The Care Quality Commission
  • Doctor
  • GP practice

Ash Grove Medical Centre

Overall: Good read more about inspection ratings

England Lane, Knottingley, West Yorkshire, WF11 0JA (01977) 673141

Provided and run by:
Ash Grove Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Ash Grove Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Ash Grove Medical Centre, you can give feedback on this service.

15 June 2023

During a routine inspection

Ash Grove Medical Centre was previously inspected on 4 and 20 April 2022. The practice was rated as requires improvement overall, and requires improvement for providing safe, effective, responsive and well-led services. We rated caring as good.

Two requirement notices were issued by the Care Quality Commission for breaches of Regulation 12, safe care and treatment and Regulation 17, good governance of the Health and Social Care Act 2008, regulated activities) Regulations 2014. At this inspection we found the practice had responded to these concerns.

We carried out this announced comprehensive inspection at Ash Grove Medical Centre on 13 and 15 June 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good.

The full report and evidence table from the previous inspection can be found by selecting the ‘all reports’ link for Ash Grove Medical Centre on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection to follow up on the breaches of regulation from a previous inspection, to review the care provided by the practice in all 5 key questions, and to review the ‘shoulds’ which were identified in the April 2022 report.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a reduced amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting feedback from patients and staff.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice had responded to the previous breaches of regulations.
  • Staff were able to raise issues and concerns at the practice, and were confident that their concerns would be listened and responded to.
  • Patients received effective and responsive care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • There was a cohesive, functioning and visible leadership team, who had introduced a number of new processes to support the effective delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Complete the review of the vaccination status of the staff team.
  • Take action to ensure that shared care agreements and protocols for patients prescribed high risk drugs, are easily accessible in the patient record and that dosing instructions reflect good practice.
  • Continue with plans to introduce ReSPECT forms. (Recommended Summary Plan for Emergency Care and Treatment) to support the recording of patient consent and Do Not Attempt Cardiopulmonary Resuscitation orders.
  • Take steps to embed the processes to ensure historical patient safety alerts are reviewed and responded to, and that any resulting risks to patients are managed.
  • Continue with actions to improve the uptake of cervical cancer screening at the practice.
  • Take action to improve the supporting documentation in the management of complaints.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

4 to 20 April 2022

During a routine inspection

We carried out an announced inspection at Ash Grove Medical Centre between 4 and 20 April 2022. Overall, the practice is rated as requires improvement with the following key question ratings:

  • Safe - requires improvement
  • Effective – requires improvement
  • Caring - good
  • Responsive – requires improvement
  • Well-led – requires improvement

Following our previous inspection on 3 March 2020, the practice was rated as good overall and for all key questions, except for the responsive key question which was rated as requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ash Grove Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection. We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in West Yorkshire. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system-wide feedback.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Circulating an electronic staff questionnaire

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We found that:

  • Staff treated patients with kindness and compassion, and respected patients’ privacy and dignity.
  • Staff helped patients to be involved in decisions about care and treatment.
  • Appropriate standards of cleanliness and hygiene were met.
  • There were adequate systems to assess, monitor and manage risks to patient safety.
  • There was evidence of systems and processes for learning, continuous improvement and innovation.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Although not a breach of regulations, the provider should:

  • Take steps to store emergency medicines and equipment to ensure they are easily accessible in the event of an emergency.
  • Improve processes to record and share any learnings identified from a complaint or incident investigation.
  • Issue patients with a steroid card where required.
  • Improve the uptake of cervical cancer screening.
  • Improve processes for the recording of patient consent and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.
  • Improve access to appointments so all patients are able to access care and treatment in a timely manner.
  • Improve processes to ensure all staff are able to raise concerns.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

3 March 2020 to 3 March 2020

During a routine inspection

This practice is rated as Good overall. At the previous inspection in January 2019 we rated the practice as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

Due to the rating of Requires Improvement for the provision of Responsive services all population groups were also rated as Requires Improvement overall.

