• Doctor
  • GP practice

Ashburnham Road Surgery

Overall: Good read more about inspection ratings

8 Ashburnham Road, Bedford, Bedfordshire, MK40 1DS (01234) 358411

Provided and run by:
Dr Satwinder Singh Basra

All Inspections

24 Sept 2019

During an inspection looking at part of the service

The service is rated as Good overall.

We carried out an announced focused desktop inspection of Ashburnham Road Surgery on 24 September 2019 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation.

The practice received an overall rating of Good at our inspection on 14 November 2019 when a requirement notice was issued. The practice was rated as requires improvement for providing safe services.

The full comprehensive report from the November 2019 inspection can be found by selecting the ‘all reports’ link for Ashburnham Road Surgery on our website at .

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

The practice is rated as good overall.

This means that:

  • An infection control audit had been completed
  • Cleaning schedules had been completed for the building and non-single use equipment. We saw evidence that cleaning had been completed appropriately.
  • Fabric chairs had appropriate cleaning schedules in place.
  • Mitigating actions were being taken to reduce the risk of legionella.
  • All significant events were recorded on a practice log and learning was shared within the team.
  • The practice had introduced protocols to ensure that children attending secondary care had this recorded in clinical records.
  • The practice continued to opportunistically screen for cervical cancer and had employed an additional female nurse to improve access to this service.

The area where the provider should make improvements are:

  • Continue to increase the number of patients attending for cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14 Nov

During a routine inspection

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Ashburnham Road Surgery on 14 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Performance quality indicators for the practice were above local and national averages in several areas.
  • The practice employed a clinical pharmacist that regularly audited prescriptions to improve care. The practice worked with local pharmacies to improve patient compliance and education.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • We received a high number of CQC comment cards that were positive about the quality of care received.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, we saw some events that had not been accurately recorded as significant events.
  • The practice did not hold a record of staff immunisations. The practice was in the process of implementing a system to record these but it had not been implemented yet. Shortly after the inspection, we received evidence and assurance that this had been completed.
  • The practice had completed an infection control audit however, not all concerns had been identified. The practice was not able to assure us or provide evidence that cleaning had been completed. The premises had areas of poor maintenance.
  • The practice did not conduct any mitigating actions to reduce the risk of legionella. (Legionella is a term for a bacterium which can contaminate water systems in buildings).

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Continue to encourage patients to access national cancer screening programmes.
  • Ensure that all information is recorded in clinical notes regarding children not attending hospital appointments.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

25 August 2016

During an inspection of this service