Ashton Gardens Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service maintained up-to-date patient assessments and ensured staff understood individuals’ current health and care needs. Vulnerable patients were prioritised, with annual health checks offered to those with learning disabilities, as 88% of patients with learning disabilities had their annual review carried out in 2025. The service had 142 carers on their register, which represented 2.8% of the practice population.

Care and treatment were regularly reviewed, with attention being placed to wellbeing and communication preferences. Feedback regarding the care received from healthcare professionals was positive, with patients feeling involved and understood. For example, 86% of respondents from the 2025 National GP Patient Survey felt their needs were met during their last appointment. Eighty-eight percent of respondents stating the healthcare professional they saw had all the information they needed about them during their general practice appointment.

Reception staff used digital flags to highlight specific needs, such as interpreter support or extended appointments. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff referred individuals with social challenges, such as isolation or housing issues, to social prescriber through their Primary Care Network.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. The service held regular clinical, staff and quality and governance meetings to discuss evidence-based care. Clinical staff took part in monthly courses offered by their Primary Care Network. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people and shared patients’ assessment of needs when moving between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Leaders and staff worked closely with colleagues within their local Primary Care Network (PCN). Referrals to specialist services were well documented, included all required details, and were actively monitored to avoid delays.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Data from the 2025 National GP patient survey showed that 76% of people felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was higher than the local average (61%) and the national average (69%). Seventy seven percent said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was higher than the local (71%) and national (74%) averages.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. The service carried out several clinical and non-clinical quality improvement audits to improve patient care. From the clinical notes we reviewed, we found that most people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice did not meet national targets for screening and immunisations. Results from the UK Health Security Agency showed the practice were underperforming on all five indicators regarding childhood immunisations. The practice informed us of actions taken to improve the uptake of childhood immunisations, This included following up with patients who missed appointments and contacting those with vaccine hesitancy to address their concerns. Result showed that the number of women between ages 25 to 49 eligible for cervical screening who had an adequate screening test was 49.5% and 69.2% for those aged between 50 to 64. The practice recognised scores were below the national targets and carried out a quality improvement project to improve the uptake of cervical screening in the practice population. The project entailed a structured contact method of those who did not attend appointments and conducted an online survey to gather further insight. The practice found that two specific communities showed consistently low screening uptake and found detailed conversations with these communities resulted in an effective method of increasing uptake, with 44% of those successfully contacted consenting to screening.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.