Kingston Health Centre

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.

This service scored 84 (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 strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

The provider had processes for staff to report incidents, near misses and safety events.

There was a GP with lead responsibility for monitoring all significant events. There had been 8 recorded events in the past 12 months. We saw that they were all recorded appropriately, investigated and responded to, with learning shared with the whole staff team. There was high a level of openness and honesty especially when it was identified as an error or omission.

The practice had a positive culture towards safety. We saw examples of incidents that had been investigated and thoroughly reported. The lead GP shared an example of an event relating to a delay in patient referral due to administration processes and co-ordination with another organisation. It was identified that the error occurred due to a change in referral pathways. This led to the practice initiating a joint piece of work with the other organisation involved. This work resulted in changes in the practice as well as the learning being shared and implemented across the local networks. The practice also arranged training for all GPs in the practice to reduce the chances of this happening again.

Managers gave examples demonstrating openness and honesty. One example was a learning event which involved a medicine error. They told us that as a result they completed an audit of all patients on the medicine to ensure the error was not repeated. They also reviewed processes for managing the medicine and provided additional training to GPs.

Staff we received feedback from felt there was an open culture, and that safety was a top priority. One person described the practice as a place where “mistakes are not taken negatively.” Many of the staff referred to the practice as having an open culture where they were confident to provide feedback.

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. Complaints was a topic discussed on the practice podcast as a way of strengthening and reinforcing learning.

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. This included having a new patient summary protocol when new patients registered at the practice. This enabled them to capture information such as whether the patient was a carer, had translation needs or any other needs.

The service worked with other providers to deliver shared care and when patients moved between services.

Referrals were managed well in the practice. Referrals were made within 24 hours, and two-week urgent referrals were sent the same day. Admin staff processed them and the practice manager told us that they audit the process to ensure there is never a backlog. As a GP training practice, all referrals from trainees were discussed and approved by the supervising GP before being sent off.

Test results were managed in a timely way. There was a policy in place to ensure lab results were processed efficiently. Each GP was responsible for reviewing their own patient results each day. There was a buddy system in place for someone to review results on a GP’s non-working day. There was also a “duty” GP who stayed to the end of the day to ensure that daily recording had been completed, and nothing missed. Our review from clinical searches confirmed that laboratory results were processed in a timely way.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They always shared concerns quickly and appropriately.

One of the GP’s was the dedicated Safeguarding Lead for adults and children in the practice and there was also a deputy lead. Their roles were to oversee all matters relating to safeguarding and ensure the safe and appropriate handling of any matters. They worked closely with local organisations in the community such as school nurses, health visitors, disability team, and domestic violence services. Quarterly meetings were held with these partners and regular in-house meetings.

The practice had led on an initiative to employ a primary care network (PCN) Safeguarding lead. They worked with the South West London designated safeguarding nurse to develop a job description and employ this lead person (a social worker) who worked with all GP practices in the PCN. Part of the PCN Safeguarding leads role was to work directly with patients who were on the safeguarding register. Staff said patients often felt distant from professionals in relation to safeguarding. The direct contact with the Safeguarding lead gave them higher levels of engagement and they had noticed an increase in patient cooperation.

The PCN Safeguarding lead also attended the local authority multi agency safeguarding meeting on behalf of the practice. This meant that the practice had a voice at this meeting on a regular basis.

In addition to their child and adult registers the practice maintained registers of vulnerable people and acted on concerns working in partnership with other organisations. These registers included families with child protection plans, adults discussed at the domestic violence multi agency risk assessment conference (MARAC), children in need, female genital mutilation, and child death reviews. This enabled the practice to ensure needs were being met, such as looked after children receiving their annual medical.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. There were separate policies for adult and children. The policies covered descriptions of the different types of abuse. In addition to this there was extensive detail on signs and indicators for female genital mutilation, looked after children and child sexual exploitation. All staff knew and understood the policies content. We reviewed the policies alongside safeguarding cases and saw examples of how staff followed the policy and procedures.

All clinical and some non-clinical staff completed safeguarding adults and children’s training to level 3. All other staff completed training to level 2. They also had recorded sessions relating to safeguarding matters on their “Whalepod” podcast which staff could always access to refresh their training.

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.

All staff completed face to face basic life support training on an annual basis. Emergency equipment was available and maintained. This included two defibrillators throughout the building and oxygen cylinders.

There was an emergency deteriorating patient policy in place which helped reception staff to recognise a deteriorating patient in the reception area and know what action to take. One member of staff gave us an example of when they had requested assistance for a deteriorating patient. They told us that colleagues responded rapidly, and it demonstrated effective implementation of the policy.

