Ash Trees 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 people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were not always learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and staff apologised and gave people support. We found, however, that documentation of incidents was not always done comprehensively, so it was not easy to understand the steps the practice had taken to investigate and what the learning outcomes were.

The service usually worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients; however, they were not always completed in a timely way. The service worked with other providers to deliver shared care, and when patients moved between services. Referrals and test results were managed in a timely way, and safety-netted to ensure time-critical referrals were followed up. The system used to oversee urgent referrals required a minor adjustment to ensure it was wholly effective. The service put this in place during our inspection.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations.

The service consistently worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

The practice had established various initiatives to review and monitor patients’ risk of chronic disease and ensure they received interventions to manage and reduce that risk.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. There was a business continuity plan in place which was monitored and reviewed. Health and safety risk assessments and audits had been undertaken. However, the documentation of such audits and risk assessments did not always identify if the risks had been addressed. It was not always clear if actions were still outstanding or had been closed. Therefore, there was not always the assurance that actions had been taken to reduce and mitigate the risks. A door was faulty or unlocked that allowed access to the restricted area of the practice by unauthorised persons.

The service made sure there were enough qualified, skilled and experienced staff, and although they received effective support, supervision and development, this was not always documented well. Some staff had not had a recent appraisal. Documentation of clinical support, particularly for staff in advanced clinical roles and non-medical prescribers, such as advanced nurse practitioners, clinical pharmacists and paramedics, was not readily available. Following the assessment, the provider informed us that all clinical staff had an up to date appraisal. The practice stated they engaged in the Integrated Care Board (ICB) prescribing audits, but they did not undertake dip sampling of consultations or record keeping nor keep individualised records of which cases were reviewed and discussed. The practice stated they had revised the appraisal process to enable it to better meet the needs of the practice. This was to be relaunched shortly after the inspection, and a recovery plan had been established to catch up on overdue appraisals. The practice told us they were ready to implement a process to provide tangible assurance around the monitoring of clinical staff also.

There was a range of clinical and non-clinical roles within the practice that worked well together to provide safe care that met people’s individual needs. We found the majority of training was up to date.

The practice provided us with their recruitment policy. The policy was in line with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and we observed that the process currently in place was effective in ensuring the safe recruitment of staff. However, records kept from previous recruitment episodes, including those in recent years, had gaps in evidence and were missing some key evidence, such as evidence of disclosure and barring service (DBS) checks, copies of evidence of photographic identity documents and evidence of professional registration. This was highlighted to the practice during the inspection, and they had started to take steps to remedy this. Following the assessment, the provider told us they had enrolled to the DBS update service to ensure the DBS checks for clinicians were up to date.

Staff were encouraged and supported to develop, and this was a particular strength of the practice. We saw evidence of staff who had successfully developed and adopted new roles and responsibilities such as becoming managers, general practice assistants, health care assistants and nurses. Some received funding to enable their development, and others were given opportunities to expand their skills in additional roles. The practice was a training practice which supported and developed student, trainee and junior doctors, feedback from whom was positive. We saw that there were opportunities for them to work independently, but with the presence of a mentor and experienced staff member for support and that there were teaching sessions built into their rotas.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading, but they did share concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and although actions were taken to mitigate risks, the documentation of this was not always recorded.

The practice had carpets in some clinical rooms; carpets are not recommended for clinical rooms, flooring should be smooth, seamless, slip-resistant, and easy to clean, such as vinyl or rubber. This had not been identified on infection prevention and control audits. The provider told us they had obtained quotes to change the flooring, and they hoped to commit to the project by the end of 2026.

We reviewed the practice IPC audits; we could see certain issues were identified, however, it was not always clear what had been done to remedy the issues and whether the issues had been addressed.

The service did not always make sure that medicines and treatments were managed and overseen appropriately to ensure they safe and met people’s needs, capacities and preferences.

Staff did not manage prescription stationery appropriately and securely. Records did not accurately show what prescriptions were kept where. Some stationery was not accounted for and recorded. The system did not provide a system of accounting for prescriptions, nor did it provide a means of determining if prescriptions had been misappropriated. Furthermore, the practice kept no records of handwritten prescription pads, so had no means to assure themselves of safe management of prescription stationery. Managers were informed about these issues identified and stated they would take immediate action. Following the assessment, the provider informed us that the issues we identified during the assessment had been rectified.

Practice nurses had not been appropriately authorised to administer certain medicines. We checked Patient Group Directions (PGDs) records, which are formal documents to authorise healthcare professionals to supply and/or administer specified medicines to patients without a specific prescription from a doctor, such as vaccinations administered as part of childhood immunisation programmes or shingles vaccinations given to vulnerable patients. Some of these had not been authorised, and in some cases, nurses were added to documents without an authorising manager having documented oversight.

We carried out a series of searches on the practice’s clinical systems as part of this assessment. We looked at patients who were being prescribed medicines that required regular monitoring, such as blood tests or blood pressure readings, in order to continue to ensure it remained safe to prescribe the medications. We found that in some cases monitoring was overdue or missing, but in most cases, patients had been sent requests to attend the monitoring. However, we found some 3 patients out of the 5 we reviewed with chronic kidney disease were overdue blood tests. This was raised with the practice who stated they would review those patients as necessary.

We looked at patient being prescribed non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are usually prescribed for pain relief, but they carry a risk of bleeding. It is recommended that they also receive proton pump inhibitor (PPI) medication, to reduce the risk of bleeding. Our searches revealed that this was not being done or documented why this was inappropriate. This was raised with the practice who stated they would review this issue without delay.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff usually followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews.

Where medicines were not available, patients were given the choice to obtain their medicines from another pharmacy to avoid delays in treatment. Prescriptions that had not been collected by patients were reviewed regularly and appropriate action taken with advice sought from the pharmacist.

Medicines for some patients were dispensed into dosette trays that divide medicines into the days and times they are to be taken.

There was a system in place to record medicines related errors, incidents and near misses. The practice should consider a more effective system for the oversight of any errors and near misses, along with analysis of themes and trends.