Kingswood Surgery

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 58 (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 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.

Examples of this have been reported under the key question of safe in ‘Medicines Optimisation’ and under the key question of effective in ‘Delivering evidence-based care and treatment.

Most feedback from people using the service was positive about their clinical treatment however and people felt involved in the assessment of their needs and were confident that staff understood their individual needs.

The National GP Patient Survey results showed that 95% of patients felt that the healthcare professional they saw had all the information they needed about them during their last GP appointment. This was above the local and national averages of 92%.

97% of patients also stated that they had confidence and trust in the healthcare professional they saw or spoke to during their last GP appointment. This was also above the local and national averages of 93%.

Staff checked people’s health, care, and wellbeing needs during health reviews and could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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.

For example, a CQC GP Specialist Advisor (SPA) completed a series of clinical searches to review the records of patients with long-term conditions and ensure the required monitoring was taking place. Some of these searches indicated that people’s care and treatment was not always reviewed and updated when it should be. Specifically:

We identified 291 patients with hypothyroidism, 7 of whom had not had the required monitoring in the last 18 months. When we looked at the records of 3 of those patients in detail, we saw evidence that there was an issue with the management of their hypothyroidism:

We identified 369 patients with diabetes, 40 of whom had a latest HbA1c score of more than 75mmol/l. When we looked at the records of 5 of these patients in detail, although 3 were managed well, 2 required a review:

We identified 28 patients as having a potential missed diagnosis of diabetes and, when we looked at 5 of their records in more detail, it was identified that the service was not always following national guidance regarding repeating a HbA1c test within 2 to 12 weeks; not always completing tasks when patients were intended for follow-up; and not always coding diabetes or prediabetes on patient records. This could mean that patients could be at risk of diabetic complications (eyesight damage, kidney damage etc.) without being identified for appropriate treatment or monitoring to reduce these risks.

No issues were identified in our clinical search for patients with a potential missed diagnosis of stages 3 to 5 chronic kidney disease (CKD) however and, although 3 patients with asthma were identified as needing to be offered a steroid card (a card which gives patients guidance on minimising the risks when taking steroids and provides details of the prescriber, drug, dosage and duration of treatment), asthma was generally managed well by the service.

During our assessment, feedback was given to the service concerning patients identified from our clinical searches so that those patients’ clinical records could be reviewed and actioned appropriately.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The surgery worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

Leaders and staff were working with their local primary care network (PCN) to meet the needs of the patient population and a team of district nurses worked with the service to provide care, advice, and support to housebound patients.

A first contact physiotherapist also visited 3, half days every week and patients did not need to be referred to them to access their services.

The service did not always support people to manage their health and wellbeing to maximise their independence, choice, and control as we identified issues relating to long term condition and medication reviews.

The service supported national priorities and initiatives to improve population health, including stopping smoking, diabetes and tackling obesity, the NHS Bowel Cancer Screening programme and winter vaccination programme.

It also promoted local initiatives on noticeboards such as the local young people's mental health support service, “Growing Healthy” (a children’s health service for 0 to 19-year-olds) and North Yorkshire Talking Therapies.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives and those with caring responsibilities.

There was a wide range of support and advice information available for patients on the practice website and within the premises.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

As previously summarised under the quality statements ‘medicines optimisation’ and ‘delivering evidence-based care and treatment,’ some of our clinical searches identified issues with regards to monitoring of certain high-risk medications and certain long-term medical conditions.

The service was slightly under the national targets for screening of cervical cancer in 50 to 64-year-old women and for women in the 25 to 49-year-old age group. They attributed this however to there being a local hub which offered cervical screening out of hours and at weekends which better suited the practice population. We saw during our assessment that the service was promoting the national cervical screening programme with leaflets and posters on noticeboards and they have subsequently provided unverified data to show that they were on target for completing smear tests in the 2025/26 financial year .

The service was also slightly below the minimum target for one childhood immunisation (children aged 5 with second dose of measles mumps and rubella vaccine). All other childhood immunisations met the 90% minimum target however and we saw that the service was actively promoting the national immunisation programme during our visit.

Patients with a learning disability were offered an annual health check and local monitoring arrangements for ensuring the checks were offered were in place. Unverified data provided by the service showed that 68 patients were eligible and, as at the beginning of September 2025, all 68 had been invited for a review and 76% of checks had been completed.

NHS health checks were offered to patients opportunistically as part of locally agreed contracts. Unverified data provided by the service showed that in the last 12 months 248 patients had been invited for an NHS health check, and 76 checks had been completed.

The service would follow up on those patients who did not attend their appointments for health checks to ensure they received the necessary care.

The service did not routinely offer health checks for patients over the age of 75.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Most staff had completed training in the Mental Capacity Act and appeared to understand and apply legislation relating to consent.

We found capacity and consent were clearly recorded in patients’ records and ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions were appropriate and made in line with relevant legislation. Appropriate discussions had been held with patients (and/or their carers) about DNACPR decisions, and the mental capacity of patients was considered.

ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment) were also completed appropriately.