Kiveton Park Medical Practice

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

Kiveton Park Medical Practice 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.

In feedback to CQC, the staff who responded confirmed that they knew how to report a significant event. Most stated that they were invited to discuss significant events and that learning was shared with them. Representatives from the Patient Participation Group (PPG) also told us they felt able to raise concerns and suggestions with practice leaders and that their views were generally listened to.

Managers encouraged staff to raise concerns when things went wrong, and the team discussed and learnt from clinical issues during staff meetings. Staff reported an open culture and described safety as a top priority.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and learning from incidents and complaints resulted in changes that improved care for other people.

Kiveton Park Medical Practice 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.

We saw that referrals to secondary care and test results were managed in a timely way and that there were arrangements to distribute internal tasks when staff were absent or on leave.

We also saw that there were systems and processes in place to deal with Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

Kiveton Park Medical Practice 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.

Safeguarding policies were in place and were known to staff who had received training in safeguarding children and adults at a level relevant to their role. One of the GPs was the safeguarding lead for the practice and there was a deputy in place for continuity. Safeguarding was a standard agenda item for all clinical meetings.

Chaperones were available at the practice and both clinical and non-clinical staff had received training in this area. The practice website contained clear information on the chaperone policy and there were notices in consultation rooms advising patients that they could request a chaperone should they wish to do so.

In feedback to CQC, all staff stated that they knew who to report safeguarding concerns to and most staff stated that they were confident in identifying safeguarding issues.

However, during our assessment we identified that the practice did not ensure that relevant safeguarding codes, alerts, or high-priority reminders were recorded on the record of all individuals linked to children at risk and this meant associated risks were not always clearly visible to staff.This was immediately addressed by the practice when it was highlighted to them with appropriate coding now added to the relevant patient records.

Kiveton Park Medical Practice 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 was available at each site and was routinely checked and maintained. It was stored in central locations and, in feedback to CQC, staff told us that they could easily access it.

All staff had completed sepsis training so that they could recognise a deteriorating patient, plus training in basic life support.

Patients were advised on risks related to their condition and what action to take if their health deteriorated.

Kiveton Park Medical Practice detected and controlled potential risks in the care environment. It made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure both sites were well maintained, and a health and safety risk assessment, environmental risk assessment, legionella risk assessment, and fire risk assessment had all been undertaken within the previous 12 months to identify potential risks to staff or the public.

Portable appliance testing and calibration of equipment were up to date, and regular fire safety checks were conducted at each site. All staff had completed fire awareness safety training. Staff stored medical gases, such as oxygen and liquid nitrogen, safely and completed required safety risk assessments.

There was a business continuity plan in place which was regularly monitored and reviewed. This included contingency plans for disruptive events such as significant staff shortages, loss of utilities, loss of telephony services, fire, or flooding.

In feedback to CQC, all staff who responded told us that they were happy with the health and safety arrangements at both sites.

However, during our visit it was noted that, although hazardous substances were stored securely, there was no appropriate signage on the cleaning cupboard at the branch site. The practice manager took immediate steps to address this once it was brought to their attention.

Kiveton Park Medical Practice 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.

The service employed a range of clinical and non-clinical staff, including the 5 GP partners, 5 salaried GPs, nurses, dispensary staff, care navigators and a management team. Additional staff worked at the practice through the NHS Additional Roles Reimbursement Scheme (ARRS) including pharmacists, a mental health worker, social prescribers, and a first contact physiotherapist.

The practice was a training practice for qualified doctors intending to become General Practitioners and also participated in a similar scheme enabling hospital doctors (who may or may not go on to become General Practitioners) to gain experience in family medicine. Medical students also undertook placements at the practice under the supervision of 2 GPs.

In feedback to the CQC, most staff confirmed that, when all staff were at work, there were enough people to provide safe, quality care and that, adequate staff cover was maintained during periods of absence such as sickness and annual leave.

Staff received annual appraisals and GP registrars were appropriately supervised, with dedicated debrief slots at the end of each clinic to discuss cases and receive feedback.

Leaders ensured staff worked within their agreed areas of competence and that they were up to date with their mandatory training.

The practice followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, verification of qualifications, obtaining professional references and undertaking an appropriate level of criminal records check.

Kiveton Park Medical Practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies where required.

The service had cleaning schedules in place which outlined how staff should clean the premises and equipment. Staff demonstrated how these were monitored for completion, providing oversight of cleaning arrangements.

