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Reports


Review carried out on 21 September 2019

During an annual regulatory review

We reviewed the information available to us about Ashville Surgery on 21 September 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 26 November 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ashville Surgery on 14 January 2016. The overall rating for the practice was good, with a requires improvement rating for the key question of safe and we issued a requirement notice for breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment). The full comprehensive report on the January 2016 inspection can be found by selecting the ‘all reports’ link for Ashville Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 26 November  2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches identified in the requirement notice.

Overall the practice is now rated as good, with the previous rating of requires improvement for the key question of safe updated to a rating of good.

Our key findings were as follows:

  • The practice was able to demonstrate that they had considered risks and identified mitigating actions in a number of areas.

  • Systems were in place to monitor the use of prescription paper

However, there was an area of practice where the provider should make improvements.

The provider should:

  • Consider current guidance from the Resuscitation Council (UK) as part of their risk assessment and rationale for no defibrillator on site.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ashville Surgery on 14 January 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where we found outstanding practice:

  • The care was delivered from a family perspective with a dynamic team.
  • The practice had received the “LGF Gold Award” from the lesbian and gay foundation for their work with this community.
  • The practice was working with other local practices and the community nursing team to actively support and mange people living in care and nursing homes to avoid unplanned admissions into hospital. Data had shown a reduction of hospital admissions by 62%.
  • A duty doctor with no appointments was available during all opening hours to see urgent appointments.
  • The practice offered an active programme of support for families undergoing the difficult process of seeking asylum.

The areas where the provider must make improvements are:

  • Ensure a thorough review of risks is undertaken with appropriate mitigating actions. For example, risks in relation to not having a defibrillator, lone working, carrying blood samples and health and safety risks.
  • Ensure there is a system to monitor the traceability of the prescription paper used in the practice with regular audits.

In addition the provider should:

  • Ensure recruitment arrangements include all necessary employment checks for all staff employed by the practice.
  • Ensure all staff have the relevant training to carry out their role and responsibilities and ensure all staff receive supervision and appraisal within appropriate timescales.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice