This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Ashburnham Road Surgery on 14 November 2018 as part of our inspection programme.

At this inspection we found:

• 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.
• Performance quality indicators for the practice were above local and national averages in several areas.
• The practice employed a clinical pharmacist that regularly audited prescriptions to improve care. The practice worked with local pharmacies to improve patient compliance and education.
• 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.
• We received a high number of CQC comment cards that were positive about the quality of care received.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice had clear 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, we saw some events that had not been accurately recorded as significant events.
• The practice did not hold a record of staff immunisations. The practice was in the process of implementing a system to record these but it had not been implemented yet. Shortly after the inspection, we received evidence and assurance that this had been completed.
• The practice had completed an infection control audit however, not all concerns had been identified. The practice was not able to assure us or provide evidence that cleaning had been completed. The premises had areas of poor maintenance.
• The practice did not conduct any mitigating actions to reduce the risk of legionella. (Legionella is a term for a bacterium which can contaminate water systems in buildings).

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Continue to encourage patients to access national cancer screening programmes.
• Ensure that all information is recorded in clinical notes regarding children not attending hospital appointments.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.