The service’s Infection Prevention and Control (IPC) lead carried out regular risk assessments and audits to ensure compliance and took action to mitigate any identified risks.

IPC training was mandatory for all staff, and records showed that all staff had completed it.

In feedback to CQC, staff told us that they knew who the IPC lead was and that they felt IPC arrangements were sufficient to protect both staff and patients.

During our onsite visit, the premises and a sample of equipment were assessed and were found to be visibly clean.

Kiveton Park Medical Practice did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They did not always involve people in planning.

Prescriptions awaiting collection were organised alphabetically and regularly reviewed to identify any that had remained uncollected for an extended period. Patients were followed up where prescriptions had not been collected. Additional labels were attached to prescriptions where fridge or controlled drug items also needed to be supplied, reducing the risk of these being omitted at the point of collection. All prescriptions sampled had been appropriately signed by a doctor and were dispensed within a timely manner.

Controlled drugs, which were subject to additional storage and record-keeping requirements due to their potential for misuse, were stored securely in a locked cupboard and at appropriate temperatures. Stock levels checked on the day of the inspection were correct and reconciled with the controlled drug register. Entries in the register had been completed with 2 staff member signatures.

Appropriate arrangements were in place for the secure storage and management of prescription stationery. Prescription pads were kept behind locked doors and in locked cabinets and were only used within the dispensary. No prescription pads were left unattended in consultation rooms. A logging system recorded when each new box was opened for use, supporting the accountability and security of prescription stationery.

There were suitable processes for staff to follow when dispensing medicines and a barcode scanning system supported safe dispensing by verifying that the correct medicine and formulation had been selected. If an incorrect item was scanned, the system would not generate a dispensing label, providing an additional safeguard against dispensing errors.

The service had appropriate processes in place for reporting and reviewing incidents and near misses. Regular governance meetings were held within the department to discuss events and share learning, supporting improvements in practice. Medicines safety recalls and alerts were disseminated to relevant staff and managed through an electronic system, which provided a record that alerts had been received and acknowledged.

Daily temperature monitoring was completed in all areas where medicines were stored. Medicine fridges were also equipped with continuous temperature data loggers, providing a record of storage conditions outside normal opening hours. This allowed staff to retrospectively review temperatures and identify any excursions that may have occurred when the surgeries were closed, including over weekends.

At one site, our inspection of the emergency grab bag identified expired medicines that had not been detected through the monthly checking process. There were also discrepancies between expiry dates recorded on the monitoring spreadsheet and those of the medicines held in the bag. This demonstrated that the existing checking process was not sufficiently robust and presented a risk that appropriate medicines may not have been available when required in an emergency. Immediate action was taken during the assessment to rectify the discrepancies identified.

As part of our assessment, a CQC GP specialist advisor undertook a series of patient clinical record searches. 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 medicine reviews and usage.

Our clinical searches showed that, in most cases, patients’ health was monitored in a way that ensured the safe prescribing of certain medicines however, some areas for improvement were identified. For example:

Our clinical searches identified 58 patients who were prescribed methotrexate, (a disease-modifying antirheumatic drug used to treat pain and stiffness in joints caused by inflammation) and when 5 of these were looked at in more detail, 3 were identified where the dose of medicine prescribed did not include the day of the week to be taken:

Our clinical searches identified 8 patients prescribed amiodarone (medication used to treat and prevent serious heart rhythm disorders) and when 5 of these were looked at in more detail, 3 patients were identified where there was no record of magnesium monitoring being completed as per national guidance as the practice were following a local protocol which did not reflect latest guidance:

Our clinical searches identified 22 patients with a potential missed diagnosis of diabetes and when 5 of these were looked at in more detail, 3 were identified who had not been coded as diabetic and therefore had not been treated or monitored appropriately:

Our clinical searches identified that for some patients prescribed gabapentinoids, benzodiazepines and Z-drugs (medication used to treat conditions such as neuropathic pain, anxiety, and insomnia), although reviews were generally taking place, what was covered and documented at those reviews was not consistent. We also identified that for one benzodiazepine patient, medication reviews during 2025 were not face to face, which was a missed opportunity to review treatment, and that for gabapentinoids, dependence risk and, for patients of childbearing age, the risk of birth defects were not consistently documented.

When these findings were shared with the practice, they were investigated and steps taken to resolve any issues identified.