We carried out an announced inspection at Ashfield Road Surgery over a period of four days, the final inspection date was the 23 September 2021 when we carried out an onsite inspection visit. Overall, the practice is rated as good.
Set out the ratings for each key question:
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 25 February 2019, the practice was rated as requires improvement overall. We rated the practice as requires improvement for providing safe and well services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashfield Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was an announced follow up inspection to follow up on:
- Breaches of regulations and ‘shoulds’ identified at the previous inspection in February 2019
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspection differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Conducting staff interviews using video conferencing
- 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 have rated this practice as Good overall and Good for all population
We found that:
- The practice had taken appropriate action to support and protect patients identified as at risk from harm.
- 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 practice had management oversight of staff qualifications and training.
- The arrangements for the management of incidents and complaints was reviewed and systems introduced to demonstrate learning and improvements at the practice.
- Staff were clear and knowledgeable about their lead roles and responsibilities.
- Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The improvements made at the practice showed a clear leadership structure and staff roles and responsibilities which promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve the documentation and monitoring of complaints, incident and significant events.
- Review systems to improve the monitoring and review of patients prescribed high risk medicines.
- Review the systems in place for monitoring relating to medicines identified in safety alerts to demonstrate that best practice guidance is followed.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care