treatment to patients. They did not always follow legislation and current evidence-based good service and standards. The service did not always make sure people’s care and treatment was effective because they did not always check and discuss people’s health needs with them. However, the service made appropriate considerations about whether patients had capacity to make decisions, and they involved relevant people to help make decisions in the best interests of a patient where necessary. The service worked well across teams and services to support people and ensure key information about patients was available to professionals who needed to review it.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. The service did not always have clear responsibilities, roles, systems of accountability or good governance however and did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
We found breaches of regulation in relation to safe care and treatment. This is on the basis that the service; did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences; did not always plan and deliver evidence-based care and treatment to patients; did not always follow legislation and current evidence-based good service and standards; did not always make sure people’s care and treatment was effective because they did not always check and discuss people’s health needs with them; and did not always routinely monitor people’s care and treatment to continuously improve it.
We have asked the provider for an action plan in response to the concerns found at this assessment.