You are here

Archived: The Ashchurch Medical Centre Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 December 2018

This practice is rated as requires improvement overall.

The practice was previously inspected on 10 October 2017. At that inspection the rating for the practice was good overall. This rating applied to the safe, caring, responsive and well led domains. Effective was rated as requires improvement.

The 2017 report stated where the service must make improvements:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, there were areas identified where the provider should make improvement:

  • Review the storage arrangements of environment cleaning equipment and consider an independent external led Infection and prevention control review.
  • Consider installing an independent thermometer to confirm accuracy of the vaccine fridge temperature.
  • Implement a tracking system to monitor the use of blank prescription pads.
  • Continue to monitor and improve Quality and Outcomes Framework performance.
  • Continue to encourage the uptake of childhood immunisations.
  • Continue to encourage the uptake of the cervical screening programme to eligible women.

We carried out an announced comprehensive inspection at Ashchurch Medical Centre on 10 October 2018 to follow up on breaches of regulations.

At this inspection the key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, there was no system in place to ensure that all staff were aware of the learning outcomes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider


make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way for patients.
  • Ensure that learning from incidents, safeguarding and complaints is shared with all staff within the team.

The areas where the provider


make improvements are:

  • Review staff training system to ensure staff are up-to-date with training requirements.
  • Continue to monitor prescription stationary to ensure they are maintained securely.
  • Provide all members of staff with a copy of team meeting minutes to ensure they are aware of developments within the service.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas


Requires improvement

Updated 7 December 2018

At our last inspection on 10 October 2017, we rated the practice as good for providing safe services. At this inspection the practice was rated as requires improvement for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a DBS check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • In July 2018, the practice had an independent Infection and Prevention Control audit. During the inspection, we saw that the practice had completed eight of the 10 identified actions.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety. However, there were areas that required improvement.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. However, the practice did not have some of the standard emergency drugs. Following the inspection, the provider forwarded evidence that they had obtained all but one, and provided evidence that one was currently unavailable.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • Resuscitation equipment was readily available and clinical staff were suitably trained in emergency procedures. Annual basic life support training was undertaken by all staff.
  • Appropriate indemnity arrangements were in place to cover potential liabilities that may arise.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients. However, this information was not effectively circulated within the team.

  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Although, at the time of inspection the practice did not have a system in place to disseminate safety alerts to staff. Clinicians demonstrated an awareness of the most recent safety alerts, including sepsis. After the inspection the service provided evidence to show processes were implemented for sharing the information with staff and ensuring appropriate action was taken.
  • Clinicians made timely referrals in line with protocols. The practice did not have a system in place to check whether patients had attended their urgent two-week wait referral appointments. However, we did not see evidence of patients missing their appointment.
  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.

Appropriate and safe use of medicines

The practice had some systems for appropriate and safe handling of medicines. However, some systems for managing high-risk medications were not safe.

  • The practice did not have a safe system for monitoring high-risk medication. For example, we reviewed the records of the three patients prescribed lithium at the practice. Two of the three records reviewed had not had their medication appropriately monitored.
  • In addition, we reviewed the records of the four patients being prescribed Azathioprine at the practice. Two of the three records reviewed showed that the patients had not had their medication appropriately monitored. The practice did not have a recall system in place for patients prescribed lithium or Azathioprine .
  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Prescription stationary was securely stored. However, the practice did not keep a log of prescription serial numbers to assure themselves that all prescriptions could be accounted for. Following the inspection, the provider forwarded a newly created prescription register.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong. That said, learning was not always shared amongst the team.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. Staff informed us that they were not always aware of the results of incidents. Although, they were aware of the folder containing meeting minutes, significant events and complaints, which was maintained in the practice manager’s office.
  • We saw evidence that the practice acted on and learned from external safety events as well as patient and medicine safety alerts. Safety alerts were discussed during clinical meetings and resulting action plans created. However, locum GPs were verbally informed of the change and did not have access to meeting minutes.

Please refer to the Evidence Tables for further information.


Requires improvement



Updated 7 December 2018

We rated the practice as good for providing caring services.

Kindness, respect and compassion

Members of staff treated patients with kindness, respect and compassion.

