Ashley Centre Surgery

We carried out an announced comprehensive inspection at Ashley Centre Surgery between 17 and 20 October 2022. The onsite visit was the 19 October 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashely Centre Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection following the provider’s registration with the Commission to provide services at a new location.

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 using video conferencing.
• 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 short 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 had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• There were adequate systems to assess, monitor and manage risks to patient safety.
• The practice had systems for the appropriate and safe use of medicines, including medicines optimisation.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• 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.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There were evidence of systems and processes for learning, continuous improvement and innovation.

Whilst we found no breaches of regulations, the provider should:

• Continue to take action in relation to recording staff immunisation.
• Continue to improve cervical screening uptake.
• Continue to review and improve patient access.
• Continue to take action to re-instate the patient participation group
• Take action to promote a Freedom to Speak up Guardian

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 Hospitals and Interim Chief Inspector of Primary Medical Services