Updated 26 March 2025
Date of Assessment: Remote clinical searches date was 10/06/2025 and site visit date was 11/06/2025.
The legal entity for this service changed from a single-handed provider to a partnership in February 2025 and inherited the previous rating. This assessment was to follow up that inherited rating of requires improvement from November 2023.
At the last assessment in November 2023, the provider was found to have breached regulations related to safe care and treatment and good governance. The provider was issued requirement notices (now called action plan requests) for the breaches identified.
Kincora Doctors Surgery is a GP practice and delivers General Medical Service (GMS) to 2,880 under a contract held with NHS England. The Practice is located within the London Borough of Hillingdon. The National General Practice Profiles states that the population make up for this location is 27.7% White, 12.3% Black, 46.9% Asian, 3.8% Mixed, 9.4% other ethnicity. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 of 10). The practice was in the fourth most deprived decile. The lower the decile, the more deprived the practice population is relative to others.
SAFE: The service did not have a good learning culture. People could raise concerns but the response and learning actions were not clearly recorded. Managers did not ensure incidents were properly recorded and investigated thoroughly. People were not always protected and kept safe as there was no system to monitor risk in relation to people who were at risk of abuse or neglect. Staff did not always understand risks to manage them as related to safeguarding. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff but not all of them had the right skills, and experience. Managers did not make sure staff received training and regular appraisals to maintain high-quality care. Staff did not always manage medicines well and involved people in planning any changes.
EFFECTIVE: People were involved in assessments of their needs. However, care based on latest evidence and good practice was not always evident.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination.
WELL-LED: Leaders and staff shared vision and strategy with staff during induction. Leaders were not always visible and knowledgeable; however, they were supportive and helpful to staff to develop their roles. Not all staff understood their roles and responsibilities which showed in the policies and procedures of the services being out of date and not specific to the practice. There was a lack of culture of continuous improvement and learning given the breaches identified previously.
At this assessment, we found additional breaches of regulation in relation to safe care and treatment; good governance and new breach of regulation as related to fit and proper persons employed. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and or appeals have been concluded, if the action has been taken forward. We have asked the provider for an action plan in response to the concerns found at this assessment as related to the breach of regulation 12 (safe care and treatment); regulation 17 (good governance) and regulation 19 (fit and proper persons employed).