Kincora Doctors 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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last assessment in November 2023, we rated this key question as requires improvement. At this assessment, the rating remained unchanged. The service was in breach of legal regulation in relation to good governance.

This service scored 50 (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 clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion and engagement. Staff did not always understand the challenges and the needs of people and their communities. For example, staff we spoke to during the site visit could not tell us what the shared direction of the practice was and how to realise it. Out of 7 members of staff we spoke to, only 3 could confidently say what the shared vision or direction was while others did not know. However, leaders told us that they always shared vision and strategy with staff at induction.

Leaders could not demonstrate the skills, knowledge, and experience to lead effectively. Leaders had not been effective in ensuring breaches and areas for improvement at the last assessment were rectified. However, staff told us the leaders were approachable and supportive of them.

The service had a whistleblowing policy, but not all staff were aware of it and not all the leaders were following the procedures stated in the policy. However, staff were encouraged to speak up and leaders operated an open-door policy.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture and ensured there was equality of opportunity and experience within the workforce.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes and shared this securely with others when appropriate. For example, practice policies and procedures were out of date and not tailored to the needs and circumstances of the service. There was no system to manage and mitigate risks. For example, the business continuity plan (for use in any emergency that could disrupt service delivery) was out of date, not tailored to the service and had missing information. Following the site visit, the service submitted policies that were updated. However, the documents still contained incorrect information (references to staff who stopped working at the service the year before) and were not tailored to the service. There was no system to monitor staff training and to prompt staff to complete any required training, and other training for safe service delivery, when it was due. This was also a concern previously identified at the last assessment in November 2023.The service made additional effort to ensure the policies were updated with current relevant information after the recent CQC visit.

The service had no process to evidence it completed regular annual appraisals for staff, and we identified a number of gaps in staff appraisal records. The service had no effective processes in place to carry out and retain evidence of recruitment checks for staff. There was no effective oversight and assurance by the service that staff had undertaken appropriate background checks. Following the site visit, the service provided evidence of actions completed to address the concerns identified.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. There was a collaboration between the service and the primary care network as demonstrated by the various community clinics running at the location.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. The service did not have a comprehensive plan of quality improvement activity including clinical audit. We were informed that there was an audit on Short-Acting Beta- 2 Agonist (SABA) inhalers used in the treatment of asthmatic symptoms, but the evidence was not provided on site and after the site visit. The diabetes audit put forward lacked detail and did not specify the impact on the patient population and no detailed follow up work to improve outcomes. The leaders did not demonstrate they took adequate actions to improve following the last CQC assessment in November 2023 where there were breaches in regulation relating to safe care and treatment as well as good governance.

Following the site visit, the service sent evidence of other clinical audits completed, however, it lacked details of parameters used in measurement but urgent actions were taken to improve the health of the patients at risk from the findings of the audit. The service collaborated with the local primary care network to deliver workshops on patient health needs, but these were not innovations specific to the service and there were no measurable impact recorded.