Kingston Health Centre

On this page

• 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 Outstanding.

This service scored 88 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider had effective systems to identify people with previously undiagnosed conditions. The practice proactively used population health management tools to assess needs and improve outcomes for patients. One of the GP’s had completed a population health management programme with the aim of understanding population health better. For example, they focused on pre-diabetes patients, particularly those who were not engaging with education and lifestyle changes. They organised a meeting with a range of partners including public health, the National Diabetes prevention programme and a team of data analysts. Patients who were not engaging with pre-diabetes monitoring, were selected, focussing on patients who had factors suggesting barriers to accessing healthcare. Data available identified 89 pre-diabetic patients with co-morbidities. Patients were contacted and introduced to the project. Over half the patients identified accepted the further referral to the diabetes prevention programme. The practice analysed lessons learnt which included understanding patients are individuals with differing challenges and priorities. Staff told us this highlighted how essential being patient focussed was.

Feedback from people using the service about how their needs were assessed was positive. People felt involved in assessments of their needs, with 92% of patients saying they were involved as much as they want to be in decisions about their care and treatment during their last GP appointment (which was in line with local and national results). Patient feedback we reviewed confirmed that patients felt confident that staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. Staff we spoke with understood needs of people and how to triage them according to their needs. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Reception staff we spoke with gave examples of patients they were familiar with and ways they assisted such as giving them a quiet place to wait (if a patient needed this due to neurodiversity) or providing leaflets and information to signpost to other services. Feedback from patients we reviewed confirmed this. The results of the GP patient survey 2025 showed that, 93% of patients said they found the reception and administrative team helpful. This was higher than the national and local averages of 83% and 85% respectively.

Staff checked people’s health, care, and wellbeing needs during health annual reviews. Annual health checks were offered to a range of patients including patients with long-term conditions. Our clinical review of records found that people with long term conditions such as asthma, diabetes and hyperthyroidism were managed well. Staff contacted patients when reviews were due. If reviews were outstanding the pharmacist team invited the patient for an appointment.

There were four GP’s who led on diabetes and patient reviews. We saw that all patients had timely reviews with HBA1C bloods (a blood test that measures the average level of blood sugar/glucose over a period of time) being taken and the relevant blood pressure and foot examination conducted in line with national guidelines. The clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The practice had processes to ensure meaningful care planning. This included recognising where a person’s mental health or mobility could impact on their care. To mitigate this, they had capacity to include blood tests or other health checks tests during the same visit so that patients could have all needs assessed as the same time.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. For example, the practice had shared learning via a podcast relating to developments relating to asthma management. They had also produced educational videos and conducted a face-to-face meeting to share the team learning.

We saw evidence that staff attended courses regularly and were signed up to channels where they received updates, for example from NHS England and monthly vaccine updates. Some staff were attending university accredited courses for conditions such as asthma and menopause. They told us they were “informative and interesting” and helped them ensure they were up to date with legislation and required clinical standards.

Clinical records we saw demonstrated care was provided in line with current guidance. Staff used templates for long term conditions to ensure consistency and appropriate monitoring. For example, for asthma reviews they send personalised action plans which documented details such as asthma control test score and number of exacerbations. Staff told us they were working through asthma reviews ensuring they discussed the most recent guideline changes in relation to inhalers.

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. For example, the nursing team told us they worked with an adult immunisation representative in relation to the changes that were made to the shingles eligibility criteria. The representative met with the team and provided information and resources around shingles. This information enabled the practice to identify patients within the new clinical risk and invite them for the shingles vaccination. This piece of work increased the update and ensured the right people were invited for the vaccination.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, staff told us about patients who they referred to colleagues in the tissue viability service when they were unable to continue with treatment of certain wound care.

The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported national priorities and initiatives to improve population health. For example, the health care assistants hosted a weekly 1hour walking group with around 10 patients attending each week. This initiative had significantly contributed to patients. A patient feedback survey they completed with attendees from the group highlighted that patients reported the group directly reduced their social isolation and positively improved mental health.

