- GP practice
Henmore Health – Ashbourne Surgery
Assessment report published 28 August 2025
Contents
Ratings
Our view of the service
Date of Assessment: 6-16 June 2025.
Dr Maxwell-Jones and Partners is a GP practice and delivers service to 8,139 patients under a contract held with NHS England. We carried out an assessment of this practice because it has not been assessed since 2016 and due to new emerging risks. The National General Practice Profiles states that the ethnic make-up of the practice area is 97.4% white, 1.2% mixed, 0.9% Asian, 0.3% black and other 0.2%. The age distribution of the practice shows a higher than average older population and lower than average younger population. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service mostly had a culture of learning and people could raise concerns. Managers investigated incidents and most staff felt supported to raise concerns. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Managers made sure staff received training and regular appraisals. Staff mostly managed medicines well and involved people in planning any changes. However, people did not always receive holistic care and there were delays in 2 week wait referrals for potential cancer being sent. Some clinical staff felt their concerns regarding safety were dismissed, disputed or ignored. There were some staffing groups where staff felt there were not enough staff. The prescribing of non-medical prescribers was not routinely audited and clinical supervision was not in place to support this. People were not always informed of potential risks associated with some of the medicines prescribed. The provider took action to inform people following our assessment.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was mostly based on latest evidence and good practice. Staff worked with some agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated people as individuals and supported their preferences. People had choice in their care and treatment. We received mixed feedback from staff regarding support for staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff did not have a collective shared vision. Staff had not been involved in developing a vision for the service. There was very mixed feedback from staff regarding leaders. Some staff felt leaders were visible, knowledgeable and supportive and helped staff develop in their roles. Other staff felt their concerns were not listened to or acted on and leaders were not compassionate towards staff. Some staff and the Patient Participation Group expressed concerns regarding poor communication within the practice, a lack of clarity in lead roles and a reactive leadership style which impacted negatively on staff. The provider used significant events and complaints to drive improvements however, clinical audits had not been completed to drive improvements in patient care.
We found breaches of regulation in relation to safe care and treatment; good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People were mostly positive about the quality of their care and treatment. Recent survey results, including from the National GP Patient Survey and the NHS Friends and Family Test, showed people were satisfied with services.
There was an active Patient Participation Group (PPG) who represented the views of people using the service. Feedback from representatives from the PPG was mixed. They told us the practice took concerns seriously and proactively made improvements to the service. For example, during the takeover of a neighbouring practice and the merger of the practice’s 2 websites. However, they felt sometimes they were controlled by leaders, kept at arm’s length and were part of a box ticking exercise. When they had challenged the practice over issues their requests for information had not been responded to.