We carried out an announced inspection at Ashmore Park Health Centre over a period of four days, the final inspection date was the 6 October 2021 when we carried out an onsite inspection visit. Overall, the practice is rated as good.
Ratings for each key question:
Safe – Good
Effective – Good
Well Led – Good
Ashmore Park Health Centre was previously inspected in June 2019 and rated requires improvement overall and for all population groups.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashmore Park Health Centre on our website at www.cqc.org.uk
Why we carried out this review
This inspection was an announced inspection to follow up on:
- the requirement notices issued at the last inspection in June 2019.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing / telephone
- Completing clinical searches on the practice’s patient records system and discussing the findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- Carrying out a site visit.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services
information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and good for all population groups
We found that:
- The practice had reviewed its systems for managing its safeguarding registers to ensure they were up to date and reflected the current situation for each patient.
- The practice had put appropriate arrangements in place to ensure children who were not brought to secondary health care appointments were followed up.
- Staff recruitment practices had improved and the required recruitment documents were available in staff files.
- The practice had reviewed its systems for the safe prescribing and monitoring of high-risk medicines.
- The practice ensured Atropine was available to be used in the event of an emergency when providing intrauterine device fitting services (coil fitting).
- Named fire marshals had been identified and received appropriate training to carry out the role.
- The practice followed up on the outcome of the health and safety risk assessments of the premises carried out by the NHS Property Services team.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
- Governance arrangements had been reviewed and a documented strategy developed for monitoring practice performance introduced.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve the monitoring and review of patients prescribed high risk medicines.
- Proactively review and act on patient feedback to ensure timely action and responses are taken when needed.
- Proactively review and act on the uptake of cervical smear screening at the practice to ensure timely action can be taken where appropriate.
- Proactively review and act on the uptake of childhood immunisations.
- Review the practice website to ensure patients have access to relevant and up to date information.
Review the process for updating clinical records and implementing appropriate action in response to safety alerts and good practice guidance received.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care