Ampleforth Surgery Also known as Ampleforth & Hovingham Surgeries

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as Good. At this assessment, the rating has decreased to requires improvement.

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

This service scored 62 (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 shared vision and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The business plan had not been updated since 2018. During the assessment, the provider submitted an updated narrative outlining current plans for 2025. Although the update did not include timescales, it was evident that leaders were aware of their objectives.

The practice upheld its vision to be caring, to work together as a team, supporting each other to deliver high-quality care to patients.

All staff worked towards the practice vision to be caring, to work together as a team, to support each other and to deliver high-quality care to patients. This included respecting all patients and staff, treating all fairly, and valuing each person as an individual. Leaders supported staff development and strived to create a culture which was inclusive and open, providing equality of opportunity for all without discrimination.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Whilst we identified some gaps in the leadership and governance oversight arrangements leaders demonstrated they had the skills, knowledge, experience and credibility to lead effectively.

Staff, PPG members, and patients told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice.

The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard. The practice had established Freedom to Speak up arrangements internal and external to the practice. All but one member of staff was aware of the Freedom to Speak up arrangements.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Adjustments had been made for staff where needed. Most staff had completed equality and diversity training.

Governance arrangements, systems and oversight were not sufficiently robust and did not provide assurance that risks were identified, managed and monitored effectively. The lack of monitoring and governance oversight systems posed some safety risks to patients as reported in the report. For example, no oversight to assure safety alerts had been acted on as per the reference to teratogenic medicines, a member of staff prescribing medicines with no authorisation to do so, no systems to check decision making of non-clinical staff and external clinical workflow platform and Schedule 3 medicines being prepared ready for patient collection with no signed authorisation.

Other areas referenced throughout the report demonstrate a lack of systems and governance oversight in areas such as the management of significant events, some areas of medicines management, recruitment, appraisals, supervision of staff not directly employed by the practice, training, staff immunisations and health and safety. For example, the provider could not evidence that staff had completed required learning disability and autism training.

Although some measures were in place at the time of the assessment, some actions such as completing safeguarding training to the required level and putting certain policies in place were completed after the assessment announcement period. It is unclear whether these areas would have been addressed had the assessment not taken place.

Immediate risks were mitigated through staff commitment and responsiveness rather than always through formal governance processes or consistent leadership oversight.

Staff and leaders engaged with people, communities and shared information and learning with partners and collaborated for improvement. Effective changes were made in response to better meet the needs of local people. They worked with the PPG to support and deliver initiatives.

The provider was an active member of the primary care network. They delivered services and developed initiatives in conjunction with the PCN to better meet the needs of the population. Multiple examples were shared. One example was the PCN established a Rural Health Team with the aim of addressing the significant barriers faced by the farming population. Staff from Ampleforth attended their first auction market in October 2025, alongside the Farming Community Network (FCN) charity. We were informed additional visits were planned for November and December. Examples of positive impact from the event was shared. Another example involved the collaboration between the practice, a local bereavement counsellor and the practice care co-ordinator to establish a bereavement support group in a local market town to bridge a gap in services. The service continues to be run by the counsellor and with the support of the PCN further sessions have been made available in a more accessible location for all practices in the PCN helping to ensure equitable access to group bereavement counselling as a way of addressing an unmet need.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. For example, the practice worked in close partnership with the local boarding college.

The service focused on continuous learning and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

All staff were encouraged to put forward and test out new ways of working, and we were provided with examples of this.

Ampleforth is an approved training practice for both GP registrars (fully qualified doctors training to be a GP specialist) and medical students. The practice was involved in the education and training of future healthcare professionals. The provider encouraged and supported staff to develop and encouraged career progression through the organisation. Where clinicians had specific areas of clinical interest, they were afforded time and supported to upskill.