Ashton Gardens Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 had a shared vision, strategy and culture. The practice, formerly a single-handed GP practice, became a partnership in April 2022. The practice grew from a patient population of 3000 to 5000 since the partnership and had increased the number of clinical and non-clinical staff. The practice informed us of difficulties in physical capacity and were looking at ways to address the challenge, including becoming a training practice so they are able to merge with another practice.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. This was reflected in the practices’ in-house survey, whereby 65% stated the management team is very effective in supporting staff and 35% stated the management team is somewhat effective in supporting staff. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Leaders provided training and resources to ensure staff were aware of their rights, including those relating to equality.

The practice supported career development and role progression, with a current member of staff currently being supported in becoming a healthcare assistant.

The service had clear responsibilities, roles and systems of accountability in place. However, staff did not always follow the systems in place to ensure good governance. For example, the service was not up to date with the management of DBS checks for some members of clinical staff, including a GP and nurse, and we found expired clinical accessories in clinical rooms during our site visit.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. They supported the local extended access service to expand appointment availability. The provider supported a GP pop up in a local church in December 2025.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The service provided evidence of clinical and non-clinical audits which actively contributed to safe, effective practice and research.

The practice participated in the GP improvement programme (GPIP). This involved face-to-face sessions over a six-month period and focused on enhanced workflow, patient access, wellbeing, signposting and care navigation. The service worked continuously to make improvements on patient care by performing clinical and non-clinical audits.