Henmore Health – Ashbourne Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 68 (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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in the planning for their care needs. For example, people prescribed a medicine used to prevent blood clots were made aware of food and drinks to avoid and risks to look out for.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. We saw the practice worked in partnership with other services to meet the needs of its patient population. For example, care homes and the community support team. The practice had worked with a local school to provide strips for the school football team.

However, relationships between the practices within the Primary Care Network (PCN) had broken down. Measures were in place to ensure people still had access to services provided by the PCN. Feedback from a local community group for people over the age of 50 was critical about the lack of support the practice had provided to their members. The provider felt this was unfounded and stated they had attended the community group meeting when requested to do so.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. For example, easy read material for people with a learning disability. The service had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. People were informed how to access their care records. The practice had visited a group of travellers who temporarily resided on the car park opposite the practice and informed them of the services they could access at the practice.

The service mostly supported people to share feedback and ideas, or raise complaints about their care, treatment and support. For example, through patient surveys and the Friends Family test. Staff were aware of how to support people to give feedback. The service involved people in decisions about their care and told them what had changed as a result. We saw complaints were managed in line with the practice’s policy and learning from complaints was in place.

However, a system for identifying trends in complaints was not in place. We received mixed feedback from the Patient Participation Group (PPG). They told us they were involved and listened to when the practice took over a neighbouring GP practice. However, the PPG had asked the provider questions about the oversight of the new triage system, training provided to staff and who was dealing with the telephones when staff were dealing with online duties. They told us there had been no clear answers to their questions.

The service made sure that people could access the care, support and treatment they needed when they needed it. People could access the service to suit their needs for example online, in person and by telephone. A practice nurse held sexual health clinics on a Saturday so people who worked had good access to this service. Treatment rooms were available on the ground floor and automatic doors had been fitted to the entrance. There was a lift to the upstairs consultation rooms.

Data from the National GP Survey showed that 52% of respondents responded positively to how easy it was to contact their GP practice on the phone. This was comparable with the national average of 50%. As part of this assessment, the CQC received feedback from 2 people that used the service who stated the telephone access to appointments was poor and feedback from 1 person who was very happy with the service. A representative of a care home told us they had noticed a significant improvement in the speed in which the telephone had been answered recently. In response to the National GP Patient Survey data and feedback from people, changes to improve access to the service had been put in place. For example, a new telephone system and an online triage form which people could complete between 6am to 5pm.

Unverified data for the Primary Care Network showed that the practice had used 66% of the extended access appointments throughout the Primary Care Network during March 2025. We reviewed the practice’s appointment schedule and found that urgent on the day appointments were available and that the next pre-bookable appointment with a GP was in 2 weeks’ time.

General Practice Appointment Data showed that 64% of face to face appointments were with a GP which was comparable with the national average of 59%. It also showed that the percentage of appointments within 14 days was below the national average. Leaders told us that following the introduction of the online triage, all patients were assessed on the day by a GP before the most appropriate appointment type was offered.

Telephone consultations were 7.5 minutes long and face to face consultations were 15 minutes long. We found 2 examples where a telephone consultation was not appropriate. In particular, a case that involved domestic abuse and a case relating to safeguarding. Staff told us of other examples when they had been given a 7.5 minute telephone appointment to care for a person with complex mental health issues. The provider told us there were systems in place to enable more time to be allocated to a call and systems for staff to feed back when an inappropriate amount of time had been allocated for a consultation.

Staff and leaders listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. Staff treated people equally and without discrimination.

Leaders proactively sought ways to address any barriers to improving people’s experience. For example, the introduction of a medicine home delivery service. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet. If someone was unable to complete the online triage form to gain access to an appointment, they called the practice on the telephone and a receptionist completed the form for them.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. Our review of patient records showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.