The Care Quality Commission
  • Doctor
  • GP practice

Ashfield Road Surgery

Overall: Good read more about inspection ratings

39 Ashfield Road, Fordhouses, Wolverhampton, West Midlands, WV10 6QX (01902) 783372

Provided and run by:
Dr Archana Nandanavanam

Important: The provider of this service changed - see old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 10 June 2026. Ashfield Road Surgery is a GP practice and delivers services to approximately 6200 people under a contract held with NHS England. There is a branch site within Pendeford Health Centre. According to the latest available data, the ethnic make-up of the service area is approximately 72% White, 12% Asian, 8% Black 6% Mixed, and 2% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 3rd decile (3 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE - Staff maintained clean facilities and ensured equipment was appropriately maintained to help keep people safe. They assessed and managed infection prevention and control risks effectively and took action to reduce the risk of infection spreading. We identified areas for improvement in the documentation of health and safety risk assessments. A documented review and risk assessment of the recently revised recruitment process was required. There were enough staff with the appropriate skills, qualifications and experience to meet the needs of people using the service.

 

EFFECTIVE - Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes. The service was aware of the challenges relating to the uptake of immunisations and health screening and were active in an approach to increase the number completed.

CARING - Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity. We observed a caring and supportive service for people.

RESPONSIVE - People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers. We saw examples of how the service ensured peoples personal choices were considered.

WELL-LED The service had a clear vision and strategy that reflected the needs of the people who used the service and the wider community. Staff understood their individual roles and responsibilities and were able to explain how their work contributed to the service’s aims and objectives. Leaders demonstrated accountability for the actions, behaviours and performance of staff through effective governance and oversight processes, which supported the delivery of safe and effective care.

23 September 2021

During an inspection looking at part of the service

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

25 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Ashfield Road Surgery on 25 February 2019 as part as part of our inspection programme.

We based on 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 safeguarding policy was not updated to reflect updated categories of abuse.
  • Not all staff had received safeguarding training appropriate to their role.

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

  • There were gaps in the practice’s governance arrangements.
  • Effective management oversight of systems to confirm ongoing monitoring and improved processes was not evident.
  • The practice did not have management oversight of the maintenance of up to date records of staff qualifications and training.
  • When incidents happened, the practice investigated but there was an absence of fully documented records of the incident to clearly show the actions taken to prevent further occurrence and embedded learning.
  • The minutes of meetings lacked detail to demonstrate, who had attended, discussions held, decisions made, action to be taken and by who and learning to be disseminated.

We rated the practice as good for providing effective, caring and responsive services because:

  • 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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice had a documented programme of planned clinical and internal audits.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had reviewed its staffing structure and skill mix to ensure it could meet the changing needs of its patients.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Update the business continuity plan to include details of new staff.
  • Develop a documented practice strategy to support its vision and values.
  • Review the contents of the spillage kit.
  • Include checks of the blinds when undertaking assessments of the safety of the premises to ensure the locking system is working.

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