Kincora Doctors Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment in November 2023, we rated this key question as requires improvement. At this assessment, the rating has changed from requires improvement to inadequate. The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. For example, not all incidents that occurred were adequately reported and recorded for monitoring. This concern was also identified at the last assessment in November 2023 which showed a lack of learning for improvement. Issues identified during the recent clinical searches had not been addressed to allow the service to learn from them and to show any measures taken to prevent a recurrence. Not all staff attended staff meetings, and when we asked, they were not sure how to access the meeting minutes. A staff member told us that since starting at the practice over a year ago they had not attended any staff meetings. Significant events were reported verbally to the practice manager who completed the required forms. Learning from complaints was not documented as evidenced by the document the service shared with us. Following the site visit, the service informed CQC that actions had been taken to improve staff meeting minutes accessibility for all members of staff including part-time workers. In addition, the service informed CQC that the significant events record had been updated, however, learning from these events were not always clear and follow-up actions when completed were not recorded.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, the service did not have a system to follow up on patients after discharge from the hospital or who needed a check-up at the hospital for further monitoring. Also, the service did not have a system to ensure test results were reviewed and any medical action or follow up were timely managed as the locum inbox was not monitored when the locum GP was not working. We found 55 test results unprocessed in the locum inbox dating back almost 3 months during our site visit. However, referrals were managed in a timely way including urgent cancer referrals. Following the site visit, the service informed CQC that the unmatched pathology results were as a result of a clinical system error but no evidence of this was provided. The service also informed us after the site visit that huddle meetings were held with clinical staff external to the service to support patient care but the evidence provided was a huddle meeting completed 2 months after the site visit.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not respond and share concerns quickly and appropriately.

For example, the practice did not have any safeguarding register. The clinical system was not used effectively to find out if there were any concerns from the commissioners or the Primary Care Network about any of the patients registered with the service. Our review of the safeguarding search showed that there were messages sent by the commissioners about patients who needed to be protected from harm and abuse which had not been followed up. Patients who were in households that showed evidence of domestic violence were not flagged on the clinical system and children in such households as well as those having parents with mental health disorders, were also not flagged on the clinical system for effective monitoring and escalation where appropriate. The service informed us that the ‘safeguarding list’ was on the shared drive and when we checked there were no patients on the clinical system coded as vulnerable. The service did not run safeguarding search on the clinical system, making them unaware of the number of patients who were vulnerable. Following the site visit, the service informed CQC that a new safeguarding register had been created and safeguarding policy updated.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do things that mattered to them. Emergency equipment was available and maintained. Staff were trained in basic life support and sepsis management. However, our review of the training records showed most of the training was out of date. For example, one clinical member of staff’s training records showed their adult basic life support was last completed in February 2024, and the child basic life support was last completed in October 2022. Both should be renewed annually. We found a record of training for a receptionist who had sepsis training due April 2025 but there was no evidence of completion. Following the site visit, the service provided CQC with evidence that staff completed sepsis training and basic life support but not all staff that were identified during the assessment activity were included.

The service did not always detect and control potential risks in the care environment. Health and safety risk assessments and audits did not always show completed actions to ensure the environment was safe for people and staff. For example, our review of the documentation showed actions from fire safety and legionella risk assessment were not completed or documented. This concern was also identified at the last assessment in November 2023. Fire drill logs showed the last drill had been completed in July 2024 and, prior to that, in April and June 2024. Documents seen during the site visit showed a fire drill was completed in March 2025. The fire safety policy was not specific to the service and lacked sufficient details to guide the staff on how often fire alarm testing was completed and which of the recommendations from the risk assessment will be adopted or included in fire safety procedures. However, the premises was visibly clean on the day of the site visit and there was a cleaning schedule for the premises. Equipment was calibrated annually. Following the site visit, the service informed CQC of the fire drills completed and recorded after the site visit.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Safe recruitment practices were not followed. For example, our review of 10 staff records showed that there was no record of a disclosure and baring services (DBS) check or risk assessment for a receptionist. Five of the staff files did not have records of appropriate references from previous employment. A nurse did not have DBS information, although there was a copy of a document from the DBS Update Service. Staff did not have regular annual appraisals. From the staff records we saw, staff training was out of date across a number of areas, such as mental capacity act training, adult basic life support, child basic life support and health and safety. This concern had also been identified at the last assessment in November 2023.

Following the site visit, the service sent CQC training certificates of completed trainings which included sepsis and basic life support training but not all clinical staff had evidence of completion. In addition, the service sent evidence of DBS check completed after the site visit for the staff identified not to have had a DBS check.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The Infection Prevention and Control (IPC) Policy was out of date (expired March 2023), and it was not specific to the practice or its needs. Actions from IPC audits were completed and the last audit was completed in February 2025. The handwashing and hygiene protocol expired March 2023. There was no evidence that sepsis management including audit of antimicrobial use, was discussed at clinical meetings. Receptionists told us they would speak to an onsite doctor if worried about any patient developing sepsis. Not all staff files had evidence of vaccination records which was also a concern previously identified at the last assessment in November 2023. However, following the site visit, the service shared complete staff vaccination records with CQC.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Staff did not always follow established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

We reviewed a sample of records of patients prescribed a medicine primarily used in strengthening bones and preventing fractures. We looked at patients prescribed this medication for more than 5 years. Three out of 5 patients we reviewed were left at increased risk of bone fractures due to not having scans within the recommended timeframes.

We reviewed the records of three patients who were asthmatic, who had suffered an acute exacerbation and who had received oral steroids. None of them were followed up within 2 working days as NICE recommends; 1 out of the 3 patients was overdue an annual review; and 1 patient had not had an assessment before steroids were prescribed. These patients were left at risk of uncontrolled asthma and increased future exacerbations and complications.

Patients with diabetes did not have monitoring and annual diabetic review. This concern was also identified at the last assessment in November 2023. We found 2 out of 5 patient records reviewed showed that the patient’s annual diabetes review was overdue and another record showed that the patient’s annual diabetes review was overdue by 2 weeks. There was no record of a future appointment for the review. The patients were at risk of deterioration and diabetic complications. Our clinical searches also identified 1 potential missed diagnosis of diabetes.

When we reviewed the patient records, we did not find evidence that, following safety alerts raised by the Medicines and Healthcare products Regulatory Agency (MHRA), patients were advised on risks related to their condition and actions to take if their condition deteriorated. For example, people with diabetes on a particular medicine were not given advice on how to identify or respond to life threatening infection that rapidly destroys deep and superficial skin tissues and complications from the condition, such as Fournier’s gangrene and diabetic ketoacidosis.

We found that emergency medicines were stored in multiple places across the site and not all the appropriate medicines were available at any one site. For example, medicine required to treat an epileptic seizure was only found in the doctor’s bag which was often taken off-site for home visits.

The prescription policy (repeat prescription and medication protocol) shared with us by the practice was out of date (last reviewed April 2024). We asked for any annual audit of prescribing as part of clinical supervision, but no evidence was provided during the site visit.

When medicines were reviewed by the practice, the context of the review was not always documented. The prescribing data reviewed as part of the assessment process was in line with national guidelines. For example, the figures for the practice showed better management of antimicrobials prescriptions than local and national averages.

Following the site visit, the service provided CQC with audit of repeat prescribing process but did not include the date the audit was completed. In addition, the service informed that actions have been taken to address the concerns identified during the assessment activity but no evidence of this was seen by CQC.