Ashcroft Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the practice met patient’s needs, and that staff treated people equally and without discrimination.

At our last inspection, we rated this key question as good. At this inspection, the rating remains the same.

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 practice made sure patients were at the centre of their care and treatment choices and they decided, in partnership with patients, how to respond to any relevant changes in patient’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The practice understood the diverse health and care needs of patients and their local communities, so care was joined-up, flexible and supported choice and continuity.

The practice worked in partnership with other services to meet the needs of its patient population. People in vulnerable circumstances were able to register with the practice, including those with no fixed abode.

The results of the National GP Patient Survey 2026 were above the national and local averages.For example, 71%of respondents said they would usually get to see or speak to their preferred healthcare professional when they would like to, compared to 46% locally and 42% nationally. This was also reflected in patient feedback as patients spoke positively about being able to access a GP when needed.

The practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the practice met the Accessible Information Standard.

The practice made it easy for patients to share feedback and ideas, or raise complaints about their care, treatment and support. They involved patients in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the practice’s policy. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints.

The practice provided patients with opportunities to provide feedback about their care through the friends and family test (FFT) and responses were positive. For example, in June 2026, the practice received 164 FFT responses. Of these, 96.3% were positive responses, 1.8% were negative responses and 1.8% were neutral.

The practice regularly reviewed their patient feedback, and we saw the practice implemented a ‘you said we did’ poster, to demonstrate to patients what improvements had been made based on feedback. For example, we saw a baby changing facility had been installed in the patients’ toilet in June 2026 following feedback.

The practice made sure that patients could access the care, support and treatment they needed when they needed it.

The practice offered a range of appointments, including on the day appointments and pre-bookable appointments. Whilst pre-bookable appointments were regularly reviewed and amended to meet demand, the practice typically operated a system to make 30% pre-bookable appointments available in advance and 70% of appointments to be made available daily.

To improve the call waiting times, the practice implemented a call back system for patients and call volumes were routinely monitored by the practice manager and senior administrator to ensure additional resources could be made available during busy periods.

The practice recently reviewed their appointment system, to ensure staff were clear when to book extended appointments for patients. For example, for people with a learning disability.

The results of the National GP Patient Survey 2026 were above the national and local averages.For example, 78%of respondents said they find it easy to get through to this GP practice by phone, compared to 56% locally and 57% nationally.

Also, 84% of respondentsdescribe their experience of contacting their GP practice as good, compared to 72% locally and 73% nationally.

During the site visit, we spoke with patients who spoke positively about how accessible the practice was in terms of appointments and access to medications via the dispensary. However, some patients told us they would prefer an option to pay by card within the dispensary and the provider told us they were looking to improve the payment system.

Staff and leaders actively listened to information about patients who are most likely to experience inequality in experience or outcomes. Feedback provided by people using the service, both to the provider as well as to Care Quality Commission (CQC), was positive.

The practice had recently made improvements to address barriers to care and improve patients’ experience and access. For example, the practice had carried out a disabilities access audit in March 2026 and identified several actions to improve access for all patients which had not previously been identified. Actions included installing a ramp at the front entrance, an automatic door at the front entrance, grab rails in the patient toilet, a patient alarm in the patient toilet and to install a hearing loop. During our first site visit, we noted the hearing loop had been installed, but staff were not aware of how to use this. The provider told us this would be addressed at the next staff meeting and we saw evidence this was completed.

The practice told us when patients using a wheelchair arrived at the practice, they would telephone the practice or ring the doorbell and wait for a staff member to support them into the building. If required, some patients could be escorted through the secured, staff-only reception area and through the side entrance but still did not have an appropriate ramp or threshold for wheelchair access. The practice told us when patients using wheelchairs were escorted through the staff-only reception area, a screen would be used to ensure the patient did not have sight of any confidential information. However, during our first site visit, we witnessed staff supporting a wheelchair user out of this side entrance and this process was not followed. This meant there was a risk the patient could have seen confidential information, such as the deceased patients’ notice board.

During our second site visit, we found the practice had completed most of their disabilities access audit actions, including the installation of a ramp and grab rails in the patient toilet. The practice was able to provide evidence to demonstrate they had a date scheduled for the installation of the automatic entrance door. The actions taken by the provider meant that the practice had been made more accessible to all patients.

Patients were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

There was a process for implementing Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions and the practice created a DNACPR policy in June 2026. However, the practice did not have an effective system in place to monitor and maintain effective oversight of DNACPR decisions and share information with other services when necessary. For example, we reviewed a sample of 3 patients DNACPR decisions and found all 3 were incomplete. For example, instructions for ambulance crew regarding patient’s wishes had not been completed and a section on who had been informed of the DNACPR had not been completed. Therefore, we were not assured that patients had access to personalised support about DNACPR decisions.

These concerns were highlighted to the practice who raised them at a clinical meeting after the inspection and sent us meeting minutes to evidence this had been discussed. These minutes showed the practice had set an action to review all DNACPR documentation to ensure patient wishes are clearly recorded and ensure patient decisions are documented consistently.