Kingston Health Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Outstanding.

This service scored 96 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 4

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff gave an example of how they were person centred in relation to laboratory results. They had a standard operating procedure outlining how abnormal results needed to be communicated. They did not send generic template messages. Instead, GPs contacted the patients to explain the results, even if they needed another appointment.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. For example, the service was person centred for transgender patients. One of the GPs had created guidance and processes for staff to support this patient group. Staff told us care plans reflected needs appropriately. In general, our clinical review confirmed patients were involved and their choices documented They recognised the difficulties transgender people experience accessing NHS gender care treatment and mental health services. To improve things, they had set up arrangements with specialists where the practice provided mental health support and medicine (under shared care arrangements) and facilitated tests. We saw examples where they had worked one-to-one with patients to ensure they were involved in treatment choices.

Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. They worked with local partners and were involved in various community initiatives. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes.

One of the GPs had completed additional training on population health to enable them to have a better understanding of the health needs of their patients.

Examples of initiatives undertaken included conducting a pre-diabetes project focussing on social determinants of health and how those impacted engagement. One of the GP’s had completed a programme with the aim of better understanding population health and the importance of delivering care. As a result, they had started work focussing on pre-diabetic patients in particular working on ways to capture those who do not engage. They arranged held with public health and the National Diabetes prevention programme locally and a team of data analyst.

The practice had also completed a piece of work in partnership with public health to identify patients at risk of harm from “cold environments” winter warmth programme. They used a risk stratification tool to identify high risk patients and booked them appointments with their health and wellbeing team. In conjunction with the social prescriber they discussed energy saving devices, tips to stay warm and exercise groups. Practical support was provided by the practice including providing free electric hot water bottles. They conducted this exercise annually. In 2025 they contacted 490 patients at risk to morbidities of heart failure, COPD and heart disease. There was a 17% uptake of this service.

In response to identifying an increased need for more specialist women’s health and advice treatment, the practice had developed a comprehensive and accessible women’s health service.

The service was exceptional at developing appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patients were asked what their communication needs when they registered and this was updated as and when necessary. Flags were added to patients’ individual records and the practice phone system. This enabled reception staff to be aware of someone’s need before they answered the phone. Information was shared appropriately with other services, for example when they made a referral.

The practice had access to interpreter services, including British Sign Language (BSL). Patients also had access to BSL signers via video call or face to face. This could be arranged remotely without pre-booking, on the day. This improved access for patients in need of interpreters.

The practice had a very comprehensive website with information for patients including booking appointments, test results, prescriptions and self-help leaflets. It was available in over 21 languages of people who used the service including Spanish, German, Arabic and Romanian. This ensured that people had access to information they needed.

Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. Text message invitations for screenings and immunisations were also sent in a range of languages ensuring information was clear and understood.

Staff told us that they often tailored information to meet the needs of individual. For example, reception staff often took time to go through information with patients when they needed clarification. Staff provided bespoke, letters and information around immunisations for example to ensure people had up to date information. Staff gave an example of a podcast that was recorded by one of the nurses to educate them on immunisations so that staff could provide better information to patients.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

The practice made it easy to share feedback and responded to patients’ requests. For example, in response to feedback from patients they implemented morning and afternoon appointments for the women’s clinic to make it more accessible. Patients also felt that appointments needed to be available further in advance, so the practice adjusted booking availability from 4 to 6 weeks in advance. They involved people in decisions about their care and told them what had changed as a result. For example, the practice received feedback from patients with dementia around the service they provided. As a result of the feedback, they devised a dementia survey to establish needs. This led to the practice becoming a dementia friendly practice. (A GP practice that adapts its environment, staff training, and procedures to support people with dementia and their caregivers). Changes they implemented included changes to the practice environment, IT system and call routing system.

We saw complaints were managed in line with the practice’s policy. There were 24. The practice manager was responsible for overseeing complaints. Staff told us that if a complaint related to their area, for example the nursing team, it was always discussed with the team to ensure that the response was thorough.

Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints. The practice also had an annual complaint learning event podcast where learning was discussed and shared.

The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

The practice reception was open for patients from 7am to 8pm. Patients could attend and make appointments, get information or advice during these times. Phone lines were open during this time, and calls were monitored consistently in relation to wait times. If the wait times audit highlighted patients were waiting longer at certain periods of times, then staffing capacity was adjusted to reduce the impact and improve access.

Personalised call routing was in place for vulnerable patients, such as those with dementia, or learning disabilities. The practice could upload patients’ numbers to their phone system so when they called, they did not hear the call options, thus avoiding potentially confusing messages. Instead, they were put straight through to reception staff without delay.

