Kingswood Surgery

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.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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

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.

Managers encouraged staff to raise concerns when things went wrong.

Staff felt there was an open culture, and that safety was a top priority. The service had processes for staff to report incidents, near misses and safety events.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

As part of the assessment, we looked at the service’s clinical systems to view the number of patient referrals and test results that were outstanding and required action. All referrals and test results were managed in a timely way and there were arrangements in place to distribute tasks when staff were absent or on leave.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

One of the GP Partners was the safeguarding lead and staff told us in feedback that they were confident in identifying safeguarding issues and knew who to report concerns to.

Chaperones were available and all staff who needed chaperone training had completed it. There were posters on noticeboards and in most clinical rooms advising patients that they could request a chaperone should they wish to do so.

All staff had received training in safeguarding adults and children at a level relevant to their role. There was a procedure in place which ensured that reminders for any outstanding training were sent to staff and flagged with the practice manager.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment (such a defibrillator and emergency medicines) was available and maintained.

Sepsis awareness training was mandatory for all clinical staff, and most staff had completed it. The clinical and non-clinical staff we spoke to could recognise a deteriorating patient and knew what action to take.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was situated in a leased building, and contracts were in place to ensure the premises were well maintained.

The service provided us with evidence of a recent health and safety risk assessment which included clear action points to address the risks that had been identified and clear timescales for completion. They also provided a health and safety audit completed in September 2025 which included a full environmental audit.

There was a business continuity plan in place which was monitored and reviewed on an annual basis.

Regular fire safety checks were conducted and most staff had completed mandatory training in fire safety.

On the day of our visit, we saw one first floor window where the window lock was not secured which posed a health and safety risk. Immediate action was taken by the service to mitigate this risk.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. Training was mostly up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Arrangements were in place to ensure staff who returned to work after a period of absence completed mandatory training.

Safe recruitment practices were being followed which included appropriate levels of Disclosure and Barred List checks made pre-employment.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The Lead Nurse was the designated infection, prevention and control (IPC) lead and most staff had received relevant IPC training.

There was an IPC action plan in place, and several risk assessments and audits had been completed, with actions taken to mitigate any identified risks. These audits included hand hygiene audits, care environment audits and an audit of personal protective equipment.

A contractor provided cleaning services, and we saw that cleaning schedules were in place and followed.

During our visit, we observed the surgery to be clean and tidy throughout.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor (SpA). This included a review of the management of patients on a sample of medicines that require monitoring as well as a review of prescribing including the effectiveness and quality of medication reviews and usage.

Our clinical searches showed that, in some cases, patients’ health was monitored in a way that ensured the safe prescribing of certain medicines. For example, we found no issues with the monitoring of patients who had been diagnosed with atrial fibrillation and were not prescribed an anticoagulant. We also found that, in the last 3 months 146 patients aged over 75 and 445 patients of any age had received a medication review.

However, some areas for improvement were identified and shared with the service to follow up on. Specifically:

Our clinical searches identified 20 patients prescribed methotrexate, a disease-modifying antirheumatic drug (DMARD) for the treatment of pain and stiffness in joints caused by inflammation, who require monitoring every 12 weeks. Of these, 5 patients were looked at in more detail and 3 who were on shared care agreements were found to have issues with monitoring (their methotrexate had been stopped by the hospital but their patient records had not been updated appropriately). 4 of the 5 patients did not have the day of the week that methotrexate was to be recorded on their records, as required by an MHRA alert issued in September 2020:

Our clinical searches identified 233 patients prescribed direct oral anticoagulant medication (DOACs) used to prevent and treat blood clots, 223 of whom were frail and require 4 monthly monitoring rather than 6 or 12 monthly. Of the 223 frail patients, 28 did not appear to have had the required monitoring and 1 was looked at in more detail. That patient had not had the required monitoring in the last 4 months:

Our clinical searches revealed that in 2 cases, patients were being prescribed metformin (a medication used to treat type 2 diabetes and gestational diabetes and help prevent type 2 diabetes if you are at risk of developing it) when it could potentially be stopped. These patients were subsequently reviewed by the surgery and one patient was advised to stop taking the medication :

Our clinical searches identified 1 patient prescribed a medication used to treat depression that may cause ventricular arrythmia as a potentially fatal side effect and their record was looked at in more detail. Although the patient had received a medication review in July 2025 and had been informed of the risks associated with taking the drug, an ECG had not been arranged.

On a positive note, staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls. There were systems and processes in place to review these.

Systems and processes were also in place to manage blank prescription stationery and, while some blank prescription stationery was found in a room which was accessible by the public during our visit, the service gave a reasonable explanation as to why and had measures in place to ensure its security.

Clinical audits of prescribing had been completed that focused on improving care and treatment. This included audits of patients taking high doses of oestrogen as part of hormone replacement therapy and an audit of male patients with folic acid on repeat prescription. Folate supplementation can be associated with an increased risk of prostate cancer.

Patient Group Directions (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place and up to date. Similarly, we found no issues with the management of Patient Specific Directions (PSDs). PSDs are an instruction to supply and/or administer a medicine to a specific patient.