The Ash 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 premises had a number of new refurbishments and building extensions since the last assessment. In older parts of the building the provider acknowledged there were on-going issues with maintenance and ensuring the building remained fit for purpose.

The service had health and safety and fire risk assessments in place to evaluate, address, and monitor any safety concerns related to the premises.The service had systems in place to test electrical equipment to ensure it was safe to use, contracts were in place for this and records we saw indicated the required electrical and health and safety checks were completed annually. There was a business continuity plan in place which was monitored and reviewed.

During the tour of the building, we observed that compressed gas, such as a liquid nitrogen was not stored in a suitable room. The service confirmed that staff carried out checks on emergency equipment however, these were completed monthly and records were not kept to demonstrate this. A central system alerted the service when medicines had become, or were about to come out of date.

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, advanced nurse practitioners and practice nurses. The service also supported GP registrars. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. A number of staff had not completed mandatory training at the time of assessment, but arrangements were in place to support this.

There were safe recruitment practices to make sure that all staff, including agency staff, were suitably experienced, competent and able to carry out their role. Processes were in place to ensure staff were fit to work at the service, for example Disclosure and Barring Service (DBS) checks for staff were completed. Systems were in place to ensure staff received good support, supervision and appraisals for their professional development. Staff confirmed they received training appropriate and relevant to their role. They told us they felt supported with their professional development and were given opportunities to learn. Interviews with staff confirmed that meetings took place with non-medical prescribers to review their prescribing practice, such as advanced nurse practitioners. We observed that some staff who required it, had not completed Level 3 training in both safeguarding children and adults. The practice manager advised this would be addressed immediately.

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 provider carried out infection prevention and control (IPC) audits and took action where needed. The last external audit was carried out in February 2026; results indicated some improvements were needed and the service achieved 94% compliance with the risk assessment.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. These were monitored by the management team to ensure effective 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 had an IPC lead, and all staff completed mandatory IPC training. The service stocked sufficient personal protective equipment and positioned it appropriately throughout the premises.

The service-maintained staff vaccinations in line with current UK Health Security Agency (UKHSA) guidance, where relevant to their roles. They also operated a system to report infection-related concerns, including notifiable diseases, to relevant agencies.

The service had arrangements for the collection, handling and testing of urine samples. However, this activity took place at the back of the reception areas which was not a suitable space for this activity and posed significant infection control risks. The sample fridge also had medicines inappropriately stored within it. We noted that staff in one of the consultant rooms, did not have access to running hot water for hand washing.

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