Ashcroft 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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection, we rated this key question as good. At this inspection, the rating has changed to requires improvement.As a result, we have identified a breach of Regulation 17: Good Governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patients and their communities.

Leaders and practice staff understood their patient population, including cultural needs and wider challenges.

All staff we spoke to demonstrated a shared commitment to the values of the practice and the practices’ vision to deliver high quality patient care and to ‘make every patient contact count’.

Not all leaders understood the context in which the practice delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Staff acknowledged the challenges they had with recent changes in leadership and spoke positively about the new manager joining and felt communication and support would improve. Staff who recently joined the practice felt welcomed by leaders and colleagues.However, some staff reported they did not feel confident actions were taken by leaders when concerns were raised.

Leaders could not demonstrate they always understood the challenges which impacted staff and patients at the practice and therefore had not always identified actions to address these. We highlighted a number of concerns during the inspection process that had not been identified or mitigated by the practice. For example, the practice provided services without being appropriately registered and infection prevention and control concerns.

However, 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 practice fostered a culture where patients 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 who the freedom to speak up guardian was and knew how to raise concerns, and we found examples where staff had used the arrangements in place.

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

Policies and procedures to promote diversity and equality were in place. Staff had undertaken equality and diversity training. Leaders told us they would make reasonable adjustments for staff where required to enable them to carry out their roles effectively.

The practice did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Staff and leaders informed us of the challenges the practice had experienced over the last 12 months due to changes in leadership. Staff told us the changes had impacted the overall governance and management of the practice. However, all staff spoke positively about the new practice manager and changes were being made to improve the overall governance of the practice.

At the time of the inspection, we found systems were not always effective in identifying, mitigating and monitoring risk. Leaders could not demonstrate they understood their regulatory responsibilities to notify the CQC of registration changes and ensure they were registered for all activities requiring registration with CQC. For example, we found the practice had been providing the service of contraceptive coil removals on site without being appropriately registered for family planning services. This was raised with the practice who told us they would cease this procedure and would submit the relevant application to update their registration. However, this had not been received 6 weeks after inspection.

The practice had not ensured consistent oversight of recruitment in line with legislation and staff files did not contain all required documentation to evidence safe recruitment was in place prior to employment. The governance system for monitoring and ensuring staff had appropriate competency, skills and completed appropriate professional development was not adequate. We identified gaps in mandatory training, including infection prevention and control and safeguarding, and a staff member had been appointed a new lead role without appropriate training in place.

The governance system for assessing the risk of, and preventing, detecting and controlling the spread of infections was not adequate. There was limited assurance staff understood their responsibilities in relation to infection prevention and control (IPC) or that the practice had identified and mitigated IPC risks effectively to ensure patients and staff safety.

The governance systems for identifying and mitigating risks related to fire, health and safety and legionella were not established. There was a lack of process and oversight over completion of administrative tasks. Governance systems to process and store information relating to new patients were not effective as we found a significant backlog of paper notes awaiting digitisation.

Systems for documenting Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were not effective as they were not routinely completed in full by a clinician. The practice did not appropriately record and ensure that all patients using the service had given consent before care and treatment and this had not previously been identified in the clinical review of staff notes.

This indicated the governance framework was not effective or embedded. Following the feedback shared at the first visit in June and the second visit in July, we saw evidence the provider had commenced a series of actions to improve the governance arrangements. However, these actions and necessary changes would take time to be sustained and embedded fully.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for patients. 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, flu and covid vaccination programmes and social prescribing.

The practice had a Patient Participation Group (PPG) which had re-engaged in April 2026, following a period of non-engagement, but membership numbers were currently low and the practice planned to try to increase participation. Despite this, the practice was able to demonstrate evidence of recent engagement and members of the PPG spoke positively about future engagement with the practice.

The practice did not always focus on continuous learning, innovation and improvement across the organisation and local system. Ineffective governance systems limited the ability of the practice to identify areas for improvement and proactively implement changes.

However, throughout the inspection, leaders demonstrated openness and a genuine commitment to addressing identified concerns. The practice engaged constructively with the inspection process and took immediate action to begin to address identified risks. At the time of the inspection, overarching governance, learning and improvement systems and processes were not operating effectively or had not yet been fully embedded.