The practice was also a GP “Parkrun” practice (a GP practice that partners with its local parkrun event to actively promote walking, running and volunteering) organising events for patients and staff to support them to live healthier lifestyles. This initiative had increased the general health of both staff and patients.

The practice had a health and wellbeing service to help promote healthier lifestyles. This service included new patient checks; lipid clinic to advise on reducing cholesterol and prevent heart disease and stroke; liver clinic to combat conditions such as fatty liver disease; and a gout clinic.

There were health and well-being coaches who advised on weight loss, healthy eating and ran a variety of specialist clinics including programmes to reduce the risk of cardio-vascular disease. In addition, they also had smoking cessation appointments with a trained clinician. A GP led on supervising the coaches and also monitored the impact. The practice found that patients who had seen the coach were more likely to participate in the national diabetes prevention programme. They had seen an increase of around 60%of patients accepting referral to a programme following the involvement of the health and wellbeing coaches. They were also doing a piece of work on patients who are not taking statins but at high QRISK (a score that calculates the risk of developing cardiovascular disease). The coaches document engagement through reminder message and a phone call. Staff told us this had significant impact on patients because as a result of this work, 40% of people, who previously declined a statin agreed to try one after appointments with the health and wellbeing team.

Staff worked with partners such as social prescribers and referred patients to them appropriately. We were given examples of instances where patients have social and economic factors impacting their access to health and the social prescriber worked with them to reduce the impact.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

They had plans in place to monitor and improve outcomes in immunisation and cervical cancer screening. This included having children immunisation and cervical screening uptake plans. Both plans were comprehensive and outlined their performance, monitoring data, recalls process, action to increase uptake, staff training and challenges.

The practice was meeting or exceeding local and national targets for immunisations. The practice told us their child immunisation uptake plan supported this. The plan included a robust recall system; details of action to take when patients decline vaccinations; and increased access to their nursing team with appointments available early mornings and evenings with next day availability when needed. They monitored local trends to compare their outcomes with other practices to establish if they were an outlier. Challenges and steps taken to address them were clearly outlined in the plan. The nursing team had recorded a podcast on their “Whalepod” outlining the challenges of increasing the uptake and how they planned to improve things. The vaccine champion had also completed a training session for the in-house podcast on how to help educate parents on vaccine hesitancy.

The practice was performing in line with local and national averages for cervical screening. All cervical screening appointments were documented following templates. Nurses were responsible for monitoring cervical screening for inadequate results. In addition, all samples taken within the practice were documented on a spreadsheet to ensure results were received.

The service monitored care and treatment of various conditions to continuously improve. For example, to improve outcomes for patients with diabetes they had a comprehensive “Diabetic Improvement Plan”. This included carrying out rolling reviews to ensure pre-diabetes patients were coded appropriately and referred for an education programme and recalled. They also had an automated 6 monthly recall. Patients received three invitations with direct booking links. Non-attenders were actively followed up. The four GPs who led on diabetes had individual lists and had completed enhanced training in diabetes. They each had one session a week to review their diabetic patient list and proactively focus on contacting these patients. Staff said this had made significant improvements in management of patients. They had seen an increase in patients meeting Hba1c targets for example patients with Hba1c below 58 had increased from 60% in 2024 to 79% in 2025. And 93% had attended for their foot examination compared to 73% the previous year. As a result of their successful outcomes, they were invited to share how they had improved chronic disease care at a healthcare event. Other local practice had also requested to visit to learn more about their processes.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. For example, this was documented in care plans for patients with autism and learning disabilities.

Staff understood and applied legislation relating to consent. We reviewed staff training and saw that all staff had completed training in consent and mental capacity.

Capacity and consent were clearly recorded. For example, the practice provided regular face to face and virtual “ward rounds” to a local care home. Consent and capacity were documented in patient records appropriately. We saw evidence that staff and family members were included in decisions about care.

Do not attempt cardiopulmonary resuscitation (DNACPR) and palliative care decisions were appropriate and were made in line with relevant legislation.