During an assessment under our new approach
Date of Assessment: 29 April to 7 May 2025. Willington Surgery is a GP practice and delivers service to 10,523 people under a contract held with NHS England. We carried out an assessment because the service had not been inspected since 2015. The National General Practice Profiles states that the ethnic make-up of the practice area is 89% white, 6.6% Asian, 2.2% mixed, 1.2% black and 1.1% other. The age distribution of the practice population indicates the practice had a higher number of older people than the local and national averages and lower numbers of working age and young people. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 10th decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained, however, not all risks had been mitigated. There were enough staff with the right skills, qualifications and experience. Not all required information was available in staff files. Following our assessment the provider took positive action to obtain this information. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. The provider was taking action to improve the process for delivering specific injections by the nursing team.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. However, not all do not attempt cardiopulmonary resuscitation decision forms were on file, or completed in line with national guidance.
People were treated with kindness, empathy and compassion and staff respected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive. There was a positive culture in helping staff develop in their roles. Staff felt very supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Staff were very positive about the culture within the practice and the support they received. There were systems in place to support continuous learning and innovation.