Ampleforth Surgery Also known as Ampleforth & Hovingham Surgeries

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.

The service was in breach of legal regulation in relation to good governance.

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 had a positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. However, documentation and management oversight of safety events could have been improved. For example, systems were not in place to review any actions introduced to monitor the effectiveness of learning.

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.

There was a system to record and disseminate Medicines and Healthcare products Regulatory Agency (MHRA) alerts. However, documentation and management oversight of the alerts could have been improved. For example, there was no oversight to ensure that alerts were actioned or a system for checking that previous MHRA alerts were revisited and actioned when needed. Reliance was on individuals taking such action. Further details can be found under the key question of safe in ‘Medicines optimisation’.

Representatives from the PPG felt leaders took concerns seriously and proactively made improvements to the service. We were provided with examples to demonstrate this.

Managers encouraged staff to raise concerns when things went wrong. Learning from issues was discussed. Feedback from staff and others involved with the practice was positive about the desire to learn and improve. Staff told us there was an open culture, and that safety was a top priority.

The service 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.

The provider procured the services of an external clinical workflow platform, to manage certain tasks relating to patient care. This included prompts for long-term condition reviews and alerts for pathology test results including those requiring follow-up. The service provided contemporaneous reminders when data was entered, helping clinicians identify patients needing action. The effectiveness of these processes relied on staff acting on alerts promptly, which we saw. However, systems for checking staff carried out these actions was not in place. We saw the clinical workflow platform produced oversight reports which could be used to check the decisions made by the external clinical workflow. However, we were informed and observed these were not well used. Following the assessment the provider informed us that several areas were highlighted for development to improve the use of the system and that developments would be ongoing.

Staff were knowledgeable about their roles to manage tasks relating to patient care. Whilst no concerns were identified with the processing of mail and test results, there were no governance arrangements in place to check how mail and tasks were managed by both clinical and non-clinical staff. For example, there were no systems to check the decision making of non-clinical staff when deciding what action to take with correspondence received into the practice regarding patients.

There were systems in place for processing information relating to new patients. At the time of the assessment the provider informed us they had a backlog of summarising of patient records which had been risk assessed. The plan provided to CQC did not include timescales for clearing the backlog. Following the assessment the provider advised they had assessed the summarising situation and provided assurances regarding the management of the backlog of patient records awaiting summarising.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies and processes were known to staff and followed. The practice had a lead and deputy lead clinician as well as an administrative lead for safeguarding adults and children. These were known to staff. Safeguarding audits were completed and recently a safeguarding practice self-assessment was completed. No concerns were identified from this. The safeguarding lead had recently established a formal list of vulnerable people and acted on concerns working in partnership with other organisations. A system for coding vulnerable people and any associated people was in place.

Most clinical staff completed safeguarding training during the assessment period; however, one locum GP and on GP registrar were recorded as not having completed the training. Following the assessment, the provider shared evidence of safeguarding training completed by the GP locum and the GP registrar. Mental Capacity Act training was completed by clinical staff, and most staff had undertaken chaperone training.

Evidence of learning disability and autism training was insufficient. Only 3 staff completed online training in 2022, and no confirmation was provided that others had enrolled or completed this requirement following the assessment. The provider informed us that all staff had previously completed this but no evidence was available to confirm this.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained.

Basic life support and anaphylaxis training had been completed. Most staff had completed Sepsis training. Staff could recognise a deteriorating patient and knew of action to take. Information for staff to refer to was easily accessible.

Patients were mostly advised on risks related to their condition and actions to take if their condition deteriorated.

People were cared for in environments, and with equipment, that was safe and designed to meet their needs. CCTV was in situ throughout the practice and appropriate documentation and management of this was seen.

Documentation and management oversight of health and safety could have been improved. Health and safety risk assessments and audits had been completed but they had failed to identify a small number of risks identified during the assessment process. For example, access by visitors to clinical rooms and storage cupboards where COSSH items were stored. The provider wrote to us following the assessment and informed us they were reviewing the risks identified.

Most staff had completed fire safety and health and staff training. Some were identified as overdue and some not enrolled for completion.

There was a business continuity plan in place which was monitored and reviewed.

Contracts were in place to ensure the premises were maintained.

There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who mostly received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Our review of patient clinical records identified effective systems of supervision of non-medical prescribers employed by the practice. Clinical staff employed via the Primary Care Network (PCN) in ARRS role received monthly supervision from clinical supervisors who were external to the practice. ARRS (Additional Roles Reimbursement Scheme) roles are various healthcare professionals funded by the NHS to expand Primary Care Networks (PCNs) in the UK. However, supervision of staff in ARRS roles was not carried out by leaders at the practice. We were told they were not actively supervised within the practice which had the potential to impact on patient care. We identified 2 examples where this had posed a potential risk to patient safety.

Staff were working within their agreed areas of competence.

