Kingswood Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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

This service scored 71 (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 shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Although not all staff who provided feedback stated that they had been involved in the development of the strategy, most stated that there was a clear vision and that they had contributed in some way to it.

All staff stated that they liked working for the service and that there was a positive culture.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

All staff stated that they felt supported by their line manager and that support was available from senior managers, who were approachable and visible.

The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had established Freedom to Speak up arrangements with other practices in the PCN and had an open-door policy if staff wanted to raise concerns.

Although we did not see any Freedom to Speak Up information for staff on noticeboards, staff told us that they were aware of the whistleblowing procedure and knew who to contact and how to raise concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Equality, Diversity and Inclusion training was mandatory, and all staff had completed it.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

As highlighted under ‘Medicines optimisation’, ‘Assessing needs’, ‘Delivering evidence-based care and treatment’ and ‘Monitoring outcomes,’ clinical oversight systems required strengthening and some prescribing and monitoring arrangements were not always aligned with current guidance. Follow-ups were missed for a few patients who required repeat testing.

However, leaders and managers did support staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff annually to complete appraisals and staff could access all required policies and procedures.

Managers held regular meetings with staff, during which they discussed concerns and any issues. In feedback to the CQC, most staff confirmed that they had the opportunity to attend meetings, and most staff felt their views were listened to and acted upon.

Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked with other practices within the Heart of Harrogate Primary Care Network to offer extended access, seasonal influenza, and covid vaccination programmes.

There was a PPG which the service promoted on its website, and while this had not met since October 2024, members confirmed in feedback that the service had previously been good in involving them in change and in encouraging a close relationship.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people.

An example of this was the introduction of a new triage system for appointments in August 2024 which the service believed has had several benefits for patients.

In addition, the service had also reviewed their system for dealing with patients with long term conditions so that patients are now given back-to-back to appointments on the same day with relevant clinicians, reducing the need for multiple trips to the surgery.