Henmore Health – Ashbourne 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 mostly had a culture of safety, based on openness and honesty. There were processes in place for staff to report incidents, near misses and safety events and staff we spoke with were aware how to do this. Our review of significant events and complaints showed that lessons were learnt. Minutes from clinical and quality meetings showed significant events and complaints were discussed with clinical staff that attended these meetings. A representative from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service.

Most staff felt managers supported them to raise concerns. However, some clinical staff told us that their concerns regarding safety were dismissed, disputed or ignored. In particular, the role out of the total triage system. One of the significant event analyses we reviewed lacked detail. Following our assessment, the provider sent us details of how they would include more detail going forward.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others and an annual audit of significant events was carried out by the practice to identify themes and trends.

The service mostly 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. Test results were managed in a timely way.

However, we found 2 examples where 2 week wait referrals for potential cancers had been delayed between 2 and 5 days due to delays in completion within the administration team. The provider explained this was due to sickness within the medical secretary team and a high staff turnover of clinical staff. They had restructured their medical secretary team and recruited 3 salaried GPs, who were due to start throughout June and July, to replace those that had left. Locum GP staff had been employed in the interim.

We found a small number of opportunities to refer people earlier for investigations had potentially been missed.For example, many letters, dating back to 16 May 2025, had not been actioned. If electronic GP to GP record transfers were required, this could potentially affect the completeness of the records of the patients that had left the practice. We found a routine referral had been sent when a 2 week wait referral was appropriate; the need for a 2 week wait referral for a patient was decided on 22 May 2025 but was not sent until 27 May 2025; and 2 patients were seen multiple times and given the repeated treatment without effect. Oversight of the history of these patients could have prompted a quicker referral.

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 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 worked with the larger multi-disciplinary team to share information and concerns. For example, health visitors and the community support team. Safeguarding meetings were used to raise awareness of potentially vulnerable groups of people. The service had systems in place to generate and corroborate the children’s safeguarding list with health visiting services and relevant cases were discussed at these meetings. There were systems in place to follow up people who failed to attend appointments in primary and secondary care or were frequent attenders to the emergency department.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. From our review of patients’ records, we found 3 patients whose care had not been managed holistically when they had returned several times with the same problem. We found that staff had treated the obvious presenting problem rather than considering why the patients kept returning with the same problem. Opportunities to investigate if there was an underlying condition had been missed.

Emergency medicines and equipment were available and maintained. Staff told us that they checked these regularly however, there were no records to show what had been checked, who by and the frequency of checking. Following our assessment, the provider sent us a schedule for monthly checking and told us they were embedding this into practice.

Staff could recognise a deteriorating patient and knew of the action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. For example, maintenance of the lift. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed or under review.

A fire risk assessment had been completed, and staff completed online fire training and attended regular fire drills. Fire marshals were in place. A legionella risk assessment had been completed and required action, as outlined in the action plans, had been completed. Regular testing of water temperatures took place. Electrical and medical equipment had been tested and calibrated as required. There was a business continuity plan in place which was monitored and reviewed.

However, the looped cords and chains on window blinds in the upstairs waiting room were not securely fitted to the wall in line with safety alerts. Following our assessment the provider sent us photographic evidence that this had been completed.

The service did not always make sure there were enough qualified, skilled and experienced staff.

During our assessment we observed dispensary staff were distracted from preparing prescriptions when called to attend to patients at the dispensing counter. Significant events had been raised to demonstrate the impact of this. For example, due to distraction when attending to a patient the wrong label had been added to a medicine that had been dispensed. Learning from the significant event was that staff were informed not to attend to patients until they had completed the task they were dealing with, consideration was being given to the addition of a partition wall between the dispensary and the patient hatch to reduce distractions and, additional dispensing hours had been identified.

