Ashville Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 72 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The practice had systems and processes to maintain a safe environment and manage associated risks. The premises were nearing completion of an extensive refurbishment, which included new treatment rooms, changes to the building layout, new ramps providing step-free access, relocation of reception to improve accessibility and installation of a lift to the first-floor treatment rooms. The waiting area provided sufficient space for wheelchair users. Records showed weekly fire alarm testing, emergency lighting testing, fire drills and checks of fire doors. Equipment calibration and PAT testing was completed annually.

The service had contracts to ensure the premises were maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, paramedics and pharmacists. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check.

The practice had systems to help ensure staff had the skills, qualifications and competencies required for their roles. Mandatory training was managed through an online platform and compliance was nearly at 100% for all staff members. Staff had also completed autism awareness training.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had completed an infection prevention and control audit in March 2026 and actions identified had been resolved.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control.

The practice had systems to support the safe use and monitoring of medicines; however, our review identified areas where these systems were not always effective or consistently applied. There was evidence that staff took action when individual concerns were identified, but improvements were required to ensure people’s medicines were appropriately reviewed and monitored.

We looked at people taking medicines that require regular blood tests and other monitoring. In some cases, these checks were overdue. There was evidence that the practice had tried to contact people who had not attended for monitoring, and staff took action when concerns were identified. However, the practice recognised that it needed a more reliable way of identifying and following up people whose monitoring was overdue.

We reviewed people taking a medicine often used to treat autoimmune disease, a medicine which requires regular blood tests. Most of the people we looked at had their medicine managed by hospital specialists. One person had overdue blood tests. The practice had sent reminders and reduced the amount of medicine being prescribed while waiting for the tests. We found that this person had blood test results available from April 2026, but these had not been added to their GP record. Their prescription also did not state which day of the week the medicine should be taken. The practice recognised this and agreed to make improvements.

Medication reviews were not always detailed enough to show that staff had considered issues such as whether people were taking their medicines as prescribed, possible interactions with other medicines and whether any monitoring was needed.