The Care Quality Commission
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  • GP practice

Archived: Kincora Surgery

Overall: Good read more about inspection ratings

Kincora Doctors Surgery, 134 Coldharbour Lane, Hayes, Middlesex, UB3 3HG (020) 8813 5346

Provided and run by:
Kincora Surgery

Important: The provider of this service changed. See new profile

All Inspections

17 August 2016

During an inspection looking at part of the service

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

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kincora Surgery on 3 November 2015. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, there was no documentation of review and shared learning when unintended or unexpected safety incidents occurred.

  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and emergency medicines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the knowledge and experience to deliver effective care and treatment.

  • Patients said they felt the practice offered a very good service and staff were helpful, caring, professional, approachable and treated them with dignity and respect.

  • Information about services and how to complain was available and easy to understand. However, we did not see evidence that the practice learned from and made improvements as a result of complaints received.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a number of policies and procedures to govern activity, but we did not see evidence that all policies were followed, for example significant events and infection control monitoring.
  • The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvement are:

  • Investigate and record safety incidents thoroughly including evidence of shared learning and ensure that people affected receive reasonable support and a verbal and written apology.

  • Ensure recruitment arrangements include all necessary employment checks for all staff, including locum staff used by the practice.

  • Review emergency medicines held at the practice and ensure they are following best practice guidelines with evidence of a risk assessment for medicines not routinely kept.

  • Ensure that staff receive annual appraisals as part of their professional development.

  • Ensure there is a robust process for recording, reviewing and circulation of minutes from all practice led meetings and complaints received and that all procedures and guidance reflect up to date information.

The areas where the provider should make improvement are:

  • Ensure there is a system in place for monitoring distribution of prescription pads.

  • Ensure formal annual infection control audits are completed.

  • Review the practice business continuity plan to ensure details are relevant and up to date.

  • Ensure clinical staff complete Mental Capacity Act training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice