Ashton Gardens Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service fostered a strong learning culture where staff felt safe to raise concerns. Managers encouraged staff to raise concerns when things went wrong. We saw evidence of discussions in team meetings to discuss clinical and non-clinical significant events. The service had a duty of candour policy in place.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had systems in place to ensure information was effectively shared across teams and agencies.

Clinicians followed established care pathways for diagnosis, treatment, and referral to specialist services. There was a system to ensure referrals to specialist services were documented and contained the required information. The service had processes in place to monitor urgent referrals with safety netting processes in place to ensure patients were followed up. Routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated.

We reviewed the services’ test results and saw they were being managed appropriately by clinicians.

The service valued safeguarding and reviewed internal safeguarding registers routinely to protect individuals from abuse and neglect. We reviewed safeguarding cases and saw the service worked in collaboration with healthcare partners to ensure safeguarding cases and procedures were discussed and managed. However, although clinical meetings took place where safeguarding cases were discussed, external healthcare partner were not involved in these meetings. The practice informed us they previously invited healthcare partners to the meetings, but they were not available to attend.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding alerts were added to the clinical record system when relevant, ensuring that all team members could identify any ongoing concerns and could act accordingly.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Staff provided an example in which they dealt with a medical emergency (patient collapsing) in the practice.

The service was equipped with medical gases, such as oxygen, and a defibrillator. However, emergency equipment was checked monthly, which did not follow guidelines from the Resuscitation Council UK for primary care settings. The service had a checklist for checking emergency medication. The service informed us they checked the oxygen and defibrillator monthly, but this was not noted down on a checklist. The services’ emergency procedures policy did not reflect the latest resuscitation guidelines published in October 2025, although the policy was created in July 2025; following the assessment, the practice updated their emergency procedure policy. During our site visit, we could not locate a razor and stethoscope in the emergency trolley. After the assessment, the service informed us the razor was in the trolley drawer, and the stethoscope was in a drawer in the same room.

The service detected and controlled potential risks in the care environment. Contracts were in place to ensure the premises were maintained. Fire, health and safety and legionella risk assessments and audits had been undertaken and risks identified had been addressed. The service had a business continuity plan which was regularly reviewed to manage major service disruptions.

The service ensured staff received effective support, supervision and development. Staff worked collaboratively to provide safe care that met people’s individual needs. The service demonstrated there were a range of skilled and experienced staff, but we found there was a lack of evidence of suitable recruitment checks being maintained for some staff members.

We reviewed training records of clinical and non-clinical staff and found mandatory training was up to date. However, gaps were identified within recruitment records. Disclosure and Barring Service (DBS) documentation was missing for three clinical staff members (a GP, a nurse and a healthcare assistant). The practice held documentation for DBS checks prior to their employment. Although the practice provided evidence of DBS checks completed from the staff members’ previous employment, an up-to-date DBS was not completed once the staff members commenced employment at the practice. During our review of HR records, we saw references for a recently employed healthcare assistant was missing. Following the assessment, the provider submitted documentation relating to the references and provided risk assessments for incomplete DBS records, including and established renewal process to ensure DBS certificates remain current. Staff appraisals were being routinely carried out.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks. Waste, sharps, and clinical specimens were managed carefully to keep everyone safe. However, during the inspection and review of clinical rooms, we found expired clinical items available for use, including swab specimen tubes, injection needles, speculums and lubricating jelly. After the site visit, the service informed us they reviewed all clinical rooms and had disposed of expired items. The practice's infection control policy stated curtains were to be changed every 18 months, however, we found the change of curtains were not included in cleaning schedules.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

As part of our assessment, our GP specialist advisor carried out clinical searches on the practices’ electronic database. We found, overall, there was appropriate monitoring of patients on high-risk drugs and most patients with long-term conditions. However, our clinical searches found 74 patients with a Hba1c reading of 75 and over. We looked at 5 patients and found 4 out of 5 patients did not have an appropriate follow-up. The 4 patients were requested to have repeat blood tests carried out but did not attend and were overdue. After the assessment, the practice provided evidence the patients were reviewed. The practice showed us a quality improvement activity regarding cohort of patients with diabetes.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.