A PCN coordinator attended a monthly multidisciplinary meeting to discuss and review patients with escalating needs and those at high risk of hospital admission.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The practice also had information available to patients in the waiting room prompting them to alert a member of staff if their condition worsened.

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

Contracts were in place to ensure the premises were maintained. For example, gas and electrical equipment had annual servicing and medical equipment was calibrated in line with manufacturers recommendations. Portable appliances were tested on an annual basis. We saw evidence to confirm maintenance checks had been completed.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. We saw copies of the most recent fire risk assessment undertaken in August 2025 and legionella risk assessment undertaken in November 2025. We saw that actions identified had been completed, or plans were in place to complete them. A premises and security risk assessment was completed annually; the last one being completed in October 2025. There was a business continuity plan in place which was monitored and reviewed.

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

The practice manager told us they always had enough staff to meet the needs of patients. We reviewed the staffing rota and saw that this was the case.There were always at least two GPs on site working more flexible sessions with no patient facing appointments. This allows for flexibility if a GP is unwell or running over, without impacting on the delivery of patient care.

In addition, they kept robust records and completed regular audits of how many sessions and appointments they offered to patients versus how many they should be offering for their list size. They demonstrated that they had sufficient staffing levels to be able to offer more appointments than what their list size suggested they needed to ensure patients got appointments when needed. Feedback from patients confirmed that appointment availability was not an issue.

Staff were skilled and experienced. They had a range of processes in place to ensure staff employed were suitably experienced and competent. For example, competency for clinical roles were assessed before appointment by a member of staff shadowing them on patient facing duties to assess consultation skills.

The lead GPs told us that as a practice they had highly skilled and qualified staff. For example, doctors in the team were specialists or had special interests in areas such as paediatric, menopause, dermatology and psychosexual counselling. To ensure the team remained highly skilled, when they recognised a gap, they encouraged and arranged additional training. For example, they recognised the gaps in mental health services causing long waiting lists and waiting times when patients were referred. To address this, two doctors completed diplomas in mental health to upskill so they could provide a more enhanced service. This was also done in relation to women’s health with staff becoming British menopause accredited specialists to reduce waiting times for access to secondary services.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Each team had a supervisor who carried out regular monthly supervision sessions with all staff. All staff had annual appraisals including GPs. In addition to annual appraisals, the leaders were assigned to mentor GP’s, with two mentoring sessions a year to discuss any concerns or challenges and development areas. GP’s, we received feedback from described this as “invaluable support”. We saw records to confirm this level of support was in place.

Induction processes were tailored to roles. There was separate induction for clinical and non-clinical staff. Both induction plans outline protocols and procedures for the first day, week and month. We reviewed records and saw completed inductions on all the records we reviewed.

Safe recruitment practices were followed. The practice had robust systems in place to ensure staff employed were employed in line with safer recruitment processes. They had a recruitment policy and separate Disclosure and Barring Services policy, both of which covered safer recruitment. The practice had a large staff team, and we saw that all necessary documents in line with their policy and regulatory requirements were available for all staff.

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 practice had a designated infection, prevention and control lead and all staff had had relevant training. They ensured staff had necessary knowledge and understanding by ensuring all staff completed annual training and discussing infection control issues regularly during team meetings and inductions.

Staff vaccination status was confirmed at recruitment and risk assessments were in place for staff who were unable to confirm childhood vaccination status. All staff were encouraged to have annual vaccinations such as influenza.

They had processes in place for reporting infection-related concerns to relevant agencies. For example, managers discussed the process for reporting the Health Protection Agency. We saw that such incidents were reported appropriately.

Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Our clinical searches confirmed that the practice carried out comprehensive medicine reviews. GPs demonstrated oversight of people’s prescribed medicines that required regular monitoring. Monitoring was appropriate and completed in recommended timescales to ensure it was safe for them to still be prescribed the medicine. For patients discharged from hospital GP’s updated medicines themselves and then scheduled a pharmacist review between 2-4 weeks later to ensure it was managed safely.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. We reviewed training records which confirmed staff had completed appropriate training and were up to date. Staff we spoke with confirmed they were confident when prescribing and administering medicines.

Staff managed prescription stationery appropriately and securely and in line with the practice policy. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. For example, our review of vaccines stored in the fridge showed that they were stored at the appropriate temperatures and staff has robust systems in place to ensure they maintained efficiency. This included daily logs of maximum and minimum fridge temperatures. Staff discussed the procedure in the event the fridges lost power. Their procedures were robust including an ability to monitor this remotely via an app on the phone.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

There was a comprehensive programme of regular clinical audits of prescribing that focused on improving care and treatment.