The Willow Tree Surgery

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

This means we looked for evidence that there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection with the previous provider, we rated this key question requires improvement. At this inspection, the rating has changed to good.

The practice had a positive 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 and any risks mitigated. There were staff with the right skills, qualifications, and experience. 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.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The practice had a learning and development policy.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff told us they knew how to identify and report concerns, safety incidents, and near misses.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously.

Staff we spoke with told us that they felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The provider had analysed themes from recent complaints and created an action plan. Learning from incidents and complaints resulted in changes that improved care for others.

Our searches of the practice’s clinical records system showed that there was an effective system for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). Clinical guidance from these safety alerts, was embedded into routine practice.
 

Practice staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They worked with other providers to deliver shared care when people moved between services. People we spoke with gave positive feedback in relation to referrals being made appropriately and being supported during waiting times to be seen by other services.

There were systems in place for processing information for people newly registering at the practice. This included people who were homeless, asylum seekers and refugees. There were also protocols in place to manage the flow of work within the practice. The practice had identified that there had been previous occasions when letters had been filed without actions or specialist instructions had been missed. They had created an action plan which was risk assessed and identified a date for review. There were arrangements in place to ensure that required actions were reviewed and authorised by an appropriate clinician.

Staff told us they had the information they needed to deliver safe care and treatment. We saw that referrals and test results were managed in a timely way. Staff who undertook referrals to secondary care understood systems and processes in place to minimise any potential delays. There were systems in place for staff to track referrals. For example, including electronic referrals and the oversight of urgent referrals relating to potential cancer diagnosis.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. They focused on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Staff shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. This included regular monthly multidisciplinary face to face meetings with health visitors and district nurses to discuss safeguarding.

Safeguarding discussions also took place during clinical meetings. We reviewed minutes of these meetings and saw that people’s needs were discussed and reviewed, and actions agreed and followed up.

Staff we spoke with told us that they were confident in reporting any concerns and knew who the practice safeguarding lead was. Staff gave examples of how they supported vulnerable people, such as conducting home visits for people who may be at risk. Staff were also able to identify risks associated with female genital mutilation (FGM).

There were arrangements in place to follow up vulnerable people who had not attended their appointments. The practice had also started a food bank to support patients in difficult circumstances.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and understood what action to take. Patients were advised about risks related to their condition and actions to take if their condition deteriorated.

Practice staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

There were effective arrangements in place for staff to identify, assess and manage people whose health was deteriorating, and for managing medical emergencies. Staff had completed basic life support and anaphylaxis training relevant to their role. People we spoke with told us that they understood how to obtain support and advice if their health was worsening.

During our site visit, we saw that emergency medicines and equipment was easy to access in the event of an emergency. The practice did not have all recommended equipment for use in an emergency, including a variety of equipment to support a person’s airway and breathing. During our visit, the provider showed they had completed a risk assessment that explained the reasons for not keeping these items of equipment and how the risks would be managed, including outlining alternative arrangements the practice had in place. This risk assessment required embedding.

We saw that the emergency equipment and medicine were checked regularly and there was clear documentation of the checks made.

Practice staff detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to maintain the premises. Health and safety risk assessments and audits had been undertaken and identified risks had been addressed. There was a business continuity plan in place which was monitored and reviewed.

Ongoing checks, such as fire safety, electrical safety, and equipment calibration, were completed. Staff we spoke with told us they had suitable and sufficient equipment to undertake their work and were satisfied with the health and safety arrangements in place. Staff had received fire safety and health and safety training.

The practice had a Health and Safety Risk Policy, which included information about risk management, risk assessment methodology, rating risks, and interpreting risk matrices. The policy also included information for staff about COSHH (Control of Substances Hazardous to Health). These policies detailed the practice’s processes for fire safety, including evacuation plans and how to keep people safe in the event of a fire. The evacuation plans included information for people with mobility issues. During the site visit, we observed that fire exits were clear and fire safety equipment was easily accessible and had been checked by an external company.

Staff at the practice used technology securely and effectively. Staff had completed training in information governance and gave examples of how they ensured people’s confidentiality and demonstrated they took information security seriously.

The provider had a plan and strategy detailing how the practice would support the Greener NHS National Programme.

Leaders and representatives from the PPG told us that there had been some episodes of violence and aggression by some people within the area. This was not always related to dissatisfaction with the practice. Staff told us some people felt able to approach them after there had been unpredictable behaviour. There were processes in place to keep patients and staff safe during these events.

We spoke with patients, representatives from the PPG and some staff who told us they did not feel that there was enough staff working at the practice. Leaders were aware of this feedback and told us they felt there was a safe level of staffing. They planned to undertake a review of how work was organised to see whether any improvements could be made.

Staff worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found that training was up to date, learning needs and staff development were managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. We received assurances during the assessment that appropriate recruitment checks were carried out, including Disclosure and Barring Service (DBS) checks for all staff.

The professional registration of clinical staff was checked at recruitment and on an ongoing basis. All new staff received an induction, adapted to their role. Leaders met with staff regularly to complete performance reviews, and a sample of records we reviewed confirmed this.

The practice was able to demonstrate that staff had the skills, knowledge, and experience to carry out their roles. Staff who were responsible for long term condition reviews, childhood immunisations and cervical screening had completed the required training, and their competency was checked on an ongoing basis.

Practice staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. Staff we spoke with knew who the IPC lead was and described the systems in place for safely dealing with clinical specimens and spilled bodily fluids.

Cleaning schedules were in place and being followed. Risk assessments and audits were completed, and actions were taken to mitigate risks. Policies and guidance were available for staff, including during induction, and were relevant to their role.

During our on-site visit, we observed the practice to be clean and tidy. We saw documented checks of cleaning and arrangements in place to effectively communicate with the cleaning company and resolve any issues. There were health promotion posters around the premises that were either laminated or wipeable in line with the practice’s IPC policy.

The practice obtained an immunisation history for all staff upon employment.

Practice staff made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People were aware what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Medicines were stored securely. Some medicines, for example vaccines, need to be stored in a fridge to make sure they remain safe to use. There were processes in place to ensure that these were appropriately kept within temperature monitored fridges, which were checked daily. Staff understood how to raise concerns if the temperature went outside of the safe range. There was a cold chain policy that referred to staff who no longer worked at the practice, the provider amended the policy during the assessment.

Staff regularly checked the stock levels and expiry dates for all medicines. Medical gases, such as oxygen, were stored safely. Staff also managed prescription stationery appropriately and securely. Patient Group Directions (PGDs) were in place, and these had been appropriately authorised for use. PGDs provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, we saw an audit for monitoring patients on a medicine called Nitrofurantoin. Our remote clinical searches showed that people received the recommended monitoring when prescribed medicines by the practice. For example, we carried out a search of the practices system and found no issues relating to Disease Modifying Antirheumatic Drugs (DMARDs) or monitoring of people who were prescribed ACE inhibitors.

The practice had systems to manage and respond to safety alerts and medicine recalls. There was evidence that safety alerts had mostly been actioned, and people received the correct information about any risks associated with their medicines. We reviewed an alert where people prescribed a medicine called hydrochlorothiazide must be informed about the important risks associated with taking this medicine. We found one person who was prescribed this medicine had not yet had a review, however an appointment had been booked to discuss the risks.

We reviewed the quality of medicines reviews and sampled 5 people’s records from 147 people who had a medication review in the last 3 months. We found that the documentation for 4 of these records lacked detail, this feedback was given to the provider during the assessment. The provider submitted assurances to us that this would be acted on in a timely manner.

We reviewed a range of prescribing indicators and found the practice was within the expected range for prescribing medicines.