Kincora Doctors Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. At the last assessment in November 2023, we rated this key question as requires improvement. At this assessment, the rating has changed from requires improvement to good because there was an improvement in how patients were cared for in a person-centred way and information was provided to people to make an informed decision about their care and treatment.

This service scored 68 (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 were at the centre of their care and treatment choices and did not always work in partnership with the people to decide how to respond to any relevant changes in their needs. There were not always alerts on the clinical systems for the staff to appropriately follow up vulnerable people. Not all the patients were supported to understand their conditions or to make decisions about their care. There were no health checks for patients that were identified as carers. Not all patients eligible for health checks were offered the service. We identified that at the time of our visit, 873 people were eligible for health checks, but only 288 were invited and only 16 health checks were completed. Patients living with learning disability were invited for health checks and 80% was completed in the last 12 months. Following the site visit, the service informed CQC that the health check reviews will be completed in collaboration with the confederation going forward.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. The service in collaboration with the local Primary Care Network offered weekend clinics to the patient population.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to the individual needs. Leaflets in multiple languages and access to interpreting services were made available. Staff were fluent in multiple languages to support communication needs of the patient population.

The service made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. Complaints were responded to in a timely manner; however, learning from complaints was not always evident and clearly recorded with any changes made as a result. Nor was there evidence any learning was shared with staff. The service shared evidence of a compliment received from a patient; however, no patient feedback analysis was shared with CQC before or during our visit. After the visit, the service sent us completed feedback action plan in response to the patient feedback, but the details did not include how many patients completed the survey and the date the actions were completed. In addition, the service had further action plan to improve the patient feedback process and service delivery.

The service made sure that people could access the care, support and treatment they needed when they needed it. The National GP Patient Survey 2025 results showed that 66.0% of the respondents had good overall experience of contacting the service (National average 70.0%; Local average 71.0%) and 62.0% of the respondents said it was easy to contact this location on the phone (National average 53.0%; Local average 60.0%). The percentage of respondents who said it was easy to contact this location using their website was 47.0% compared to the national (51.0%) and local (52.0%) averages. Feedback received by CQC from patient experience forms showed that patients were positive about their experience of care at this location. However, there were some negative feedback related to getting appointments for urgent consultations and attitude from some of the staff. The service did not share any action plan to improve patient experience with CQC.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. Feedback received by CQC from patient experience forms showed that patients were positive about their experience of care at this location.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including end of life. The service worked together with the local palliative care team with weekly meetings with community matrons. Home visits were completed by the lead GP to support patients on palliative care. Our review of records showed that there were no patients identified to have Do Not attempt Cardiopulmonary Resuscitation (DNCPR) decisions.