Ashfield House - Annesley Woodhouse

Updated 31 January 2018

• Ashfield House provides primary medical services to approximately 6000 patients in Kirkby-in-Ashfield. The practice operates from a single location at 194 Forest Road, Kirkby-in-Ashfield, Nottingham NG17 9JB.

• The practice opens between 8:30am and 6.30pm Monday to Friday with appointments available between these times. The phone lines are open from 8am to 6.30pm. An extended hours service is offered on a Tuesday and Friday morning from 7am to 8am for patients who are not able to attend during regular opening hours. Additional pre-bookable appointments are available for patients Monday to Friday from 6.30pm to 8pm and Saturday 9am to 12pm. This service is offered in collaboration with eight local practices.
• The practice has opted out of providing out of hours services to their own patients and there is information available on the website and the practice answerphone which directs patients to the out of hours service.
• Services provided include minor surgery, family planning and midwifery, health promotion and screening and a range of clinics for long-term conditions. The practice holds a General Medical Services contract to deliver essential primary care services.
• The practice currently has a team which includes two male GP partners, advanced nurse practitioners, practice nurse, healthcare assistants, practice manager, assistant practice manager and reception, administrative staff and cleaners.

Updated 31 January 2018

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Ashfield House on 17 November 2017. This inspection was to confirm that the practice had carried out their plan to make the improvements required identified in our previous inspection on 6 April 2017. This report covers our findings in relation to those requirements and any additional improvements made since our last inspection.

We carried out an announced inspection in March 2015 and the practice was rated as requires improvement. The practice was required to make improvements within six months as the safe domain had been rated inadequate. At the October 2015 inspection, the practice had made the required improvements to the safe domain. The October 2015 inspection found breaches of legal requirements relating to responsive and well-led domains and the practice was required to make improvements.

An announced comprehensive inspection was carried out on 6 April 2017 to confirm the practice had met the legal requirements in relation to the breaches in regulations identified in the October 2015 inspection. As a result, a requirement notice was issued for Regulation 17 HSCA Good governance as safe and well-led required improvement. This inspection is to follow up on the requirement notice.

The full comprehensive reports on the March 2015, October 2015 and April 2017 inspections can be found by selecting the ‘all reports’ link for Ashfield House-Annesley Woodhouse on our website at www.cqc.org.uk.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had updated their incident reporting and significant events policy to include non-clinical incidents with specific examples and definitions. Staff understood what types of incidents needed to be reported and how to do this.

• The cold chain policy had been reviewed and digital data loggers had been purchased and installed on all fridges as the second thermometer. We saw fridge temperatures were recorded daily and the data loggers were downloaded weekly.

• Patient safety alerts were reviewed actioned by the clinical pharmacist. Alerts relevant to the practice were discussed at the practice meeting and were a standard agenda item.

• Medication audits were carried out by the clinical pharmacist to check prescribing compliance and to monitor improvements to patient outcomes.

• Staff who had not received an appraisal in the last year were prioritised and completed an appraisal within four weeks.

• Prescription security was reviewed and strengthened. Blank prescription forms and printing paper scripts were stored in a locked room with key code security.

• Clinical audits were carried out based on NICE guidance and were discussed at practice meetings.

• The practice updated their complaints policy to include information on how to act upon the receipt of a verbal complaint. We looked at two complaints received in the last six months, one of which had been discussed at the practice meeting. We were unable to see evidence of complaint investigation within the records we examined. Complaints responses contained an apology, were concise and contained learning actions. They did not contain information on how to complain to the Parliamentary and Health Service Ombudsman, in line with the complaints policy.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Ensure significant events are recorded using all available information and that the lessons learnt, actions required and by who are completed on the practice form.

• Ensure complaints are dealt with in line with the practice policy which states complaints are dealt with promptly, efficiently and courteously and are discussed and documented at the practice meetings. All responses should include information on how to complain to the Parliamentary and Health Service Ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 31 January 2018

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Updated 31 January 2018