The Willows Medical Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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

Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and said they were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. We observed there had been improvements from the previous inspection, but further work was required to fully embed the new systems.

This service scored 71 (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 staff had shared direction and culture. The leaders stated they were dedicated to fostering a culture of continuous learning, professional development, and excellence in patient care. The staff had a commitment to teaching and training.

The practice had developed a business plan for 2025 to help them to share direction and plan for the future. The plan covered quality improvement, patient experience, operational efficiency, financial stability and workforce development. The practice had a business continuity and plan and disaster recovery plan to allow them to operate under exceptional and adverse circumstances. The practice had a change of GP partners and business and practice managers in May 2023. In addition, we were told the partners held regular meeting to discuss performance and direction.

The practice offered flexible working arrangements where possible. The leaders explained they encouraged celebration and recognition of all religious needs and festivities.

The practice had completed a staff survey in November 2024, eight staff had responded when asked whether the resources and support you need to perform your job effectively. The practice had achieved a score of 4.5 out of possible five. (This ranged as from 1 never to 5 always). In response the management planned to upgrade the working environment.

The leaders understood the context in which the practice delivered care, treatment and support. The practice had a business, practice and reception manager, who all worked part-time, ensuring a manager was accessible to staff throughout the week. The leaders explained the GP partners were also accessible to staff during work time. The managers explained the practice offered flexibility in the hours staff worked to enable them to meet their cultural and caring responsibilities. The staff we spoke with and who submitted questionnaires felt supported by the leadership team. A review of a sample of staff files found the practice was following an improved recruitment process. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities. Staff told us they had access to training and development.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. All staff had completed whistleblowing training and there was a whistleblowing policy in place last reviewed February 2024. The practice had a freedom to speak up guardian for staff to speak to. Staff we spoke with said they would feel comfortable in making their views heard.

The leaders explained that they provided flexible working arrangements and time for staff to follow their religious and cultural beliefs. Most staff had access to continual professional development, support and mentorship. For example, the senior receptionist, received additional leadership training and support and as a result, they had successfully progressed into the role of reception and administration lead. Also, a staff member was encouraged to pursue a nursing career. Staff were able to attend clinical, partner and weekly huddles to keep updated about any changes. The leaders had offered mental health support and provided resources such as counselling service and physical health initiatives for staff. Such as workplace chair yoga.

The practice had a quality, diversity and inclusion policy, which was last reviewed in October 2024. The policy applied to all employees, patients, visitors, contractors and stakeholders.

The practice had completed a staff survey in November 2024, eight staff had responded when asked about whether the work environments was inclusive and respectful. The practice had achieved a score of 4.5 out of possible five. (This ranged as 1 for never to 5 always). In addition, when asked about how they would rate satisfaction with professional development and encouragement of further training, the practice had achieved a score 3 out of possible five. In response to this practice planned to increase the opportunity for professional development.

The practice had completed a staff survey in November 2024, eight staff had responded when asked about how they would rate the communication between staff and management. The practice had achieved a score 3 out of possible five. (This ranged as 1 for never to 5 always). In response the practice had introduced weekly staff huddles to discuss any changes or concerns. The practice had developed a business plan for 2025 to help them to share direction and plan for the future. The practice had monthly partners meetings to discuss the management and sustainability of the practice and had put a business continuity plan and an operational risk assessment in place to mitigate risks. They had monthly clinical, and practice meetings and weekly huddles to keep the staff informed about any changes or concerns at the practice. We found improvement had been made to the governance systems, for example recruitment, training, supervision, significant events, risk assessments, staff roles and communication but further work was required to fully embed the new systems.

The partners were involved in the local primary care network and acted as clinical director, digital, homeless leads and international medical graduate clinical lead. In addition, 4 of the partners were GP trainers and 1 a GP appraiser.

The practice contributed to the broader healthcare landscape through participation in Integrated Care Systems. The integrated approach supports the development of streamlined pathways and improved health outcomes across the community.

The staff understood their duty to collaborate and work in partnership, so that services work seamlessly for people. The practice had shared care agreements in place and carried out referrals. The practice had been involved community engagement such as, cardiovascular and diabetes awareness sessions, community coffee mornings at a local church and mosque, which offered one to one session with a doctor, oxygen level and blood pressure checks and body mass index checks. There was a patient participation group (PPG) who represented the views of people using the service, who met every three months. We were provided with copies of the last three meetings, where the access, interpreters, complaints, new staff and new events were discussed. The PPG also issued a newsletter which included information about vaccinations, blood tests, the enhanced access hub, and blood pressure checks. We spoke with a member of the PPG who confirmed that the partners attend the meetings and listened to their views.

The practice had completed a staff survey in November 2024, eight staff had responded when asked about how they would rate satisfaction with professional development and encouragement of further training. The practice had achieved a score 3 out of possible five. (This ranged as 1 for never to 5 always). In response the practice planned to increase the opportunity for professional development.

The practice was a GP training practice, as part of their training the trainee GPs carried out projects, examples of this were use of artificial intelligence and review of patient medication to ensure patients were on the correct medicines.

The leaders had implemented a new telephone system which enabled receptionist to monitor the patient calls and identify preferred times and type of contact and respond to their needs.

The practice had been involved with community engagement such as, diabetes awareness sessions, community coffee mornings at a local church and mosque, which offered one to one session with a doctor, oxygen level and blood pressure checks and body mass index checks. For people who had frequently attended the practice, the GPs had introduced a personalised approach by engaging patients directly through phone/ face to face consultation. Which staff said had addressed their health concerns and needs and resulted in a reduction of the patients’ need to frequently attend the practice.