All inspections: Ashmore Park Health Centre

We carried out a review of the data available to us about Ashmore Park Health Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Ashmore Park Health Centre, you can give feedback on this service.

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

We carried out an announced focused inspection at Ashmore Park Health Centre on 4 June 2019 following our annual review of the information available to us. This inspection looked at the following key questions (Safe, Effective and Well Led). The service was previously inspected in April 2018 and was rated requires improvement in safe and good overall. The report on the April 2018 inspection can be found by selecting the ‘all reports’ link for Ashmore Park Health Centre on our website at .

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

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

The practice had not ensured that all staff had completed safeguarding training.
The practice had not reconciled its safeguard register with the support of other professionals.
Effective arrangements were not in place to ensure children who were not brought to a secondary health care appointments were followed up.
Staff recruitment practices were not consistently followed and there were gaps in the staff recruitment documents available in staff files.
The practice did not have effective systems in place for the safe prescribing and monitoring of all high-risk medicines.
The practice carried out intrauterine device fitting services (coil fitting) but did not have Atropine available to be used in the event of an emergency.
There was a lack of records to demonstrate that the provider had ensured all staff were up to date with immunisations relevant to their role.
Fire marshals were not named in the fire safety policy and evidence that they had been trained for the role was not available.
The practice had a lack of documented risk assessments and had not followed up on the health and safety assessments carried out at the health centre.

We rated the practice as good for providing effective services because:

There was monitoring of the outcomes of care and treatment.
The practice was able to show that most staff had the skills, knowledge and experience to carry out their roles.
The practice ensured that consent to care and treatment was always obtained.
Performance data for the practice showed that it was significantly above local and national averages in most areas.

We rated the practice as requires improvement for providing well-led services because:

While the practice had made some improvements since our inspection on 15 January 2018, it had not appropriately addressed the Requirement Notice in relation to the monitoring and recording of emergency equipment and emergency medicines. At this inspection we also identified additional concerns that put patients at risk.
Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a clear vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements were ineffective.
The practice did not have clear and effective processes for managing risks, issues and performance.
The practice did not always act on appropriate and accurate information.
We saw little evidence of systems and processes for learning, continuous improvement and innovation.

Although the population were rated as good for providing effective services. The overall rating for the practice is rated as requires improvement and affects all population groups, so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services at the inspection in April 2018. These areas were not inspected at this inspection.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Recruitment procedures must operate effectively to ensure that all the documents specified in Schedule 3 were available for each person employed in the carrying out of regulated activities.
Ensure the practice premises have appropriate documented health and safety and security risk assessments in place.

(Please see the specific details on action required at the end of this report).

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

This practice is rated as good overall.

The key questions 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 Ashmore Park Health Centre on 18 April 2018 as part of our inspection programme.

At this inspection we found:

When incidents happened, the practice learned from them and improved their processes.
The practice had systems to keep patients safe and safeguarded from the risk of abuse.
Staff recruitment practices were not in line with legal requirements.
Systems had not been implemented to ensure that health and safety risk assessments were completed.
Effective systems were not in place to monitor training completed by staff and some staff had not received mandatory training.
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.
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. However, some patients expressed concerns about the length of time they had to wait at their appointment.
The patient participation group was active.
There was a strong focus on continuous learning and improvement at all levels of the organisation. There were some gaps in the practice’s governance arrangements.

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
Ensure specified information is available regarding each person employed.

For details, please refer to the requirement notices at the end of this report.

The areas where the provider should make improvements are:

Review the arrangements for the ongoing maintenance of all equipment used at the practice to ensure it is safe to use.
Implement clearly identified systems to monitor staff receive training and are up to date in health and safety related topics.
Review the induction records to make sure the induction process reflects individual staff roles.

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

Ashmore Park Health Centre

All Inspections

6 July 2023

During a monthly review of our data

6 October 2021

During an inspection looking at part of the service

4 June 2019

During an inspection looking at part of the service

18 April 2018

During a routine inspection