We carried out an announced comprehensive inspection at Ash Grove Medical Centre and the branch surgery at Whitleybridge on 3 March 2020. The inspection was carried out to check improvements made following our previous inspection in January 2019. The practice was rated as Requires Improvement at the previous inspection because:

  • Staff had not all received recent safeguarding training appropriate to their role.
  • The risk assessment for the storage and handling of hazardous substances lacked detail.
  • There was no evidence that actions needed in response to the last fire risk assessment had been fully actioned.
  • Window blind cords in the branch surgery were long and posed the risk of entrapment and injury.
  • Staff tasked with the monitoring of refrigerator monitoring at the branch had limited knowledge of operating temperatures and key trigger temperatures.
  • Patient satisfaction with appointment access was mixed and there was limited assurance that improvements in access had been fully embedded.
  • 2017/18 performance in relation to the provision of effective services for people with long-term conditions showed areas of low performance. Whilst we saw unverified interim data which showed some improvement in 2018/19 this improvement needed to be continued.

At this inspection we found:

  • The practice had low patient satisfaction in relation to appointment access; reported via the national GP survey (January to March 2019). Since this survey, the practice had instituted a number of changes to both increase access and clinical capacity. Recent patient satisfaction data obtained via in-house surveys showed some improvement. However, other feedback from patients and comment cards indicated some continued dissatisfaction. Improvements instituted, therefore, needed to be embedded further
  • The practice had since the last inspection shown improved performance in relation to long-term conditions, and in general were either at or above local and national averages. At times though, this was accompanied by higher than average rates of patient exception reporting.
  • The practice had shown improvement in cancer screening participation rates, and had worked with their local Clinical Commissioning Group to improve awareness and take-up.
  • At the branch surgery, we identified issues in relation to emergency medicines stocking, emergency equipment, and infection prevention and control. Immediately after the inspection the practice undertook remedial actions to rectify these issues.
  • The practice was actively involved in health improvement activity and took part in a number of local and national improvement initiatives.
  • The practice worked closely with external organisations to improve local community health and wellbeing, and actively supported vulnerable or at-risk groups such as veterans and carers.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Patients told us that they were satisfied with the level of care offered by the practice and found staff to be caring.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Ensure that risk assessments used to support key decisions such as the stocking of emergency medicines are effective and mitigate risks associated with any decisions made.
  • Improve processes for the checking of emergency equipment, and ensuring effective cleaning is undertaken at the branch surgery.
  • During the planned refurbishment of the branch surgery ensure that infection prevention and control standards are complied with.
  • Gain assurance that the triage system was effectively operated through clinical supervision and audit.
  • Continue the improvement work carried out in relation to cancer screening participation.
  • Continue to monitor two-week wait cancer referral performance and prescribing performance in relation to non-steroidal anti-inflammatory drugs.
  • Continue to review, monitor and improve patient satisfaction in relation to access and appointments.
  • Continue to monitor and review levels of patient exception reporting in line with practice operating policies.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

18 January 2019 to 18 January 2019

During a routine inspection

This practice is rated as Requires Improvement overall. At the last inspection in December 2017 we rated the practice as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

In addition, we found all population groups to be Requires Improvement.

We carried out an announced comprehensive inspection at Ash Grove Medical Centre and the branch surgery at Whitleybridge on 18 January 2019. The inspection was carried out due to the provider receiving a rating of Requires Improvement for the last inspection carried out in December 2017. The practice was rated as Requires Improvement at this latest inspection because:

  • Staff had not all received recent safeguarding training appropriate to their role.
  • The risk assessment for the storage and handling of hazardous substances lacked detail.
  • There was no evidence that actions needed in response to the last fire risk assessment had been fully actioned.
  • Window blind cords in the branch surgery were long and posed the risk of entrapment and injury.
  • Staff tasked with the monitoring of refrigerator monitoring at the branch had limited knowledge of operating temperatures and key trigger temperatures.
  • Patient satisfaction with appointment access was mixed and there was limited assurance that improvements in access had been fully embedded.

In addition, it was seen that 2017/18 performance in relation to the provision of effective services for people with long-term conditions showed areas of low performance. Whilst we saw unverified interim data which showed some improvement in 2018/19 this improvement needed to be continued.

This rating meant all population groups were rated as Requires Improvement.

At this inspection we found:

  • The practice did not have clear systems in place to fully manage risk.
  • The practice had taken action to tackle areas highlighted as requiring improvement at the last inspection carried out in December 2017. This included increasing clinical capacity and increasing the numbers of carers identified from the patient population. We saw that improvement activities were effectively planned and that performance was closely monitored.
  • We saw that there were areas of low performance with regard to long-term conditions and mental health in 2017/18. We saw unverified data from 2018/19 which indicated an improvement in performance, although that in relation to long-term conditions needed to be sustained.
  • The practice had some areas of low patient satisfaction in relation to appointment access and consultations reported via the national GP survey (January to March 2018). The practice had since this survey instituted a number of changes to both increase access and clinical capacity. Recent data showed an improvement in patient satisfaction, however this needed to be embedded.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice was actively involved in health improvement activity, and took part in a number of local and national improvement initiatives.

