Kincora Doctors Surgery

Updated 11 January 2024

Kincora Doctors Surgery is located in Hayes at:

134 Coldharbour Lane

Hayes

Middlesex

UB3 3HG

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated in Hillingdon within the North-West London Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 3,200. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called Hayes and Harlington Collaborative.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 42% Asian, 37% White, 13% Black, 4% Mixed and 4% Other.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of four GPs who provide cover at the practice. The practice has a team of two nurses. The GPs are supported at the practice by a team of reception/administration staff. There is currently no practice manager. The senior administrator is being supported to carry out this role.

The practice is open between 8 am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 11 January 2024

We carried out an announced comprehensive inspection at Kincora Doctors Surgery on 9 and 10 November 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - good

Caring - good

Responsive – requires improvement

Well-led - requires improvement

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

• Key questions inspected – safe, effective, caring, responsive and well-led

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, we identified shortfalls in the processes for medicine monitoring, health and safety monitoring and incident management.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. National GP survey results (2023) showed the practice was performing generally in line with national averages for patient experience.
• In relation to access, although we did not identify concerns with access on the inspection, the practice’s National GP Patient Survey results (2023) showed they were generally performing below the national average for some years and performance had been declining each year.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, we identified areas where governance, oversight and risk management required improvement.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Ensure all non-clinical staff undertake safeguarding training to the appropriate level for their role.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care