In response to the National GP Patient Survey data and from feedback from members of the community the provider had identified changes to improve access to the service. Reception staff had completed additional training to help them identify the needs of vulnerable patients including those with autism and dementia (the practice was an approved dementia friendly practice). Adjustments were made to make it easier for these patients to access the service. This included scheduling appointments at times where there were shorter waiting times. They also had aids such as ear defenders and sensory toys for patients to use.

People could access the service to suit their needs for example online, in person and by telephone. The practice was committed to ensuring people had access to the service even if they arrived late for an appointment. Access was never denied, especially if the reason for being late was outside of their control. The practice was proud of this policy, and GPs described it as being a procedure that “supported patients” regarding access. Patient feedback we received confirmed that they valued this policy and provided equity in access.

Treatment rooms were available on both floors of the service. The premises were fully wheelchair accessible with a ramp and automatic door at the entrance.

For example, the practice was an approved Dementia Friendly practice. They had worked with the Alzheimer’s society to deliver a detailed action plan which included additional staff training. They also reviewed the practice environment with improved signage and changed taps in patients’ toilets to make them easier to use.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this. This included being part of the Safe Surgery Initiative. This meant people (such as homeless, travellers and asylum seekers) could register at the practice with no identification or proof of address, no immigration status checks.

They had a comprehensive system in place to ensure that homeless people had access to the service. They worked closely with local organisations to ensure continuity of care. Homeless people could register without an address. Once registered they offered same day appointments and were always seen on the day they requested to be seen. Recognising the vulnerability of this group the practice implemented a “one stop shop”. This meant that once a patient was in the building they dealt with all their needs including carrying out blood test, vaccinations and any other service they may need access to whilst in the practice. All homeless patients were flagged in the electronic recording system so staff were aware and could offer the one stop service to them. At the time of our inspection, they had 45 homeless patients who they were supporting and tailoring services to their needs. This included some patients who were undergoing treatment from secondary care services which was co-ordinated by the practice (so all referral letter, hospital appointment details were available for them to access via the practice). Staff told us that their work with homeless patients had positive impact on their health. An example was successfully working with homeless patients to manage long-term conditions and obtain improved health outcomes. All these patients had care plans, and their individual health and social needs were documented well.

They worked collaboratively with local organisations and demonstrated that they had considered and identified barriers asylum seekers experience in accessing health care. They worked closely with a local hotel which housed asylum seekers. One issue identified was that asylum seekers often wait to access services when they are at crisis point and often present at accident and emergency (AE) departments. To combat this, they had developed a system in conjunction with partner organisations.The practice was part of a project working on improving the experiences of asylum seekers. Initially they attended a local hotel to register the patients. Those who did not want to register during the visit were offered an appointment at the practice where they could register later. Following this they provided organisations with paper registration forms so there were no barriers to accessing registration via the online form. Patients were also offered an Ayslum Seeker Healthcheck, (some of these were initially carried out at the hotel but after feedback this was moved to the practice).We saw that they had a high rate of take up. The health check covered questions about general health, patient concerns, mental health assessment, pregnancy testing, immunisations and any vulnerabilities. Health inequalities were reduced through this initiative and asylum seekers were able to access care and treatment.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Staff treated people equally and without discrimination.

Leaders proactively sought ways to address any barriers to improving people’s experience. They ensured gaps in service were catered for they the practice. Examples included –recognising delays in patients accessing mental health services, the practice arranged for two GPs to complete mental health diplomas so they could offer additional support and manage more complex mental health patients with psychiatrist support. In response to dermatology clinic wait times they set up an in-house skin clinic training two GPs to complete diplomas in dermatology and minor surgery. Thirteen appointments per week had been added resulting in 700 patients being seen (and not having to wait for the hospital referral).

Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The practice maintained a palliative care register and one of the GPs led on this. The register included details about the patient’s demographic, allocated GP, other services involved, specific needs and whether a DNACPR was in place. All staff were made aware of the register. This was used alongside the palliative care policy. Staff told us that the list enabled them to have more regular reviews of patient’s need and plan more proactively for their future needs. They also completed post death audits which looked as how many patients who passed away were on the palliative care register. The audit identified patients who should have been on the register, which were not. As a result, they put an action plan in place to address this. When they re-audited the following year staff told us they found “significant” improvements which included improved coding and management of the register and educational material on their “Whalepod” which provided staff with clarity.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

Part of end-of-life planning included “ceiling of care discussions (an agreed maximum level of medical treatment a patient will receive) and lasting power of attorney. Our records review confirmed these were in place and used appropriately.

The practice demonstrated that they implemented Gold Standards framework for palliative care which included having advanced care plans in place, discussions with the patient and their family and documenting and acting on their wishes clearly.