You are here

Inspection Summary


Overall summary & rating

Good

Updated 23 November 2018

This practice is rated as Good overall.

Ashley Centre Surgery was previously inspected in December 2017 where the practice was rated good overall and good in effective, caring, responsive and well led services. However, we found breaches in regulation for the safe domain and this was rated as requires improvement. We carried out an announced focused inspection on 31 October 2018 to check if the areas of concern had been addressed.

The key question at this inspection is rated as:

Are services safe? – Good

We carried out an announced focused inspection at Ashley Centre Surgery on 31 October 2018. The inspection was to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made from the inspection in December 2017. This report covers our findings in relation to only those requirements found within the safe domain. The full comprehensive reports for the previous inspections can be found by selecting the ‘all reports’ link for Ashley Centre Surgery on our website at .

Our findings were:

  • The practice had effective ways to record actions taken after receiving safety alerts including MHRA alerts.
  • The practice was conducting frequent checks of the general environment and monitoring the cleaning by the external company.
  • The practice had ensured that a COSHH assessment has been completed for cleaning products used.
  • The practice was tracking blank prescriptions forms used throughout the practice.
  • The practice ensured staff had received the appropriate training required which included safeguarding vulnerable adults and children and infection control.
  • The practice ensured that staff who acted as chaperones had a Disclosure and Barring Service (DBS) Check completed.

We also saw evidence that the practice had:

  • Increased the number of carers. At the inspection in November 2017 the practice had 103 registered carers. At this inspection there were 170 carers registered including two young carers. There was also a new carers lead.
  • The practice had contacted the CCG in relation to their clinical waste storage facilities and we saw evidence that a new company was going to be used from January 2019. The practice was in communication with the new company to ensure their previous concerns were addressed before the start of the new contract.
  • We spoke with the practice in relation to their verbal and low level complaints. They told us that the complaints lead reviewed comments on NHS choices and ensured that any comments were reviewed, investigated and replied to. The practice was also in the process of renewing their website and was ensuring that patients could use the website to record any concerns or low level complaints that they had.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 23 November 2018

At our previous inspection in

December 2017

, we rated the practice as requires improvement for providing safe services as the arrangements in respect of the recording of actions

taken after receiving safety alerts including MHRA, monitoring blank prescriptions forms, training including safeguarding and infection control, DBS checks for staff who act as chaperones and checks of the cleaning for the general environment and COSHH assessments needed improvement.

These arrangements had improved when we undertook a follow up inspection on 31 October 2018.

Safety systems and processes

  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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.) The practice was only using nursing staff as chaperones. It had been decided to extend this to non clinical staff. Staff had completed their training, but were waiting for their DBS checks to be returned before starting the role.
  • Staff had received the mandatory training required by the practice. Including safeguarding vulnerable adults and children and infection control. We reviewed the new online training matrix and staff certificates that confirmed this.
  • There was an effective system to manage the cleaning of the general environment. The practice manager and external cleaning company lead monitored the standard of cleaning on a monthly basis. A communications book was also used to ensure any concerns of the standard of cleaning or extra requirements could be quickly passed on to the cleaning team.
  • We reviewed the cleaning equipment used. We noted there were risk assessments (Control of Substances Hazardous to Health) for the cleaning substances used.

Appropriate and safe use of medicines

  • The practice kept prescription stationery securely and was monitoring its use. The practice was keeping clear records of prescription stationery stock received and when distributed to the different clinical rooms within the practice.

Lessons learned and improvements made

  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons; identified themes and took action to improve safety in the practice. The practice recorded all significant events and the actions taken onto a central spread sheet. These were also discussed at the GPs meetings where minutes were recorded of the discussions held.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. The practice was keeping a record of the actions taken when safety alerts were received including Medicines and Healthcare products Regulatory Agency

(MHRA) alerts.

Please refer to the evidence tables for further information.

Effective

Good

Updated 15 January 2018

Caring

Good

Updated 15 January 2018

Responsive

Good

Updated 15 January 2018

Well-led

Good

Updated 15 January 2018

Checks on specific services

People with long term conditions

Good

Updated 31 March 2015

The practice is rated as good for the population group of patients with long term conditions. When needed longer appointments and home visits were available. All these patients had structured annual reviews to check their health and medicine needs were being met. The GPs followed national guidance for reviewing all aspects of a patient’s long term health. Patients with palliative care needs were supported using the Gold Standards Framework

.

The practice nurses were trained and experienced in providing diabetes and asthma care to ensure patients with these long term conditions were regularly reviewed and supported to manage their conditions.

Flu vaccinations were routinely offered to patients with long term conditions to help protect them against the virus and associated illness.

Families, children and young people

Good

Updated 31 March 2015

The practice is rated as good for the population group of families, children and young patients. Appointments were available outside of school hours and the premises were suitable for children and babies. Specific services for this group of patients included family planning clinics, antenatal clinics and childhood immunisations. The practice offered contraceptive implants and coil fitting. Practice staff had received safeguarding training relevant to their role. Safeguarding policies and procedures were readily available to staff. All staff were aware of child safeguarding and how to respond if they suspected abuse. The practice ensured that children needing emergency appointments would be seen on the day.

Older people

Good

Updated 31 March 2015

The practice is rated as good for the care of older patients. Nationally reported data showed that outcomes for patients were positive for conditions commonly found in older patients. There were arrangements in place to provide flu and pneumococcal immunisation to this group of patients. Patients were able to speak with or see a GP when needed and the practice was accessible for patients with mobility issues. Clinics included diabetic reviews and blood tests. Blood pressure monitoring was also available. The practice offered personalised care to meet the needs of the older patients in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits. The practice had a safeguarding lead for vulnerable adults. The practice had good relationships with a range of support groups for older patients.

Working age people (including those recently retired and students)

Good

Updated 31 March 2015

The practice is rated as good for the care of working-age patients (including those recently retired and students). The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. Patients were able to request a GP to telephone them instead of attending the practice. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 31 March 2015

The practice is rated as good for the care of patients experiencing poor mental health (including patients with dementia). Patients with severe mental health needs had care plans and new cases had rapid access to community mental health teams. The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. It carried out advance care planning for patients with dementia. The practice had sign-posted patients experiencing poor mental health to various support groups and local organisations. The practice worked closely with the local mental health team and consultants.

People whose circumstances may make them vulnerable

Good

Updated 31 March 2015

The practice is rated as good for the care of patients whose circumstances may make them vulnerable. The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It had carried out annual health checks for patients with a learning disability and 100% of these patients had received an annual health check and agreed an action plan. The practice offered longer appointments for patients with a learning disability where necessary. Translation services were available for patients who did not use English as a first language. The practice could accommodate those patients with limited mobility or who used wheelchairs.

Accessible toilet facilities were available.

The practice supported patients who were registered as a carer.