The Care Quality Commission
  • Doctor
  • GP practice

Ashwell Medical Centre

Overall: Good read more about inspection ratings

Ashwell Road, Manningham, Bradford, West Yorkshire, BD8 9DP (01274) 495879

Provided and run by:
Ashwell Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Ashwell Medical 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 Ashwell Medical Centre, you can give feedback on this service.

28 September 2021

During a routine inspection

We carried out an announced inspection at Ashwell Medical Centre on 23 and 28 September 2021. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - good

Effective – good

Caring - good

Responsive - good

Well-led – good.

The practice was inspected on 13 February 2019 and was rated as requires improvement overall and requires improvement for providing caring and responsive services. All of the population groups were rated as requires improvement.

A comprehensive follow-up inspection was completed on 10 March 2020. Following this inspection, the practice was rated as requires improvement overall and requires improvement for providing safe, effective and well-led services. The population groups; families, children and young people and working age, were also rated as requires improvement. We rated caring and responsive as good.

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

At this inspection we rated the practice as good overall and good in all five key questions. We rated all the population groups as good.

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to check that improvements had been made in respect of concerns and issues identified at our previous inspection.

At the last inspection in March 2020, breaches of regulation 12, safe care and treatment and regulation 17, good governance of the Health and Social Care Act 2008 (regulated activities) Regulations 2014 were found and it was noted that the practice should make the following improvements:

  • Continue to encourage and improve uptake rates for childhood immunisations.
  • Continue to encourage and improve uptake rates for cancer screening programmes, particularly those relating to cervical screening.
  • Develop systems to monitor and track referrals.
  • Improve systems for reviewing complaints and concerns to ensure learning arising from these is captured and embedded into processes for continuous improvement.

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 inspections 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 of the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A site visit
  • Requesting staff complete feedback forms.

During the site visit we conducted interviews with the registered manager and lead GP, the business manager, the assistant manager, the lead nurse, patient engagement lead, the referrals lead and the data quality manager.

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.

At this inspection we found:

  • At this inspection we found that the provider had responded to the previous concerns and breaches of legislation. We saw that improved systems and processes supported good governance.
  • During the inspection we found that the actions which the practice were taking to encourage the uptake of immunisations and cancer screening supported good care. We found that improvements had been made in the uptake rates for childhood immunisations, bowel and breast screening.
  • The provider had developed a system to monitor and track referrals. We saw that patients were supported through the process of choosing and making an appointment in secondary care.
  • The support offered by the team to a local nursing home was described by the home manager as exceptionally positive. We were told that nothing was too much trouble for the team, weekly reviews were carried out and visits made on request throughout the COVID-19 pandemic.
  • 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 variety of ways at a time to suit them.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • We saw that the practice was managing complaints as per their policy and these were used to drive improvement.

We saw an area of outstanding practice :

  • End of life care was person-centred, family orientated and delivered in a culturally sensitive and coordinated manner. When a terminal diagnosis was received, the GP, patient engagement lead and a community team member visited the patient at home. This appointment aimed to identify a named family contact to ease communication with the practice and begin difficult conversations regarding the person’s wishes. For example, this included offering advice regarding benefits and available support, do not resuscitate orders and a preferred place of death discussion. The family were also offered a copy of the newly implemented practice protocol for managing bereavement and continued support.

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

  • Review historical safety alerts to reduce the potential for error with patients who take a combination of medicines which may interact with each other.
  • Take steps to improve the recording of meeting minutes, to provide enough information to update those staff who were unable to attend the meeting.
  • Continue to encourage and improve uptake rates for childhood immunisations.
  • Continue to encourage and improve uptake rates for cancer screening programmes, particularly those relating to cervical screening.

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

10 Mar to 10 Mar 2020

During a routine inspection

We carried out an announced comprehensive inspection at Ashwell Medical Practice on 13 February 2019. The overall rating for the practice following that inspection was requires improvement. The key questions of caring and responsive along with all population groups were rated as requires improvement. The inspection report for that inspection can be found by selecting the ‘all reports’ link for Ashwell Medical Practice on our website at.

This inspection was an announced comprehensive inspection, which we carried out on 10 March 2020, to check progress the provider had made to address concerns previously raised and make the necessary improvements.