The areas where the provider should make improvements are:

  • Continue to review and improve the systems in place so that reviews of patients with long-term conditions are completed in accordance with their care and treatment requirements.
  • Review the provision of safeguarding training so that all revelant staff receive the necessary training.
  • Review the assessment of hazardous substances handled or used within the practice to ensure that it is comprehensive.
  • Review the fire risk assessment for the branch surgery to ensure areas raised had been actioned. .
  • Survey all public areas to give assurance that all window blind cords are secured at an appropriate length and do not pose a risk of entrapment or entanglement.
  • Review and improve the knowledge of staff tasked with monitoring duties in respect of refrigerator storage temperatures.
  • Review and improve processes concerning the transportation of vaccines and medicines which required temperature control.
  • Review and continue to monitor two week wait cancer referral performance.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

6 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall.

The practice had been rated as Good overall at the previous inspection carried out on 19 January 2016.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Good

As part of our inspection process we also look at the quality of care for specific population groups. The issues identified as requiring improvement overall affected all patients. In addition the provision of effective services for people with long-term conditions was also rated as requiring improvement. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those retired and students) – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Ash Grove Medical Centre and Whitleybridge branch surgery on 6 December 2017. The inspection was carried out as part of our inspection programme and was also used to follow up areas where the provider had been informed previously that they should make improvement.

At this inspection we found:

  • The practice had clear systems and processes in place to manage risk so that safety incidents were less likely to happen. When incidents did happen we saw that these were investigated by the practice and that processes were revised and improved to prevent a recurrence.

  • The practice had experienced a high turnover of staff over a period of time and this had reduced their capacity to deliver services. The practice had actively sought to recruit additional staff and had implemented new processes to redress this.

  • Patients reported difficulty in contacting the practice and accessing services. In addition patient satisfaction in relation to their involvement in decisions about their care and treatment were significantly below local and national averages.

  • We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • The practice was actively involved in health improvement activity, and took part in a number of local and national improvement initiatives. For example the practice worked with a local NHS Trust who provided a telemedicine service to two local nursing homes.

  • The practice provided additional services for those with mental health needs and dementia. For example the practice had received accreditation for both its work to support dementia patients and for learning disability patients.

The areas where the provider should make improvements are:

  • Improve the identification of carers to enable this group of patients to access the care and support they require.

  • Review and improve the systems in place so that reviews of patients are completed in accordance with their care and treatment requirements.

  • Review areas of poor patient satisfaction with the services provided and take steps to improve satisfaction in these areas. This should include telephone and appointment access and patient’s feeling involved in planning and making decisions about their care.

  • Review and risk assess the decisions made with regards to choosing not to stock certain emergency medicines in line with recognised guidance.

  • Review and improve quality improvement activity within the practice, including the effective use of clinical audit.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ash Grove Medical Centre on 19 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.

We saw one area of outstanding practice :

  • The practice held awareness raising events for patients and their families covering subjects such as alcohol consumption by the isolated elderly and weaning for babies.

     We saw one area where the provider should make improvement:

  • The practice needed to hold regular fire drills and fire tests during periods of time when the majority of practice staff are present to ensure that they are familiar with the fire evacuation process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 October 2013

During a routine inspection

We saw that steps had been taken to encourage patient feedback as the practice had an established patient reference group and a comments and suggestions box located in the entrance.

We spoke with two members of the patient reference group who were able to give examples of the changes that had been made to the service as a result of feedback.

The patients we spoke with happy with the care and treatment they received. Comments included;

'I've been ill for several weeks and the practice has been brilliant.'

'The practice have looked after me very well over the years and I have no complaints.'

There was a nominated safeguarding lead within the practice. Staff were able to outline the different types of abuse that people may be at risk of and explain what signs they would look for to indicate that a person may be suffering from abuse.

The practice had a recruitment policy in place and two of the staff files we reviewed contained all relevant checks. One of the files we looked at did not contain references. We discussed this with the provider at the time of our inspection and were assured that references would be obtained for all future roles.

The practice had a complaints procedure in place and had taken steps to ensure that patients were aware of this process.