Cherry 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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this practice since its registration with CQC. This key question has been rated as Good.

The practice had a good learning culture and people could raise concerns. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment at the main site met the needs of people, were clean and well-maintained and any risks mitigated. We found some minor issues with the premises at the branch site at York House, however we noted that the provider was aware of this, and had been in discussions with commissioners in attempts to develop new premises. We were also advised that the branch site had reduced opening hours, opening for only 1 hour per week when predominantly home visits were offered. There were enough staff with the right skills, qualifications and experience. However, we found some concerns with the management of records in relation to recruitment and training records, complaints and significant event analysis. Action was taken during the assessment to address some of these issues, and this is explained in more detail in the relevant section of this report. Staff managed medicines well and involved people in planning any changes.

This service scored 62 (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. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care. The practice had systems and processes in place to manage referrals, clinical correspondence and pathology results. This included ongoing monitoring of urgent 2-week wait cancer referrals to ensure that patients had attended for their appointment. We found some concerns with the process for summarising new patient records. During our site visit we were advised that 33.5% had not been summarised. However, following further analysis the practice found discrepancies with this data and had highlighted with the West Yorkshire Integrated Care Board (ICB) data team for investigation. Upon completion of this investigation it was confirmed that only 9.8% of notes had not been summarised. The practice had a clear plan to address this within the coming months.

The practice worked with patients and healthcare partners to understand what being safe meant to them, and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The practice maintained a register of vulnerable people and acted on concerns working in partnership with other organisations, for example health visitors, school nurses and the local authority safeguarding team. Patients on the safeguarding register were discussed at monthly multidisciplinary team meetings.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. There was a dedicated GP lead for safeguarding.

During our clinical searches, we reviewed a sample of patient records and saw that there was a system in place to ensure healthcare professionals were made aware of any patients on the safeguarding register.

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled people to do the things that mattered to them. During our site visit we saw that the practice had access to a defibrillator to support medical emergencies, at Cherry Tree Surgery this was located on site, and at York House Surgery staff had access to a community defibrillator located adjacent to the practice. Emergency medicines were located at each of the sites, however the medicines at York House Surgery were limited to adrenaline and Dextrogel. We discussed this with the provider during our site visit and outlined the requirement to complete a risk assessment to support the limited supply of medicines. We saw that appropriate checks of emergency medicines and equipment were undertaken.

Staff we spoke with, and received feedback from, knew how to identify patients presenting with ‘red flag’ symptoms and we heard examples of steps taken to support such patients from members of the non-clinical team.

We reviewed 2 staff files and saw evidence that staff had completed basic life support training. All the staff we spoke with and received feedback from confirmed they had also attended this training.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had recently funded an extension to the premises at Cherry Tree Surgery in order to provide additional space to expand the service.

Treatment rooms were available on the ground floor and an automatic door had been fitted to the entrance at Cherry Tree Surgery. The entrance to the branch site at York Road Surgery did not have accessible access, however we noted that this site had minimal opening times and we were informed the majority of patient contact from this site was through home visits.

We found some further issues at York House Surgery. For example, the external pathway was cracked, there were no car parking facilities or designated disabled spaces, and limited access for wheelchair users at the reception desk. We saw evidence that the provider had approached the commissioners of the service with plans to redevelop more suitable premises, or relocate to other premises. However at the time of our assessment these had not been accepted.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place, however this was overdue review. The provider addressed this during our assessment.

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. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.

The practice assessed and managed the risk of infection. There was a dedicated infection, prevention and control (IPC) lead and all staff were aware of who this was and how to raise concerns.

We that found the premises to be clean and well maintained. However, we noted that taps in the clinical room at the branch site were hand operated and therefore not compliant with IPC standards. We raised this with the provider during our assessment.

There were arrangements in place for the collection of clinical and non-clinical waste.

Risk assessments and audits were completed and action taken to mitigate risks. For example, we saw that a hand hygiene audit had been carried out in November 2024 and an IPC audit in September 2024.

All the staff we spoke with and received feedback from advised us that the practice had recorded their immunisation status at the point of recruitment. However, there was no evidence of this in staff files and the provider did not have this recorded anywhere else. Following the site visit the provider provided confirmation of immunisation status for the clinical staff member whose file we had reviewed. The practice also provided evidence of some vaccination history for the non-clinical staff member whose file we reviewed, for example; COVID-19, influenza, measles, mumps and rubella. However, the practice informed us that the staff member did not handle specimens and therefore did not require Hepatitis B vaccination. We also noted that no records regarding varicella immunisation was recorded. This was not in line with guidance outlined in Chapter 12 of the Green Book.

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. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.