The Care Quality Commission
  • Doctor
  • GP practice

Dr C D Lenton & Partners Also known as Ashfield Surgery

Overall: Requires improvement read more about inspection ratings

Ashfield Surgery, 8 Walmley Road, Sutton Coldfield, West Midlands, B76 1QN (0121) 351 3238

Provided and run by:
Dr C D Lenton & Partners

All Inspections

During an assessment under our new approach

The practice is registered with CQC under the Health and Social Care Act 2008 to provide the following regulated activities: diagnostic and screening procedures, family planning, midwifery and maternity services, surgical procedures and treatment of disease, disorder or injury. We carried out an announced focussed assessment of 19 quality statements, under the safe, effective, caring, responsive and well-led key questions between 15 April 2024 and 10 May 2024. This assessment was carried out in response to concerns we had received, to help us understand how the practice identified and managed risk and performance related issues and what the practice was doing to try to meet patient demand and the current experience of people who use this service. When people raised concerns about safety and ideas to improve, leaders used this information to learn and improve. However, there was not always evidence that solutions to risks were developed collaboratively with all staff. Patients were supported to make choices that balanced risks of harm with positive choices about their lives. However, there was not always enough skilled staff to deliver safe care that promoted choice and control for patients and wellbeing of staff. There was also poor organisation and management of non-clinical roles for clinical staff. People were treated with kindness, empathy and compassion. Their privacy and dignity was respected. The provider was aware that people could not always access services when they needed to and was taking appropriate action to improve access to services. However, further improvements were needed to ensure equity in access for all patients. We found a breach of the legal regulations in relation to governance. Systems were not effective in identifying, mitigating and monitoring risk related to staff recruitment, storage and monitoring of medicines and infection prevention and control. We have asked the provider for an action plan in response to the concerns found.

20 November 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr AP Blight & Partners (also known as Ashfield Surgery) on 25 August 2016. The overall rating for the practice was good; however, the practice was rated as requires improvement for providing well-led services. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr AP Blight & Partners on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 20 November 2017 to confirm that the practice had carried out their plan to make improvements in relation to prevention and control of infections, encouraging the uptake of health checks and improving support available for non-clinical staff that we identified in our previous inspection on 25 August 2016.

This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated as good.

Our key findings were as follows:

  • Infection Prevention and Control (IPC) procedures had improved since our previous inspection. Documentations provided by the practice showed that cleaning schedules were being completed which provided clear evidence that specific cleaning tasks relating to the clinical rooms had been carried out.

  • Data from the 2016/17 Quality Outcomes Framework (QOF) showed improvement in the completion of various health checks. For example, since our previous inspection the number of patients diagnosed with dementia who had their care reviewed in a face-to-face consultation had increased from 63% to 85%, and was comparable to the Clinical Commissioning Group (CCG) average of 85% and national average of 84%. Members of the management team explained that since our previous inspection the practice had improved the clinical system template to ensure more accurate recording for dementia reviews.

  • The practice continued working with other health care professionals in the case management of vulnerable patients. Since our previous inspection, the practice improved the accuracy of their clinical records. Data provided by the practice showed that the number of patients on the practice learning disability register had reduced from 55 to 50 patients as of the 31/03/2017. Unverified data provided by the practice showed an increase in the number of annual learning disability health checks from 22 to 38 patients, (demonstrating an increase from 40% to 76%). Staff explained that they targeted patients during their annual Flu campaign to increase uptake. The practice also commenced dedicated GP time for more structured clinics which focused on this population group. Staff continued writing and calling patients inviting them in for their annual health check.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr AP Blight & Partners of Ashfield Surgery on 25 August 2016. Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
  • The practice used innovative and proactive methods to improve patient outcomes, For example diabetes group session for newly diagnosed patients were held every two weeks.
  • Feedback from patients about their care was consistently positive.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • We saw that staff were friendly and helpful and treated patients with kindness and respect. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs. For example the practice ran a Contraception and Advanced Sexual Health Service (CASH) for the local community.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result.
  • There was a clear leadership structure, but staff felt they were not supported enough by management and the GPs.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Staff spoken with demonstrated a commitment to providing a high quality service to patients.
  • The practice operated a consultant led vasectomy clinic. This was a two part service; one of the GPs at the practice offered a weekly counselling service for patients who were considering having this procedure.
  • The practice held a twice weekly Contraceptive and Sexual Health Clinic (CASH) for the local community which was run by two of the practice GPs who had specialised in this area.

We saw an area of outstanding practice including:

A diabetic group session was held every two weeks for newly diagnosed patients by one of the practice nurses who had qualified in diabetic care and with the support of one of the GPs. The group supported a maximum of ten patients at each session and the practice had seen positive outcomes from the sessions with an improvement in the diabetic blood monitoring (HbA1c test) with 84% of patients having a lower result of 7 or less. The practice attributed this to the positive effect of having an expert patient group, with an innovative approach to the management of diabetes and lifestyle changes.

However there were areas of practice where the provider should make improvements:

  • Review infection control processes to ensure infection prevention continues to be monitored effectively and cleaning schedules are monitored and completed to reduce the risk of infection.
  • Continue to encourage patients to attend health checks including patients with learning disabilities.
  • Review current procedures and management support for non clinical staff and implement a system of appraisals for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

At our previous inspection on 2 January 2014 we found that disclosure and barring service (DBS) checks were not in place for all staff working with vulnerable people. Following the inspection, the provider sent us an action plan setting out how they had addressed the issues. We also asked the provider to send information to confirm appropriate action had been taken.

The provider sent us confirmation that appropriate DBS checks had been made immediately following the inspection in January 2014. A risk assessment had been completed. To ensure the process in place was robust the practice had also updated their recruitment policy.

2 January 2014

During a routine inspection

On the day of the inspection we spoke with one staff member, the practice manager, a GP and a practice nurse manager. We also spoke with seven patients who had arrived for their appointments. All the patients we spoke with were generally positive about the experiences of care they had received at the surgery. Some patients commented that it was difficult to get an appointment but were able to see a GP if it was an emergency. Some patients also commented that they often had to wait longer after their appointment time for a GP of their choice because that GP was more popular.

We found that care and treatment was planned and delivered in a way that met patients' needs. Patients we spoke with told us they were happy with the level of care they had received.

Appropriate guidance was available for staff to follow if abuse was suspected. However, some staff had not received training in safeguarding adults and we did not see evidence of background checks for a practice nurse.

Appraisals for staff had not been carried out for a number of years but plans were underway to ensure they were being carried out.

The practice carried out a range of audits to monitor the quality of the service. This ensured that on-going improvements could be made.