Ashcroft 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 and found some systems and governance processes were not always monitored and operated effectively.

At our last inspection, we rated this key question as good. At this inspection, the rating has changed to requires improvement.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood how to raise concerns and report incidents. Staff provided positive feedback about the new practice manager and felt the culture to raise concerns and share learning was improving. However, some staff reported they had not always felt confident all leaders would take appropriate action.

The practice implemented a new system for recording and acting on significant events and we reviewed 2 recent examples and found they had been appropriately investigated, and learning was shared at staff meetings. For example, a clinical letter had been filed in the wrong patient record which resulted in an inappropriate prescription being issued. Learning and actions were discussed at both a clinical meeting and a reception meeting, to ensure all relevant staff were aware of actions to prevent this reoccurring.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

The practice did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Systems to process information relating to new patients were not effective and patients’ paper records were not stored securely in the practice. At the time of the inspection, the practice had a backlog of 1,978 patients’ paper records awaiting digitisation. The practice was not aware of how far the backlog dated but, from our onsite review, we found paper records awaiting digitisation dated back to 2010.

Staff told us when new patients registered with the practice, they did not review paper records for any pertinent information, such as safeguarding, allergies or regular medications. Instead, staff told us they relied on what the patient had recorded in their registration form. This meant there was a risk patient records and information was not always accessible or accurate to deliver people’s care and treatment in a way that meets their needs and keeps them safe.

The practice had carried out 2 audits to review the extent of the summarising risks in March 2026 and May 2026. However, we found the audit did not accurately account for all records awaiting digitisation, which meant the risk had not been reduced or mitigated at the time of inspection. The practice told us about the actions planned for July 2026 onwards, to make improvements and train additional staff, including accessing external support.

There was a lack of process and oversight of clinical and administrative tasks. For example, we found 2,854 tasks (including correspondence, referrals and other tasks) within the clinical system which dated back to 1 April 2021.

The practice was unable to provide assurance that these tasks and corresponding actions had had the correct intervention and been appropriately completed. Staff we spoke with confirmed this. We reviewed 10 tasks during our on-site visit and found 2 which required further action. For example, we found a clinician’s request for a patient to be referred for an x-ray and ultrasound on 1 May 2024, and this had not been completed. This was raised with the practice who acted immediately, contacted the patient and booked the patient in for a review.

Clinical meeting minutes from April 2026 had identified the backlog of administrative tasks. Actions were identified for all clinicians and staff to review and close historical tasks. However, during the inspection, we found only 1 administrative staff member was reviewing tasks and there were no plans in place to find additional support.

However, referrals to specialists and urgent services, including urgent suspected cancer referrals, were suitably operated.

The practice did not always work well with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The system to maintain oversight of safeguarding was not always effective. For example, we found patient records did not always have appropriate safeguarding flags added to patient and linked family records. This meant there was a risk staff would not always be aware of potential safeguarding concerns prior to or during consultations. The practice told us this would be raised at an upcoming clinical meeting and after the inspection, we were sent evidence of those meeting minutes which set out actions to improve safeguarding coding.

The system the practice used to manage and monitor mandatory training showed 6 staff were overdue safeguarding adults training, including 2 GPs and a physician associate, and 7 staff were overdue safeguarding children training, including 2 GPs, a physician associate and the safeguarding administrative lead. This meant not all staff were appropriately trained in safeguarding procedures. However, staff we spoke to knew who the safeguarding lead in the practice was and felt able to raise concerns.

Following the inspection, the practice told us a further GP had completed their safeguarding training, but this had been incorrectly recorded with the practice training monitoring system. The practice provided evidence to confirm this.

The practice shared concerns quickly and appropriately. The practice had worked with 2 local accident and emergency (AE) departments to help to improve communications regarding children who had attended AE. This included to add information about who the child presented with and to ensure health visitors were being informed where appropriate.

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

Emergency equipment was available and maintained. Staff had completed basic life support training, for adults and children. However, we found 3 members of staff were overdue sepsis training. Staff we spoke to could recognise a deteriorating patient and knew the action to take.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The governance systems for identifying and mitigating risks related to fire, health and safety and legionella were not established. We saw evidence an external provider carried out risk assessments related to fire, health and safety and legionella on 26 June 2026. However, no evidence was available to demonstrate these external risk assessments had been undertaken prior to June 2026 and all 3 risk assessments identified a significant number of high-risk actions requiring urgent completion.

The fire risk assessment identified 63 high-risk actions, including to digitise archived records and reduce the quantity of combustible paper records stored in the premises.

The health and safety risk assessment identified 50 high-risk actions, including to provide suitable measures to maintain a comfortable indoor working temperature and to replace the worn and damaged carpet.

The legionella risk assessment identified 7 actions as mains temperatures were unsatisfactory being above the maximum temperature, and the storage of hot water was well below the minimum requirement. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

The risk assessment reports had been received on the day of the inspection and therefore, the practice had not had time to review the findings of the external risk assessments at the time of the inspection.

