Kingsway Surgery

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

The management and leadership team did not have sufficient oversight of the training compliance of the staff team nor that monitoring of medicines was delivered in line with national guidance. This was a breach in good governance. However, the practice was responsive on inspection and assurances were obtained during the assessment period and identified risks were mitigated. The practice has a stable, core team including GP partners and managers with clear lead roles and responsibilities. Leaders and staff worked with a clear governance framework where information was regularly shared with all staff to help improve the service. However, leaders lacked systems to identify risks and monitor performance which led to patients not always receiving the best clinical outcomes.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Managers did not have complete oversight of staff performance in varying roles and responsibilities. Although, the practice had processes in place such as a training matrix, the managers lacked awareness as to what training had been completed and didn’t always engage with staff when training was overdue. However, when the shortfalls in the oversight were highlighted the practice provided assurances that the overdue training has now been completed. Team managers also did not oversee training outside of the protected learning time sessions once a month and as a consequence, there were gaps in completed training for both clinical and non-clinical staff roles. Staff were aware of data protection principles to keep patient information safe and secure.

The systems and processes in place to monitor performance, risk and outcomes were not always effective. There were gaps in mandatory training and the staff competency monitoring system. The oversight and review of patients taking specific medicines did not adhere to national guidelines. However, once we identified these areas, the service took action to address these and to mitigate the identified risks to patients

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.