Background to this inspection
Updated
24 November 2021
Ashfield Road Surgery is located in Wolverhampton at Ashfield Road, Fordhouses, Wolverhampton, West Midlands WV10 6QX. The practice operates over two sites. The main practice is based at Ashfield Road Surgery and the other is located at, Pendeford Health Centre, Whitburn Close, Pendeford, Wolverhampton WV6 5NJ. For this inspection a visit was made to the Ashfield Road Surgery site only. Patients can access services at either practice.
The provider is registered with CQC to deliver the Regulated Activities; Diagnostic and screening procedures, Family planning, Maternity and midwifery services 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.
Ashfield Road Surgery 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 5,690.
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, 77.9% White, 8.9% Asian, 6.7% Black, 5.7% Mixed and 0.7% 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.
There is a team of two GPs (one female, one male) who provide cover at both practices. The GPs work a total of 17 sessions between them. The practice also uses a regular locum GP to support the practice and provide continuity for patients at times of absence. Other clinical staff who all work part time include a specialist nurse practitioner, an advanced nurse practitioner, an advanced clinical pharmacist and a health care assistant. The clinical staff are supported by two practice managers, and seven administration/reception staff. In total there are 15 staff employed either full or part time hours to meet the needs of patients across both sites.
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 part of the Wolverhampton North Primary Care 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.
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. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Additional information about the practice is available on their website:
www.ashfieldroadsurgery.co.uk
Updated
24 November 2021
We carried out an announced inspection at Ashfield Road Surgery over a period of four days, the final inspection date was the 23 September 2021 when we carried out an onsite inspection visit. Overall, the practice is rated as good.
Set out the ratings for each key question:
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 25 February 2019, the practice was rated as requires improvement overall. We rated the practice as requires improvement for providing safe and well services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashfield Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was an announced follow up inspection to follow up on:
- Breaches of regulations and ‘shoulds’ identified at the previous inspection in February 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 inspection differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Conducting staff interviews using video conferencing
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short 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 and
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and Good for all population
We found that:
- The practice had taken appropriate action to support and protect patients identified as at risk from harm.
- 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 had management oversight of staff qualifications and training.
- The arrangements for the management of incidents and complaints was reviewed and systems introduced to demonstrate learning and improvements at the practice.
- Staff were clear and knowledgeable about their lead roles and responsibilities.
- Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The improvements made at the practice showed a clear leadership structure and staff roles and responsibilities which promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve the documentation and monitoring of complaints, incident and significant events.
- Review systems to improve the monitoring and review of patients prescribed high risk medicines.
- Review the systems in place for monitoring relating to medicines identified in safety alerts to demonstrate that best practice guidance is followed.
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