We identified 5 members of staff were overdue training in health and safety, 2 members of staff were overdue fire safety training and 1 fire warden was overdue fire warden training.

However, the practice had created a new business continuity plan in May 2026 and planned to review this annually.

The practice did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles in the practice. Staff told us gaps in the reception and dispensary team had increased pressures to others in the practice. For example, the practice manager, practice nurse and health care assistant had to cover reception on several occasions and some lacked confidence in this role. The practice told us this had stopped in June 2026 as another receptionist had commenced employment.

The practice could not provide assurance that all staff were competent and skilled in their roles.

Not all staff were up to date with training identified by the practice as mandatory. A staff training list demonstrated 1 clinician had only completed 42% of their required mandatory training and 1 non-clinical member of staff had only completed 48% of their required training. We reviewed staff training records for all staff and found there were gaps in completion. For example, out of 14 staff members, 10 had not completed the appropriate level of training for learning disabilities and autistic people, 3 staff were overdue sepsis training, an identified fire warden was overdue appropriate training, and 7 staff were overdue safeguarding training.

The practice had not ensured appropriate recruitment checks were conducted in line with national requirements prior to staff starting work. The practice recruitment policy was last reviewed in December 2024 and did not align with national legislation. The practice had recently identified this risk and carried out a risk assessment to highlight gaps in all staff recruitment files and had started to obtain appropriate recruitment documentation for all staff members retrospectively. This included Disclosure and Barring Service (DBS) checks for 1 GP, 1 dispenser and 2 receptionists; references for 2 GPs, 2 receptionists and 1 medical secretary; evidence of the health care assistant’s care certificate; and immunisations for 4 non-clinical members of staff. We also found a physician’s associate had been providing cover support for 2 months without appropriate recruitment documentation, including references and DBS checks, in place prior to their start date. This meant the practice could not be assured they employed fit and proper staff before they commenced employment.

We found staff employed prior to March 2026 did not receive an appropriate induction programme or regular appraisals. This meant the practice could not be assured all staff were appropriately supported and prepared to carry out their roles effectively. In addition, ongoing support and development needed by staff was not being identified as part of a system of governance to enable staff to carry out the duties they were employed to perform. This had been identified by the newly appointed practice manager in March 2026, and a new induction programme and appraisal process were introduced as a result but had not been applied to staff employed prior to March 2026. During the inspection process, the practice ensured all staff received an appraisal.

The practice did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice had recently appointed a designated infection, prevention and control (IPC) lead but they had not yet attended appropriate training to carry out this role.

We reviewed 4 IPC audits completed by the newly appointed IPC lead between March 2026 and June 2026 and found all 4 lacked necessary information to illustrate the risk identified. They also did not have an action log to monitor progress and did not identify all IPC concerns. Risks which had not been identified in the audits included lack of mixer taps in clinical rooms, cleaning equipment had not been stored correctly and fabric non-wipeable noticeboards were in clinical rooms and the waiting area.

We found cleaning schedules were in place, but the practice did not monitor compliance and completion of these. The practice told us a new cleaning company was due to take over the contract on 13 July 2026, and compliance would be monitored appropriately. However, during the on-site visit, we did not observe any concerns regarding cleanliness of the environment.

There was limited assurance staff understood their responsibilities related to infection prevention and control (IPC). All staff had access to IPC training, but we found 3 members of staff were overdue IPC training. Staff and patients raised a significant IPC concern at the practice and told us that, until approximately 6 months ago, a cat was regularly allowed into the practice and into a clinical room, where it was fed and provided with a litter tray. The practice could not provide evidence this had been risk assessed at the time and we did not see evidence that the provider had considered potential risks related to allergies, phobias, IPC or that any changes or action had been taken following 2 staff members being scratched by the cat. At the time of the inspection, the practice assured us this would not reoccur and the new practice manager had implemented a risk assessment regarding this.

The practice could not provide assurance that all staff understood and consistently followed appropriate hand hygiene procedures. For example, only 1 hand hygiene audit had been carried out, in May 2026, but this only assessed the hand hygiene practice of 1 staff member out of 17 staff members, which was insufficient in terms of identifying any related risk and training requirements.

The issues identified at the inspection around hand hygiene and IPC raised concerns that the practice could not assure themselves that staff understood and consistently followed good practices and clinical guidelines.

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

As part of the inspection, we carried out clinical searches on the patient record system. This included a review of the management of patients prescribed medicines that required monitoring. We found systems and processes were in place to ensure patients prescribed medicines with associated risks had received recommended monitoring to mitigate those risks.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

There were processes which ensured medicines, including controlled drugs, were stored safely, at appropriate temperatures and stored securely with access restricted to authorised staff. This included processes for the appropriate authorisations to administer medicines (including Patient Group Directions). Staff managed prescription stationery appropriately and securely.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.

There were suitable processes for staff to follow when dispensing medicines. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.