Kincora Doctors Surgery

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. At the last assessment in November 2023, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement because we found concerns with how needs were assessed, and outcomes were not improved and monitored.

This service scored 54 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Patients with long term conditions such as asthma and diabetes, were not always monitored appropriately. However, text messages were sent to patients ahead of the medicines review and abnormal readings were followed up in patients with chronic kidney disease. Staff could refer people with social needs to a social prescriber. Patient feedback CQC received as part of the assessment process showed the patients were positive about the service received at this location.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. The practice’s clinical systems were not effectively utilised to deliver evidence-based care and treatment. Clinical records we reviewed demonstrated that care was not always provided with current guidance.

The service worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan and deliver people’s care and treatment and support. Staff could refer people to relevant services where needed.

The service did not always support people to manage their health and wellbeing so people could not always maximise their independence, choice and control as seen from our clinical searches. However, staff supported national priorities and initiatives to improve population health including stopping smoking and tackling obesity. For example, there was a local weight management service and there was access to Primary Care Network (PCN) dietician.

The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of the people. The practice did not meet national targets for screening and immunisations. For example, the cervical screening test among 25-49 years of the female patient population was 56.2% which was lower than the expected average (80.0%). The uptake of the cervical screening test was equally lower (70.8%) among patients who were 50-64 years old compared to the expected average (80.0%).

The percentage of children aged 5 who received immunisation for measles, mumps and rubella (2 doses of MMR) was (76.9%) which was below the minimum target uptake (80%). The percentage of children aged 2 who received their booster immunisation for Pneumococcal infection was (88.0%) which was below the 90% minimum uptake target and World health Organisation (WHO) target (95.0%). Rates of childhood immunisations and cervical screening remained low, primarily due to inadequate follow-up following missed appointments and no proper recall. There was no consistent process in place for notifying health visitors of non-vaccinated children or proactively chasing up non-attenders.

We were informed by the service that people who refuse the screening and immunisations offers could complete a disclaimer form on the service’s website. The service did not share any action plan to improve the uptake of the cancer screening and childhood immunisations.

There were no clinical audits submitted before or during the site visit despite our repeated requests. The provider sent us evidence 4 weeks after the site visit. This consisted of two record reviews, we were not provided with any examples of clinical quality improvement work by the practice in the previous 15 months such as multi-cycle audits. The service also submitted a resource for primary care staff developed by the British Heart foundation in conjunction with the local primary care network in which practices were advised to complete audits of patients living with high blood pressure recordings not coded on the system and to use search tools built into different clinical systems used in primary care. However, the service did not share any such audit completed or review of patients coded with high blood pressure with CQC.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Our review of patient records showed there were no patients on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). However, staff understood the principles and legislation relating to consent.