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 provided by the practice,

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

At this inspection we have rated the practice as requires improvement overall, and for providing safe and well-led services. We rated the practice as requires improvement for providing effective services to the population groups of families, children and young people and working age people, and therefore requires improvement for effective overall.

We rated the practice as good for providing a caring and responsive service and for providing care to the four population groups of older people. People with long term conditions, people whose circumstances make them vulnerable, people experiencing poor mental health (including people with dementia).

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm. This was because the systems in place did not adequately ensure the security of blank prescription stationery, some Patient Group Directions were not valid, equipment and clinical supplies which were past their use by date were still in use and named patient medicines were kept in unlocked cabinets.
  • The practice had recruited new staff to support the running of the service. This included a practice nurse and a patient experience lead.
  • Patients did not receive effective care and treatment that met their needs. Key quality indicators showed further reduction in performance including uptake of childhood immunisation and cancer screening.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice patient participation group was committed to supporting patients, particularly with healthy lifestyle interventions, such as healthy eating information events.
  • Staff were engaging with patients and providing information for patients whose first language was not English.

The areas where the provider must make improvements are:

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

  • Continue to encourage and improve uptake rates for childhood immunisations.
  • Continue to encourage and improve uptake rates for cancer screening programmes, particularly those relating to cervical screening.
  • Develop systems to monitor and track referrals.
  • Improve systems for reviewing complaints and concerns to ensure learning arising from these is captured and embedded into processes for continuous improvement.

13 February 2019 to 13 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Ashwell Medical Centre on 13 February 2019.

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. The practice had previously been inspected in February 2015 when it was rated good overall.

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

  • Patient satisfaction regarding consultations and their involvement in discussions regarding their care and treatment was significantly below local and national averages.
  • The numbers of carers identified and supported by the practice was below 1%.

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

  • Patient satisfaction regarding making and accessing appointments was mixed. Although the practice had introduced improvements to increase access to appointments these still needed to be fully embedded and reviewed for their effectiveness.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing safe, effective and well-led services because:

  • 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.
  • 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.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • Staff told us that felt supported by the practice, and we saw evidence that staff had been enabled to attain additional skills and qualifications.
  • The practice had made active provision to support patients whose first language was not English.

The areas where the provider should make improvements are:

  • Review and improve the identification of patients who acted as primary carers for others.
  • Review and improve child immunisation performance.
  • Review and improve performance in relation to cervical, breast and bowel screening.
  • Continue to improve patient access and the involvement of patients in their own care and treatment.

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

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

17 February 2015

During a routine inspection

We carried out an announced inspection visit on 17 February 2015. The overall rating for the practice was good. Specifically, we found the practice was good in providing: safe, responsive and effective care for all of the population groups it serves.

Our key findings were as follows:

  • Where incidents had been identified relating to safety, staff had been made aware of the outcome and action was taken where appropriate, to keep people safe.
  • All areas of the practice were visibly clean and where issues had been identified relating to infection control, action had been taken.
  • Patients received care according to professional best practice clinical guidelines. The practice had regular information updates, which informed staff about new guidance to ensure they were up to date with best practice.
  • The service ensured patients received accessible, individual care, whilst respecting their needs and wishes.
  • We found there were positive working relationships between staff and other healthcare professionals involved in the delivery of service.
  • Evidence we reviewed demonstrated patients were satisfied with how they were treated and this was with compassion, dignity and respect. It also demonstrated the GPs were good at listening to patients and gave them enough time.
  • The practice had an open culture that was effective and encouraged staff to share their views through staff meetings and significant event meetings.

We saw several areas of outstanding practice including:

  • The patient participation group (PPG) worked with the practice to provide a voice for the patient and to help develop the service collaboratively. The PPG were also involved with health campaigns for instance diabetes advice and during the flu season promoting vaccinations.
  • The practice actively supported ‘Practice Health Champions’ who were volunteers. They work in partnership with the practice to find new ways to improve the patients’ health with healthy eating groups and walking groups.
  • The appointment system was effective providing a mix of open access appointments, emergency and routine appointment. Waiting times for routine appointments were no longer than four days on average.
  • A translator for the South Asian languages was available in the practice throughout surgery times to support patients with their language needs.

However, we also found an area in which an improvement was needed.

  • While the practice did undertake an annual fire safety check, more frequent audits of their systems was needed as was further training of their staff on actions they should take in the event of fire.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice