The Care Quality Commission
  • Doctor
  • GP practice

Kingswood Surgery

Overall: Good read more about inspection ratings

14 Wetherby Road, Harrogate, North Yorkshire, HG2 7SA (01423) 887733

Provided and run by:
Kingswood Surgery

All Inspections

During an assessment under our new approach

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.

14 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingswood Surgery on 14 June 2017. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

Our key findings across all the areas we inspected were as follows:

  • The ethos and culture of the practice was to provide a good quality service and care to patients.

  • Patients told us they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • The practice was able to meet the needs of patients. Information regarding the services provided by the practice and how to make a complaint was readily available for patients.

  • Patients reported they were positive about access to the service. They said they found it generally easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested.

  • The practice complied with the requirements of the duty of candour. (The duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment.)

  • The practice had a culture of openness and honesty which was reflected in their approach to safety.

  • Risks to patients were assessed and well managed.

  • There were comprehensive safeguarding systems in place; particularly around vulnerable children and adults.

  • The practice sought patient views on how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and the Paient Participation Group (PPG).

  • There was a clear leadership structure, staff were aware of their roles and responsibilities and told us the GPs and manager were accessible and supportive

  • The practice was forward thinking, aware of future challenges and were open to innovative practice.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Continue to make improvements in response to the patient survey results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingswood Surgery on 1 December 2015.

Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when there were unintended or unexpected safety incidents, reviews and investigations were not thorough enough.
  • Some of the systems and processes to address and identify risks to patients and staff were not always in place or implemented well enough to ensure patients were kept safe.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of people’s needs. Multi-disciplinary team (MDT) meetings took place and the practice was involved in a number of specific MDT initiatives to improve outcomes for patients.
  • Data from the Quality and Outcomes Framework (QOF) for 2014/2015 was below the local CCG and national averages. (QOF is a system intended to improve the quality of general practice and reward good practice). We saw evidence that new systems had been put in place to address this and patients were now being systematically recalled and reviewed.
  • The practice could not demonstrate how they ensured mandatory and role-specific training was completed for relevant staff.
  • Results from the national GP patient survey in respect of patients being treated with compassion, dignity and respect and being involved in care planning was below the CCG and national averages. However, we received mostly positive feedback from patients and CQC comment cards.
  • The practice reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • The practice offered a wide range of appointments outside of core appointment times.
  • Whilst data and some feedback from patients showed that access to appointments was lengthy the practice demonstrated they kept this under review and were trialling new initiatives to improve patient satisfaction. Urgent appointments were available daily with the duty doctor.
  • Staff told us they felt supported by the GP partners and made particular reference to the excellent level of support and direction provided by the interim practice manager.
  • The practice did not have a business plan in place which was subsequently not monitored or regularly reviewed. The practice had experienced staffing challenges in the last year and demonstrated they were on an improvement trajectory in some areas.
  • The practice had an overarching governance framework but this was not always effective. Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not always effective or timely.

There were also areas of practice where the provider needs to make improvements.

The areas where the provider must make improvement are:

  • All employed persons providing care or treatment to patients must have the qualifications, competence, skills and experience to do so safely. Specifically, this includes ensuring staff training is up to date and the relevant staff are competency assessed and records kept in individual staff files.
  • The practice must always assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be put at risk which arises from the carrying on of the regulated activity.
  • There must be systems for assessing the risk of preventing, detecting and controlling the spread of infections. Specifically, ensure that staff are trained and documented audits are carried out in respect of the management of infection control.
  • The practice must take action to ensure recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. Specifically, this includes completing Disclosure and Barring Service (DBS) checks for those staff that need them.
  • The practice must ensure that systems for good governance are in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and staff are effective.

The areas where the provider should make improvements are:

  • Ensure access to routine appointments is kept under review so that routine appointments can be accessed in a timely way
  • Ensure the practice provides care and treatment in a safe way by ensuring that patients are reviewed in a timely way.
  • Ensure the practice records actions from clinical meetings.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice