We carried out an announced comprehensive inspection at Ashover Medical Centre on 28 August 2019 as part of our inspection programme. The inspection was triggered by a change in registration status with the Care Quality Commission (CQC). The practice was previously registered a single-handed GP but became a partnership which registered with the CQC on 11 October 2018.
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 and
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall. The practice was rated as requires improvement for providing safe services, and good for effective, caring, responsive and well-led. All population groups were rated as being good.
We have rated this practice as requires improvement for providing safe services because:
- The practice did not always have effective systems in place for some processes relating to the safe management of medicines. This included:
- The management of some systems within the practice dispensary were not effective. This included the safe management of Monitored Dosage Systems.
- Some processes had insufficient evidence to provide assurance that they operated safely. This included the tracking of prescription stationery, and the monitoring of vaccine refrigerator temperatures.
- Action plans for infection control audits and further to risk assessments needed documented evidence of follow up actions being completed in a timely manner.
We rated the practice as good for providing effective, caring, responsive and well-led services, and for all population groups because:
- Patients received effective care and treatment that met their needs.
- Staff treated patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way. The practice organised and delivered services to meet their patients’ needs.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
We also found the following area of outstanding practice:
- The practice offered outstanding access to GP appointments. Outcomes from the national GP patient survey showed that results for the practice were significantly higher than local and national averages. This was supported by CQC patient comment cards completed by patients in the two week period prior to our inspection.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
In addition, the provider should:
- Take action to review the scope and impact of the practice clinical audit programme to effectively demonstrate the outcomes achieved for patient care. For example, in relation to broad-spectrum antibiotic prescribing, and areas identified for improvement within the QOF.
- Include training on the Mental Capacity Act for the practice team, and ensure nursing staff complete adult safeguarding training at the appropriate level.
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