• Doctor
  • GP practice

Ashmore Park Health Centre

Overall: Good read more about inspection ratings

Griffiths Drive, Wolverhampton, West Midlands, WV11 2LH (01902) 732442

Provided and run by:
Dr Rajashree Rajcholan

Latest inspection summary

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Background to this inspection

Updated 6 December 2021

Ashmore Park Health Centre is located in Wolverhampton at Griffiths Drive, Wolverhampton, West Midlands WV11 2LH.

The provider is registered with CQC to deliver the Regulated Activities: Diagnostic and screening procedures; Family planning services, Maternity and midwifery services; Surgical procedures and Treatment of disease, disorder or injury.

Services provided at the practice include the following clinics: long-term condition management including asthma, diabetes, hypertension (high blood pressure), minor surgery and immunisation.

Ashmore Park Health Centre is a member of the NHS Black Country and West Birmingham Clinical Commissioning Group (CCG).

The practice provides services to patients of all ages based on a General Medical Services (GMS) contract with NHS England for delivering primary care services to a patient population of about 4,193.

Information published by Public Health England shows that deprivation within the practice population group is in the third decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is, 88.8% White, 5.2% Asian, 3% Mixed and remaining 3% black and other ethnicity.

The age distribution of the practice population closely mirrors the local and national averages.

There is an equal number of male and female patients registered at the practice. The main population group are of working age.

The practice team consists of a lead GP (female), two part-time salaried GPs (both male) and a long-term GP locum (male). The GPs work an equivalent of ten sessions per week. The GPs are supported by a practice nurse and a healthcare assistant who both work part time. Clinical staff are supported by a practice manager, and four administration / receptionist staff. In total there are 11 staff employed either full or part time hours to meet the needs of patients.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations.

The practice is open and offers appointments between 8.30am and 6.30pm Monday, Tuesday, Thursday and Friday, 8am to 1pm on Wednesday.

The practice is part of the Unity East Network, a wider network of GP practices. Extended access is provided locally at identified sites through the group of practices within the network where evening appointments are provided between 6.30pm and 8pm.

The practice does not provide an out-of-hours service to its own patients but directs patients to out of hours services through the NHS 111 service.

Additional information about the practice is available on their website:

www.ashmoreparkmedicalcentre.co.uk

Overall inspection

Good

Updated 6 December 2021

We carried out an announced inspection at Ashmore Park Health Centre over a period of four days, the final inspection date was the 6 October 2021 when we carried out an onsite inspection visit. Overall, the practice is rated as good.

Ratings for each key question:

Safe – Good

Effective – Good

Well Led – Good

Ashmore Park Health Centre was previously inspected in June 2019 and rated requires improvement overall and for all population groups.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashmore Park Health Centre on our website at www.cqc.org.uk

Why we carried out this review

This inspection was an announced inspection to follow up on:

  • the requirement notices issued at the last inspection in June 2019.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing / telephone
  • Completing clinical searches on the practice’s patient records system and discussing the findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • Carrying out a site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services

information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall and good for all population groups

We found that:

  • The practice had reviewed its systems for managing its safeguarding registers to ensure they were up to date and reflected the current situation for each patient.
  • The practice had put appropriate arrangements in place to ensure children who were not brought to secondary health care appointments were followed up.
  • Staff recruitment practices had improved and the required recruitment documents were available in staff files.
  • The practice had reviewed its systems for the safe prescribing and monitoring of high-risk medicines.
  • The practice ensured Atropine was available to be used in the event of an emergency when providing intrauterine device fitting services (coil fitting).
  • Named fire marshals had been identified and received appropriate training to carry out the role.
  • The practice followed up on the outcome of the health and safety risk assessments of the premises carried out by the NHS Property Services team.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • Governance arrangements had been reviewed and a documented strategy developed for monitoring practice performance introduced.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve the monitoring and review of patients prescribed high risk medicines.
  • Proactively review and act on patient feedback to ensure timely action and responses are taken when needed.
  • Proactively review and act on the uptake of cervical smear screening at the practice to ensure timely action can be taken where appropriate.
  • Proactively review and act on the uptake of childhood immunisations.
  • Review the practice website to ensure patients have access to relevant and up to date information.

Review the process for updating clinical records and implementing appropriate action in response to safety alerts and good practice guidance received.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care