Staff at all levels had opportunities to learn and develop their practice. Most staff received training appropriate and relevant to their role. Gaps in staff training and limited oversight reflected weaknesses in governance. Mandatory training had not been defined, and systems to monitor compliance were not robust. Management acknowledged this and confirmed work was underway with the PCN to identify mandatory training. The training matrix showed a high volume of completions during the assessment announcement period, indicating reactive rather than proactive oversight. There were a range of clinical and non-clinical roles within the practice. Not all staff received an annual appraisal; this was particularly evident for staff in the dispensary but included staff in all roles. There was a sporadic approach to recorded 1:1 supervision. We were informed that work was underway to review the appraisal process with a review of the documentation being used to make it more meaningful and in a response to feedback from heads of departments the provider had sourced additional training on how to undertake an appraisal. We were told this was planned for January 2026.

The management and oversight of staff recruitment could have been improved. We were informed that the systems were being reviewed as they needed ‘tightening up.’ A new recruitment policy had been created during the assessment process although this lacked specific detail of what the practice would do. The last version from 2018 could not be located. Whilst recruitment checks had been carried out there was evidence that clinical staff had commenced work before a Disclosure and Barring Service (DBS) had been carried out. However, assurances were provided that when clinical staff commenced work without a DBS that they were not seeing patients alone.

Systems had not been in place to provide assurance that staff received the immunisations that were appropriate for their role. We were shown work that was in progress to gather this information.

The service assessed and mostly managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. During our visit, we observed the practice to be clean and tidy throughout.

Designated infection, prevention and control leads were in place. An infection, prevention and control (IPC) audit had been conducted, and an action plan was in place with action evident to manage the small areas for improvement. No timescale had been added to the action plan.

Documentation and management oversight of IPC could have been improved. For example, checks were not always routinely carried out to ensure that water temperature checking was completed as identified in their legionella risk assessment. We identified a small number of times when this had not been undertaken.

Most staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed and actions mostly taken to mitigate risks.

The service did not always make sure the systems for managing medicines were always safe.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on a sample of medicines that require monitoring, as well as the review of prescribing, including the effectiveness and quality of medication reviews and usage.

Findings from clinical searches showed people prescribed medicines with specific risks mostly received recommended monitoring.

Our clinical searches reviewed action taken in response to drug safety alerts from the MHRA. Appropriate action had been taken in respect of a combination medicine alert. An alert for women of childbearing age on teratogenic drugs (a substance or agent, that can interfere with the normal development of an embryo or foetus, potentially leading to birth defects or other abnormalities) was not always well managed. We looked in detail at 5 patients clinical records. We found 2 patients had only received a recent text message warning them of the risks of taking such medicine. We found in 3 of the records that timely information or discussions had not taken place.

The findings were shared with the practice to follow up on by reviewing specific patient records.

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.

Our clinical searches looked at the quality of medication reviews. We looked in detail at 10 medication reviews with no issues of concern noted.

Most Patient Group Directions (PGDs) reviewed were not properly authorised or signed for use. We also found a clinician had administered vaccines without being authorised under the relevant PGD. Although the provider had attempted to obtain signatures, assurance processes were lacking.

As well as reviewing medicines optimisation, we looked in detail at the dispensary and dispensing arrangements at Ampleforth.

Controlled drugs, which require extra storage and recording requirements due to their potential for misuse, were kept in an appropriate locked cupboard within the dispensary. However, it was noted that until recently, stock level checks had not been completed alongside the electronic register. This meant that entries had previously been missed which were not noticed in a timely manner, resulting in the register balance being incorrect without staff noticing. After investigation, the entries missed were when the prescriptions had been delivered and not entered into the register. Monthly balance checks had now been implemented to ensure stock levels were checked alongside the register.

Two prescriptions for Schedule 3 controlled drugs had been dispensed and bagged up awaiting collection which had not been signed by a GP. This was rectified immediately to ensure they would not leave the dispensary without a GPs signature.

Other prescriptions checked on the day of assessment that were waiting to be dispensed or had already been dispensed and collected or delivered to patients did have a GP’s signatures on them.

Prescriptions awaiting collection were organised alphabetically and these were regularly reviewed and followed up on if patients had not come to collect them. Extra labels were added to the prescriptions if they also had fridge or controlled drug items to ensure these were not missed during collection.

When prescriptions were dispensed, a barcode system was in use to ensure the correct drug and formulation was picked by the dispenser. If an incorrect drug or formulation were picked by a staff member, the system would not allow this to be dispensed as no label would be produced. However, for non-barcoded items this system could not be used. Staff stated only non-barcoded items, and controlled drugs would be second checked by another member of staff. The Standard Operating Procedure (SOP) did not include this information, therefore there was a risk that incorrect items could be picked and bagged up without a second member of staff checking the prescription.

Prescription pads were stored securely behind a locked cabinet, and the pads in use in dispensary printers throughout the day were locked back away at the end of each shift. A log of serial numbers was documented on a spreadsheet and stated when each box had been opened.

A ‘near-miss’ folder was in use to document any dispensing errors which had occurred. Senior staff would look for any trends and themes and if necessary, discuss them in the head of department fortnightly meetings.

Temperature checks were carried out twice daily in areas where medicines were stored, including fridges and the dispensary. Air-conditioning was in place to ensure the dispensary did not exceed 25°C. However, we identified some gaps in the recording of room temperature monitoring.

Processes were in place for people that required their medicines to be dispensed in dosette boxes and there was a designated area of the dispensary for this to be completed.