The Willows Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

The practice had made improvements following the previous inspection. For example, the practice had a system in place for the oversight and action of significant events. Staff we spoke with understood and managed risks. The facilities and equipment were clean and well-maintained, and any risks mitigated. The practice now carried out the necessary recruitment checks, and staff confirmed they had completed an induction into their role. Most staff had completed mandatory training. There was a system in place for medicines management. However, on the day of the assessment we found the leaders did not have full oversight of role specific training or staff immunisations.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice and business manager told us they were responsible for oversight and action of significant events. Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information and we observed these were discussed at clinical meetings and staff meetings. The staff we spoke with and those who completed a questionnaire also said they felt comfortable raising concerns. The practice had purchased new computer software to record and manage significant events, a review of the system found that events were recorded, and actions taken. However, the recording of the event and actions were brief, and it did not demonstrate the event had been reviewed and signed off by a member of the leadership team. The significant event and incident policy did not include the use of the new computer software. The leaders were aware of their responsibility to carry out duty of candour.

The practice had a system in place to manage safety alerts, which was supported by a Central Alerting System Policy last reviewed in 2024. The leaders explained safety alerts were managed and responded to by the pharmacy team. As part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. We reviewed a sample of patient records who may have been affected by a Medicines and Healthcare products Regulatory Agency alert and found, these had been followed up and patients informed of any possible adverse effects of the medicine.

At the time of the assessment the practice had an effective system in place to assure all urgent referrals to secondary care received a prompt assessment. The practice had a referral policy and procedure in place last reviewed July 2024. Leaders and staff told us there was a designated lead for referrals who monitored the system to ensure both routine and urgent referrals to specialist services were documented, contained the correct information, and there were no delays. This also included safety netting to ensure all patients were followed up. In addition, routine referrals were regularly monitored to ensure patients continued to require the specialist support or check if their condition had intensified.

The leaders explained they had attended multidisciplinary team meetings to discuss and improve outcomes for people with complex needs when needed and met with the safeguarding team to discuss child and adult safeguarding. The local integrated care board told us they did not have any concerns about the practice.

The leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly. On the day of the assessment, we did not find any delays in the patient workflow tasks. The standard operation policy for workflow was last reviewed in August 2024.

The systems to identify, review and safeguard patients were effective. The staff were aware of the safeguarding lead, who reviewed patients with a safeguarding need two weekly and met with external agencies when appropriate. Safeguarding concerns were reviewed during clinical meetings. The practice had a system to highlight vulnerable adults and children. Staff told us they responded to safeguarding multi agency risk assessment conferences request for reports within 48 hours. Staff had completed the correct level of safeguarding and Prevent training, (Prevent training looks at the threat from terrorism and extremism in the UK and how to support people susceptible to radicalisation.)

Staff explained they had a system to follow up children who were not brought to appointments and carried out audits to review both children not brought to appointments and A&E attendances to identify any patterns.

Staff told us there was an effective approach to managing staff absences and busy periods, this was reviewed weekly by the practice manager.

Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient. Staff had triage information to enable them to direct the patients to the correct clinician and were supported by a duty doctor. In addition, the lead receptionist planned to attend care navigation training and cascade this to the receptionists. The practice manager told us that registration processes were up to date, and they had a member of staff allocated to summarise new patient records to ensure all medical safety alerts were in place.

Leaders told us there were enough staff to provide appointments and prevent staff from working excessively. To demonstrate workforce management and staff flexibility, the leaders provided the example of reception staff sickness when the GPs and practice manager covered and answered the telephones. This incident was discussed at the partners meeting to reduce the risk of it happening again. The reception manager explained the reception reviewed the telephone data to anticipate patient demand and work flexibly to cover it.

The practice had mostly detected and controlled potential risks in the care environment. The practice was in a multi-agency NHS building which had other healthcare providers. The overall management of the building was carried out by the NHS maintenance team, with whom the practice manager met regularly to discuss any issues. They made sure equipment, facilities and technology supported the delivery of safe care. We visited the practice, and observed it was well maintained and there were systems to ensure equipment was safe to use. We saw risk assessments were in place for the practices, premises, fire safety, and legionella and actions had been taken. However, the premises risk assessments submitted to CQC for April 2024 to November 2024 were not fully completed. The provider told us that equipment was maintained according to manufacturers’ instructions. The practice provided evidence of annual portable appliance testing, and calibration of equipment. All staff had completed their fire safety training and 14 out of 20 had completed the principles of health and safety training.

The national GP patient survey carried out from January to March 2024 had 120 responses. This found 96% of patients had confidence and trust in the health care professional they saw or spoke to, and 88% stated the health care professional was good at treating the patient with care and concern. In addition, 94% stated that their needs were met and 89% found the receptionists helpful. The patients’ responses for these categories were above the national and local area national averages.

The practice now carried out the necessary recruitment checks, which included references and Data and Barring Service (DBS) checks, and staff confirmed they had completed induction into their role. Staff had mostly completed mandatory training. For example, basic life support, safeguarding, and infection prevention and control.

The practice had put in a supervision system for all clinical staff, which included patient consultation notes reviews, spot checks and daily oversight. The findings

were reviewed at partners meetings. The leaders told us they did not use locum GPs.

However, the leaders did not have oversight of role specific training or staff immunisations on the day of the assessment. This was actioned during the assessment. A review of the clinical records found, although the GP partners explained medical students carried out patient consultations, under their supervision, the patient record did not always reflect that supervision had taken place. Also, a consultation carried out by a medical student did not contain sufficient information to establish if all the correct monitoring was carried out.

The practice assessed and managed the risk of infection. We visited the practice and found appropriate standards of cleanliness and hygiene were being met. The practice manager and business partner were the leads for infection control, and they carried out regular infection prevention and controls checks of the premises. In addition, the cleaners carried out daily cleaning and staff carried out daily checks of the rooms they worked in. A legionella risk assessment was in place. All staff had completed infection prevention and control training.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. Overall, we found the monitoring of patient’s medicines mostly followed national guidelines. For example, we identified patients administered disease-modifying anti rheumatic drugs (DMARDs) commonly used in people with rheumatoid arthritis. had received the correct monitoring. For example, we reviewed a sample of 5 patient records and found only 2 patients were minimally overdue the three-month period. However, we found GPs had not recorded the day of the administration of the weekly medicine on the prescription form. (The Medicines and Healthcare products Regulatory Agency Published 23 September 2020 guidance advises GPs to decide with the patient which day of the week they will take their methotrexate and note this day down in full on the prescription to prevent taking an accidental overdose). Following the assessment the practice has informed CQC they had now recorded the day of administration for more than 50% of patients.

The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates. We saw staff ensured vaccines were stored safely and securely with access restricted to authorised staff. However, we found some of the appropriate authorisations to administer medicines were not always completed appropriately (including Patient Group Directions or Patient Specific Directions), these were rectified on the day of the assessment. At the time of the assessment, leaders said the practice did not have an independent prescriber.

The NHS Business Services Authority medicines data in April 2024 to September 2024, which reviews hypnotic, multiple psychotropics and antibacterial prescribing results were three out of six results were below national average.