The Willow Tree Surgery

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

This means we looked for evidence the practice was led effectively and in a way that was inclusive, supported improvement and innovation and made sure patients received care that was safe and effective.

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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles. Staff felt supported to give feedback and 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. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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 clear and well-embedded shared vision, strategy and culture, underpinned by principles of transparency, equity, equality and human rights, diversity and inclusion and meaningful engagement. Staff demonstrated a strong awareness of how care, treatment and support were delivered in line with the practice’s values. Practice leaders aimed to maintain a relaxed, friendly and inclusive ethos to encourage transparency and an open culture.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. Leaders had a documented mission statement, clear vision and business plan. Staff told us there was a positive culture and we saw this during our assessment.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Staff told us leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Staff told us leaders were approachable and responded to any concerns raised in a compassionate, inclusive and timely manner. There were regular management and staff meetings to ensure all staff members were aware of changes to service delivery. Staff also told us leaders modelled the values of the practice.

We saw the leadership team, worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice had an equality and diversity policy and promoted equity to all people – including staff, patients and visitors to the practice. Leaders demonstrated a clear understanding and embedded commitment to equality, diversity and inclusion. Leaders created a culture where individuality was valued and differences were seen as a source of strength.

Practice leaders fostered a positive culture where people and staff felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements, and information was displayed in the practice.

Not all staff were aware of who the Freedom to Speak up Guardian was. Staff we spoke with told us that this was because they did not feel the need to contact them, as they felt they could speak with leaders if they had any concerns and would be listened to.

Practice leaders valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There were systems in place to support workforce equality, diversity and inclusion, with an emphasis on the safety and well-being of staff. This included an equality and diversity policy, training for staff and access to support from external services.

Staff had completed training in equality, diversity and inclusion and were aware of how to support people with protected characteristics such as age, gender, sexual orientation, religion and disability. Some staff gave examples of reasonable adjustments they had received.

The practice had clear responsibilities, roles and systems of accountability and governance. There were effective governance and management systems in place where information and data were used appropriately to monitor risk. Practice staff acted on information about risk and outcomes and shared this securely with others when appropriate.

Leaders were supportive to staff, and all of the staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff were able access all required policies and procedures.

There were regular staff meetings during which clinical concerns and emerging risks were discussed. Minutes of these meeting were clearly recorded and actions arising from these meetings were shared with staff. Staff took patient confidentiality and information security seriously and there were effective systems in place to manage this.

Practice staff understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The practice consistently shared information and learning with partner organisations and engaged in joint efforts to drive improvement.

Leaders and staff worked closely with community teams, secondary care providers and social care services to deliver coordinated, person-centred care.

This collaborative approach was evident in a range of initiatives, including hosting complex dressing clinics, being involved in an NHS Hepatitis C elimination programme and working closely with local asylum hotels.

The practice worked with other practices within their primary care network to offer extended access, and flu and COVID vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through regular meetings centred on the care of those at higher risk of hospital admission.

Practice leaders focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Leaders told us they aimed to provide staff with a wide range of training courses to support personal development plan and maintain competence. Leaders used a centralised system for online staff training and oversight. This system was chosen for its functionality, ease of use and comprehensive range of training courses for all staff. To ensure training requirements was not overwhelming for staff, courses were organised into monthly topics.

The practice had a quality improvement plan in place to help drive improvements in services. This focused on the appointment system.