Two salaried GPs had left the practice and another salaried GP had handed in their resignation. Some staff told us there had been times when there was only 1 duty GP available to triage people and there were no GP appointments available that day. This meant the duty GP was required to triage and see people that required an on the day appointment. Clinical staff also told us that there was no protected time during the day for administrative tasks such as reviewing results or correspondence. The provider told us they had recruited 3 new salaried GPs who were due to start imminently. They also employed locum GPs to support the GP team. The provider told us they had taken action to increase staffing within structural limitations beyond their control

Due to staff sickness, there had been a back log in the work carried out by the medical secretaries. The provider told us that they had restructured the way in which medical secretaries worked to address this.

We received a mixed response from staff working in the practice when asked if there were enough staff to provide safe care and treatment. Of the 11 staff questionnaires we received as part of this assessment, 6 people said there were not enough staff and 4 people said there were. During our staff interviews, 1 person told us there were enough staff and 2 people told us there were not. Some staff told us this placed additional pressure and stress on staff which had resulted in fatigue and staff leaving the practice. Feedback from staff that had left or were leaving the practice confirmed this.Theprovider told us they reviewed staffing levels at least annually and had increased staffing by 26% in the dispensary, 20% in the care navigation team and 148% in the medical secretary team. They had also recruited an additional person to their quality team.

There was a range of clinical and non-clinical roles within the practice. We found training was mostly up to date and learning needs and development of staff was mostly in place. Staff gave examples of how they had been supported to develop and take on new roles. For example, a practice nurse had been funded and supported to complete training to become an advanced nurse practitioner. Daily meetings were provided for staff to attend to discuss any concerns or cases they wished to discuss.However, systems to support non-medical prescribers were not robust. The provider told us they carried out regular audits of the prescribing of non-medical staff. Our review of the audits showed they lacked detail of what had been audited, only 1 consultation per non-medical prescriber had been completed and there was minimal learning identified. A non-medical prescriber we spoke with was not aware of the audits and had not received clinical supervision to discuss them. Another non-medical prescriber told us they had received clinical supervision but it had dropped off lately and they had raised this as a concern with the provider.Competency checks had not been completed for dispensing staff. Clinical staff did not feel adequately prepared or trained when a new triage system was introduced.

Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was a designated infection, prevention and control lead and most staff had received appropriate training. The practice was visibly clean and tidy, and nurses had systems in place to clean down equipment following its use. However, completed cleaning schedules for the cleaners to demonstrate what needed to be cleaned and when it had been done were not available. Risk assessments and audits were completed, and action plans were in place to mitigate potential risks.

Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role.

The service mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Our remote clinical searches identified there were effective systems in place for the management of medicines that required monitoring and medicine reviews were detailed.

We identified 35 people prescribed addictive medicines used in the treatment of pain who had not had a review in the last 12 months. We reviewed the records of 5 of these people and found there was no evidence of routine reviews to reduce the dosage or advice on the risk of dependence. Following our assessment the provider sent us an action plan outlining the action they would take to address this issue with a completion date of July 2025. We looked at a Medicines and Healthcare products Regulatory Agency (MHRA) alert for the prescribing of a medicine used in the treatment of diabetes to check that patients had been made aware of the risks associated with the medicine. We looked at the records of 5 of the 168 patients prescribed this medicine and found it had not been coded in their records to indicate that the appropriate advice had been given. Following our assessment, the provider forwarded an action plan detailing the actions they had taken and evidence that they sent leaflets to this group of people informing them of the risks.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages.

Staff mostly managed prescription stationery appropriately and securely. However, a record of the prescription pads held within the practice was not available. Following our assessment, the provider sent us evidence that records had been updated.

Staff regularly checked the stock levels and expiry dates for all medicines, vaccines, and controlled drugs. Most of the recommended emergency medicines were available within the practice. A medicine used in the treatment of nausea and vomiting was not. Following our assessment, the provider sent us photographic evidence that this had been purchased and added to the emergency trolley.

The practice dispensed medicines and we assessed this service as part of our assessment. Medicines were dispensed in line with required standards and stored safely and securely. Incidents relating to the dispensing of medicines had been investigated appropriately and action taken to prevent a re-occurrence. The provider had effective systems to manage and respond to safety alerts and medicine recalls relevant to the dispensary.