Kiveton Park Medical Practice

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.

Kiveton Park Medical Practice had a shared vision, strategy, and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion, and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

In feedback to the CQC, staff confirmed that they felt supported by their line manager and senior management and that managers were visible. They also stated that they had enough guidance, policies, and procedures to do their job well, that they liked working at the practice and that there was a positive culture and good working atmosphere.

Leaders demonstrated an understanding of the challenges facing the practice and its growing patient population, including increasing patient demand, and took a proactive approach to planning for the future. The practice secured NHS funding and worked in partnership with external stakeholders to redesign and refurbish clinical space, increasing clinical capacity and improving the environment for GP training. This reflected a shared commitment to ensuring the service remained sustainable and responsive to the needs of both patients and staff.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

Although some staff who provided feedback to CQC stated that they had not been involved in the development of the practice’s mission statement, vision, values, or strategy, most stated that the practice had a clear vision for the future.

Kiveton Park Medical Practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support.

Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty. They embodied the culture and values of their workforce and organisation.

Staff told us that leaders in the practice were approachable and that they felt their views were listened to.

Leaders worked collaboratively with other practices within the primary care network and played an active role in the development of primary care services across the local area. This demonstrated capable leadership and a commitment to partnership working to improve population health.

Kiveton Park Medical Practice 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 another practice in the primary care network.

In feedback to the CQC, staff confirmed that they knew how to raise concerns, and that they felt that, if they were to speak up, it would be welcomed.

Kiveton Park Medical Practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The practice had appropriate policies and procedures in place to promote equality and diversity. Equality, Diversity, and Inclusion training was mandatory and had been completed by all staff.

The practice proactively implemented reasonable adjustments to support staff to work safely and effectively, with examples including providing equipment following surgery, adapting roles and responsibilities where required, and offering flexible working arrangements to accommodate caring responsibilities. This reflected a flexible and inclusive approach to supporting staff wellbeing and enabling staff to fulfil their roles effectively.

Governance systems were not always effective in providing sufficient oversight of clinical risks. As identified under the quality statements ‘Involving people to manage risks,’ ‘Medicines optimisation’ and ‘Monitoring and improving outcomes,’ arrangements for monitoring prescribing and patient safety required strengthening.

The provider had not consistently ensured that prescribing and monitoring processes reflected current guidance, that people were fully informed of the risks associated with prescribed medicines, or that repeat testing and follow-up monitoring were undertaken within appropriate timescales. In addition, systems for the oversight of emergency medicines were not sufficiently robust. These issues demonstrated that governance arrangements had not always identified, monitored, and mitigated risks effectively.

On a positive note, however, leaders and managers had established arrangements to support the day-to-day delivery of services. Staff were clear about their roles and responsibilities and had access to the policies and procedures required to undertake their work. Managers carried out regular appraisals and performance reviews and met with staff routinely to discuss performance, clinical issues, and emerging risks. Actions arising from meetings were documented and shared appropriately. Staff told us they had opportunities to contribute to discussions about the service, and most felt their views were listened to and acted upon. Staff also demonstrated an understanding of their responsibilities in relation to patient confidentiality and information governance.

Kiveton Park Medical Practice 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 provider demonstrated effective partnership working with a range of external organisations including Hospital at Home and Virtual Ward services, acute trusts, specialist services, social prescribing teams, social care, safeguarding partners, care homes, and the Local Medical Committee. This collaboration led to tangible improvements in communication pathways, transfer-of-care arrangements, safeguarding coordination, and patient safety processes. The practice also demonstrated leadership beyond its own organisation by influencing changes to external provider processes where risks to patient care were identified.

For example, the practice raised concerns about a disclaimer included within correspondence from a hospital multidisciplinary team (MDT), which could have created ambiguity regarding clinical responsibility. The issue was escalated through appropriate channels, including the Local Medical Committee, and resulted in the hospital service agreeing to remove the disclaimer. This demonstrated the practice's commitment to patient safety and its willingness to work collaboratively with system partners to improve care processes across organisational boundaries.

Kiveton Park Medical Practice 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.

Learning from significant events, complaints, audits, and clinical governance meetings resulted in practice-wide improvements to referral pathways, prescribing processes, patient safety systems, and communication arrangements.

The practice also demonstrated leadership beyond the organisation by working with partner organisations, including acute trusts and Hospital at Home services, to improve system-wide communication and patient safety processes across the local health and care system.

Additionally, the practice demonstrated a proactive approach to quality assurance and continuous improvement by commissioning an external review of its services against the CQC single assessment framework in summer 2026. The review provided independent scrutiny of the practice's governance arrangements, quality of care and regulatory compliance, helping the practice identify strengths and opportunities for further development. The findings informed ongoing service improvement and provided assurance regarding the quality and safety of care delivered.

The provider demonstrated a broader commitment to continuous improvement and innovation through its approach to environmental sustainability. The practice supported the NHS Net Zero ambition by implementing a range of measures to reduce its environmental impact while maintaining safe, high-quality care. Initiatives included replacing LED lighting, increasing the use of digital communication and electronic records to reduce paper usage, improving recycling arrangements, and reducing energy consumption through changes to equipment and facilities. The practice also promoted staff awareness of responsible energy use and had identified further opportunities for improvement, including monitoring utility consumption, increasing recycling rates, reducing paper use, and incorporating environmental considerations into future planning and procurement processes.