Yew Tree Medical Centre

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 assessed all quality statements under this key question. The rating given is Good. The service had a good learning culture and people could raise concerns. Safety was a priority, and the provider took all concerns and incidents seriously. These were discussed, fully investigated and action was taken to prevent a recurrence. Staff knew how to identify and raise concerns and managers investigated incidents when they occurred. People were protected, involved in decisions about their care and kept safe. Staff managed medicines well and there were processes for monitoring patients’ health in relation to the use of medicines including medicines that required regular review. There was a suitable process to manage safety alerts and we saw this worked well. Systems and procedures were in place to safeguard patients who may be at risk of abuse and staff had undergone checks to ensure they were suitable for the role and were appropriately trained. Members of the staff team provided positive feedback about staffing levels which they said had recently improved. The premises were safe and well maintained and there were suitable procedures to manage health and safety. However, there were areas that required action by the provider in risk management and staff records.

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 service demonstrated and provided evidence of a positive culture of safety, based on openness and honesty. Processes were in place for staff to report incidents, near misses and safety events. The provider listened to concerns about safety and investigated and reported safety events. Staff felt there was an open culture, and that safety was a priority. Although not always documented consistently, incidents and complaints were investigated, and regular meetings were held where the learning from these was shared and discussed. The provider reviewed significant incidents and complaints with a view to identifying themes and trends although verbal complaints were not always reported and documented.

The provider worked with people who used the service and healthcare partners to establish and maintain safe systems of care. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. The service worked with other providers to deliver shared care when patients moved between services. Feedback from people who used the service indicated they felt involved in decisions about treatment pathways and they reported prompt follow up care. Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health. Reception staff had been trained in care navigation to direct patients to the most appropriate service or services to meet their presenting needs. Regular multi-disciplinary meetings were held where the needs of patients with more complex conditions or those approaching the end of life could be discussed. Clinicians followed care and treatment pathways for treating and referring people to other services. Referrals to secondary or specialist care were made promptly, and patients referred under the two-week wait rule for suspected cancer were followed up appropriately. Correspondence from secondary care such as discharge letters/summaries were processed quickly and effectively. People could request a chaperone for intimate examinations if they wished and there was information to alert them to this in the waiting room and in clinical rooms.

The service worked to safeguard people from the risk of abuse. This included working with partner agencies. There were systems and processes to respond when it was suspected that people may be subject to abuse or neglect. Staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. Staff had a clear understanding of safeguarding and knew their safeguarding lead. They knew the action to take if they had concerns about a patient’s safety and they told us they would feel confident to report concerns. Alerts were added to the patient record system when a patient was subject to a safeguarding concern so that all relevant members of the staff team could readily identify this. People were well known to the practice. Feedback from people who used the service did not include any concerns with regards to safeguarding. Staff recruitment procedures were in place to ensure staff were suitable to work in the service but this was not always documented sufficiently for non-clinical staff.

The service worked with people to understand and manage risks. The care and treatment provided was safe, supportive and encouraged people to remain healthy. People were advised on risks related to their condition and actions to take if their condition deteriorated. Staff, including locum staff, were trained in areas to support people who lived with long term health conditions, for example, diabetes. People were called in for regular checks on their health when they were living with a long term condition. There was an effective system in place for dealing with patient safety alerts. The provider encouraged patients to attend for health screening. However, the percentage of persons eligible for cervical screening as at 31/06/2023 who were screened was 63% which was lower than the local and national averages. We discussed this with the nurse who demonstrated that people who had not attended for cervical screening were followed up and encouraged to attend. We saw data from 2025 which showed that cervical screening uptake had improved. Childhood immunisation uptake was below the 80% World Health Organisation targets in all age categories. The practice nurse explained the reasons for the poor uptake and demonstrated the efforts the practice made to educate patients around the importance of immunisation and encourage uptake.

The service was located in a purpose built building that provided the required facilities such as safe access for people with physical disabilities. The premises were clean and contained the appropriate facilities to support infection prevention and control. The provider detected and controlled potential risks in the environment and noted that the premises could be accessed by non-patients, particularly in the evenings when there were limited staff around. Leaders made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Health and safety related assessments and procedures to manage health and safety were in place. This included fire safety. Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. Staff told us in discussions and feedback forms that they had no concerns with the arrangements in place for ensuring health and safety other than the occasional lone working when it occurred. There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and opportunities to develop. Staff told us they had protected learning time (PLT) meetings once a month to undertake learning and professional development but felt they would benefit from more regular PLT during working hours for any updates. They had all however received training appropriate and relevant to their role. People experienced care and treatment from a recently stabilised clinical team and consistency of care was provided as a result of this. Staff in all roles told us there was enough of them to provide safe, high quality care and they worked effectively as a team. However, leaders should review whether there is enough staff for the end of the day shift as we were told this was not always the case. There were appropriate arrangements in place for covering staff sickness, absence and vacancies and the use of temporary staff was minimal. Feedback from people who used the service that was shared directly with CQC positive about satisfaction with members of the staff team and with access to clinicians. We looked at the recruitment records for a sample of staff. These showed recruitment practices were carried out in line with requirements for clinical staff but appropriate documentation was not maintained for non-clinical staff. In a sample of 8 personnel files, records were incomplete.

The facilities and premises were appropriate to support cleaning and limit the spread of infection. Personal protective equipment was in good supply and located appropriately around the premises. The provider assessed and managed the risk of infection. There were clear roles and responsibilities around infection prevention and control with a dedicated lead person and staff had undergone training appropriate to their role.

Cleaning schedules were in place and infection prevention control and cleaning audits were carried out on a regular basis. Cleaning equipment was stored securely and in line with best practice. The arrangements for managing waste, sharps and clinical specimens kept people safe.Staff vaccination was mostly maintained in line with current UK Health and Security Agency (UKHSA) guidance. At the time of the assessment updates were required for some non-clinical staff. There was a system for the service to report infection-related concerns to the relevant agencies (e.g. notifiable diseases).

The provider made sure that medicines and treatments were safe and met people’s needs. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that medicines were managed very safely and the approach to medicines reflected current and relevant best practice and professional guidance. There was evidence that people taking medicines with specific risks that required monitoring were appropriately monitored before their medicines were prescribed. A small number of people were overdue checks relating to their medicines and the provider evidenced that all of these were rectified during the assessment process. Regular medicines reviews were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

Staff had access to emergency medicines and equipment including oxygen and a defibrillator. These were regularly checked for stock availability and to ensure they were in date. There was evidence of risks to emergency equipment being identified by way of a recently raised incident. This had been discussed and learning was achieved. Vaccines were stored appropriately, and regular checks were carried out to ensure safe storage and stock. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Appropriate action had been taken in response to the medicines alerts we looked at. defibrillator. We noted that Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients in planned circumstances for example, vaccinations) were in good order. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.