  • We received 18 Care Quality Commission comment cards. Seventeen were positive about the service received from both clinical and support staff at the practice.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practices GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion. For example, 90% of patients say the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them. We noted that the practice’s identified carers had increased from 88 in October 2017 to 122 (2.4% of the patient list) in October 2018.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment. For example,
  • 94% of patients said that they felt involved in decisions about their care and treatment during their last general practice appointment. This was in line with the CCG and national average.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.



Updated 7 December 2018

We rated the practice, and all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • There was a medicines delivery service for housebound patients.

People with long-term conditions:

  • Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The practice offered appointments at 8:30am daily and up to 6:30pm three days of the week but there was no provision of extended hours for working patients who could not attend during normal opening hours.
  • The practice offered telephone access to GPs and the nurse.
  • Patients were able to order repeat prescriptions online

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • Patients had a named GP to help provide a point of contact in the practice and to help coordinate health needs.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held GP led dedicated monthly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs. However, there was room for improvement to appointment availability.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment. Pre-bookable appointments were available up to two weeks in advance.
  • Patients we spoke to told us they experienced difficulty in booking appointments in advance and experienced long waiting times at the practice. The practice manager informed us that urgent appointments were available daily for people that required them.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that they had a good experience making an appointment.
  • The practices GP patient survey results were in line with local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. The practice had completed a review of the complaints received in 2017/18 and acted as a result to improve the quality of care. However, findings and actions were not always communicated to team members who had not attended relevant meetings.

Please refer to the evidence tables for further information.


Requires improvement

Updated 7 December 2018

At our previous inspection on 10 October 2017, we rated the provider as requires improvement for providing effective services and stated that the practice must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The practice was rated as requires improvement for well-led because:

  • Processes in place did not ensure that accurate records had been maintained

Leadership capacity and capability

Leaders knew of the challenges they faced and were putting arrangements in place to address these. However, oversight of certain areas related to safety were lacking and governance processes were not always effective.

  • Effective leadership and oversight of key areas in the practice was lacking. For example, in respect of some aspects of medicines management, QOF performance, patient safety alerts and staff training.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills.
  • The practice held reception team meetings every three months and a clinical meeting was held every month; however, there were no whole practice meetings held with both clinical and non-clinical staff.

Vision and strategy

The practice had an overarching vision regarding the future direction of the practice but it was evident that the lack of effective leadership and governance impacted on the practice’s ability to implement strategic goals, deliver high quality care and promote good outcomes for patients.

  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.


The practice had a culture of high-quality sustainable care.

The practice encouraged staff to be open and honest but in some respect support was insufficient. For example, staff informed us that they were not always involved in the resulting action taken for incidents and significant events.

  • Staff stated they felt respected and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients. However, the systems in place were insufficient to ensure quality improvement outcomes for patients.
  • The practice had procedures in place to act on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

Governance arrangements did not consistently ensure patient safety. We were informed that the provider had going through a period of transition due to not having a practice nurse for three months.

  • The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety. However, there was no process in place to assure themselves that they were operating as intended.

Managing risks, issues and performance

The practice had some processes for managing risks, issues and performance. However, there were areas that required improvement.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints. Although, this information had not been disseminated to all members of the team.
  • Clinical audits were used to review the quality of prescribing and ensure that it was in line with current national guidance. There was clear evidence of action to resolve concerns and improve quality.
  • There was no programme of continuous monitoring to make improvements.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

We saw that in some instances practice acted on appropriate and accurate information. Nevertheless, leaders and staff did not always receive information to enable them to challenge and improve performance.

  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information. Although, meeting minutes were documented, they were not forwarded to team members to support consistent learning outcomes.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice had sought patients’ feedback and engaged patients in the delivery of the service. However:

  • At the inspection carried out on 6 January 2016, the practice informed us that they were in the process of developing a patient participation group. This was not in place at the inspection undertaken on 10 October 2018.
  • The practice sought feedback through the ‘Friends and Family Test’ survey and we observed this was available for patients to complete at the reception desk. However, although staff told us they read the comments received from this survey; there was a formal analysis of the results and the practice had taken action in response to patient feedback.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. However, staff told us that they were not always aware of the learning outcomes of incidents and complaints.
  • Staff informed us that leaders and managers encouraged them to take time out to review individual and team objectives, processes and performance.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement