Ash Grove Medical Centre

Updated 30 June 2023

Ash Grove Medical Centre is located in Knottingley, West Yorkshire at:

England Lane,

Knottingley,

West Yorkshire,

WF11 0JA

The practice has a branch surgery at:

Whitley Bridge Surgery,

87 Selby Road,

Eggborough

DN14 0LJ

Both sites were visited as part of this inspection activity.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.

The practice offers services from both the main practice location and the branch surgery. Patients can access services at either surgery.

The practice is situated within the West Yorkshire Integrated Care Board (ICB) and delivers personal medical services (PMS) to a patient population of about 12,280. The practice is one of 4 practices within the Wakefield Health Alliance Central Practices primary care network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 97.7% White, 0.9% Asian, 0.9% Mixed, 0.3% Black and 0.1% Other.

The age distribution of the practice population largely mirrors the local and national averages; however, there are and more younger people aged 10-14 years when compared to local and national averages.

There is a team of three GP partners, and two salaried GPs (male and female) an advanced nurse practitioner, 3 advanced clinical practitioners, 2 nurses and 3 healthcare assistants all of whom are female.

The clinicians are supported a pharmacist and a phlebotomist, a team of medical receptionists and a range of administration and secretarial staff and prescription clerks. The practice manager and 2 assistant practice managers provide managerial oversight and support.

The Ash Grove Medical Centre is open between 8am to 6.30pm, Monday to Friday. The Whitley branch surgery is open between 8.30am and 12.45pm, Monday to Friday. The practice offers a range of appointment types including book on the day, telephone and on line consultations and advance appointments.

Extended access is provided locally by GP Care Wakefield, where late evening and weekend appointments are available.

Out of hours services are provided by NHS 111 and Local Care Direct Limited.

Updated 30 June 2023

Ash Grove Medical Centre was previously inspected on 4 and 20 April 2022. The practice was rated as requires improvement overall, and requires improvement for providing safe, effective, responsive and well-led services. We rated caring as good.

Two requirement notices were issued by the Care Quality Commission for breaches of Regulation 12, safe care and treatment and Regulation 17, good governance of the Health and Social Care Act 2008, regulated activities) Regulations 2014. At this inspection we found the practice had responded to these concerns.

We carried out this announced comprehensive inspection at Ash Grove Medical Centre on 13 and 15 June 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good.

The full report and evidence table from the previous inspection can be found by selecting the ‘all reports’ link for Ash Grove Medical Centre on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection to follow up on the breaches of regulation from a previous inspection, to review the care provided by the practice in all 5 key questions, and to review the ‘shoulds’ which were identified in the April 2022 report.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a reduced amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting feedback from patients and staff.
• Requesting evidence from the provider.
• A short 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 and
• information from the provider, patients, the public and other organisations.

We found that:

• The practice had responded to the previous breaches of regulations.
• Staff were able to raise issues and concerns at the practice, and were confident that their concerns would be listened and responded to.
• Patients received effective and responsive care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• There was a cohesive, functioning and visible leadership team, who had introduced a number of new processes to support the effective delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

• Complete the review of the vaccination status of the staff team.
• Take action to ensure that shared care agreements and protocols for patients prescribed high risk drugs, are easily accessible in the patient record and that dosing instructions reflect good practice.
• Continue with plans to introduce ReSPECT forms. (Recommended Summary Plan for Emergency Care and Treatment) to support the recording of patient consent and Do Not Attempt Cardiopulmonary Resuscitation orders.
• Take steps to embed the processes to ensure historical patient safety alerts are reviewed and responded to, and that any resulting risks to patients are managed.
• Continue with actions to improve the uptake of cervical cancer screening at the practice.
• Take action to improve the supporting documentation in the management of complaints.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care