Ashley Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff monitored people’s care and treatment and supported them to live healthier lives. At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to Good.

This service scored 83 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service mostly planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, a review of clinical records identified practice, in line with national guidance, had not always been completely complied with in a small number of cases.

As part of our assessment, we conducted a detailed review of people’s care records. Records reviewed showed that best practice in the management of asthma exacerbations had not always been consistently followed. The practice had attempted to recall people following exacerbations of their asthma however, for a very small number of people, this was not carried out consistently.

Where people had not received the required monitoring for diabetes, the practice had made attempts to recall them and undertake a review. An escalation policy for non-compliance had also been put in place. However, recall, monitoring and follow-up processes were not consistently effective. People with significantly elevated blood test results were not always monitored or reviewed in line with planned follow-up arrangements, resulting in gaps in ongoing diabetes management and clinical oversight. This was judged to be a medium risk to people. Following our assessment, the provider reviewed the records of these 4 patients and shared with us the actions they had taken to appropriately address the concerns identified. They also told us that they had met with the nursing team and identified that staff had been performing searches on a regular basis however, the searches were flawed in their design meaning some patients had not being identified. Following our assessment, the provider updated their searches to ensure prompt escalation to ensure patients received the correct monitoring at appropriate intervals.

People with chronic kidney disease or hypothyroidism had received the required monitoring.

The provider had systems in place to ensure staff kept up to date with evidence-based guidance and legislation.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Our remote searches showed that patients with a potential diagnosis of diabetes had received appropriate care and treatment in line with guidance. Clinical staff told us they referred this group of people to a diabetic prevention programme. This was to help them to permanently lower their risk of developing type 2 diabetes through structured, expert-led guidance on diet, exercise, and weight loss.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives; patients at risk of developing long-term conditions; and those with caring responsibilities to support national priorities and initiatives to improve the population’s health. Staff championed national healthcare initiatives by signposting patients to lifestyle support. This included smoking cessation services and referring them to a local gym's discounted 12-week weight loss programme. Clinical staff promoted long-term well-being by signposting people to local walking groups and referring them to a social prescriber for lifestyle, well-being, and benefits advice.
 

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive, consistent and met the expectations of people themselves.

The service had exceeded the national average for the uptake of breast and bowel cancer screening. It met national targets for childhood immunisations reaching the 90% target for 4 indicators and the World Health Organisation (WHO) target of 95% for another indicator. However, national data from June 2024 for the uptake of cervical screening showed that screening rates fell short of the 80% national target. In particular, only 73% for women aged 25 to 49 years old and 76% for those aged 50 to 64 years. The service showed us more recent, unverified data from August 2026. This demonstrated a positive upward trend, with cervical screening uptake rising to 79% for the younger cohort and meeting the 80% target for the older cohort.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.