Kincora Surgery - Care Quality Commission

Background to this inspection

Updated 30 March 2017

Kincora Surgery is a well-established GP practice located in Hayes situated within the London Borough of Hillingdon. The practice lies within the administrative boundaries of NHS Hillingdon Clinical Commissioning Group (CCG) and is a member of The Clover Health GP Network in the Hillingdon locality.

The practice provides primary medical services to approximately 3,200 patients living in Hayes. The practice holds a Personal Medical Services contract and Directed Enhanced Services Contracts. The practice is located at 134 Coldharbour Lane, Hayes, UB3 3HG with good bus transport links. The GP father and daughter partnership owns and manages the premises which have been extensively refurbished. There is wheelchair access to the entrance of the building and accessible toilet facilities for people with disabilities. There are limited car parking facilities at the front of the practice.

The practice population is ethnically diverse and has a higher than the national average number of male and female patients between 0 and 14 years of age and between 20 and 44 years of age. There is a lower than the national average number of patients 55 years plus. The practice area is rated in the fourth more deprived decile of the national Index of Multiple Deprivation (IMD). People living in more deprived areas tend to have greater need for health services. Data from Public Health England 2014/15 shows the practice has a lower percentage of patients with a long-standing condition compared to CCG and England averages (42%, 50%, and 54% respectively).

The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic & screening procedures, family planning, maternity & midwifery services, surgical procedures and treatment of disease disorder & Injury.

The practice team comprises of one male senior GP partner, one female GP partner and a female locum GP who collectively work a total of eight clinical sessions per week. There are two part-time practice nurses, one part-time healthcare assistant, a part-time phlebotomist, practice manager and five administration/reception staff.

The practice opening hours are 8am to 1pm and 2pm to 6.30pm Monday to Friday with the exception of Wednesday when it closes at 1pm. and 8am to 1pm on Wednesday. Consultations are available from 9am to 11.30am Monday to Friday and from 2pm to 4.00pm Monday, Tuesday and Thursday and from 2pm to 5pm Friday. Extended hour pre-bookable appointments are offered from 6.30pm to 7pm Monday, Tuesday and Thursday.

Monday, Tuesday and Friday and 3pm to 6.30pm on Thursday. The out of hours services are provided by an alternative provider. The details of the out-of-hours service are communicated in a recorded message accessed by calling the practice when it is closed and on the practice website.

The practice provides a wide range of services including chronic disease management, minor surgery and health checks for patients 40 years plus. The practice also provides health promotion services including, cervical screening, childhood immunisations, contraception and family planning.

Overall inspection

Good

Updated 30 March 2017

We carried out an announced comprehensive inspection at Kincora Surgery (also known as Kincora Doctors Surgery) on 3 November 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the 3 November 2015 inspection can be found by selecting the ‘all reports’ link for Kincora Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 August 2016 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection on 3 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

The practice had effective systems in place for reporting, recording and learning from significant events and for dealing with national patient safety alerts received.
The practice had ensured recruitment arrangements included all necessary pre-employment checks including formal reference checks.
The practice had undertaken a recent infection and prevention control (IPC) audit and actions had been taken by the practice as a result.
Prescription stationery was monitored when received and distributed by the practice.
Arrangements in place to respond to emergencies and major incidents.
Relevant staff had received Mental Capacity Act (2005) training and staff appraisals had been completed for all staff.
The practice had ensured governance arrangements now included scheduled review of policies and procedures and formal documentation of minutes from practice meetings for circulation to staff.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice