During an assessment under our new approach
Date of Assessment: Remote clinical searches date 12/02/2025 and site visit date- 13/02/2025. This location was assessed due to emerging risks raised with the Care Quality Commission (CQC).
The concerns that identified the emerging risks related to negative culture of the practice, quality of care provided to the patients, infection prevention control, lack of clinical oversight, staff not knowing the correct processes, no continuity of care for patients, staff completing tasks outside of their competency and patient access. In addition, we received information of concern that the leadership of this practice had instructed the staff not to disclose any concerns to CQC during the site visit.
The Willow Tree Surgery is a GP Practice and delivers services to 3,327 patients through a contract held with NHS England. Its parent provider is Dr Minoli Rehana Handalage under a sole trader legal entity. The National General Practice Profile states that the patient population make up for this location is 44.0% Asian, 28.3% White, 12.9% Black, 4.5% Mixed and 10.3% other demographic/ ethnicity. Information published by the Office for Health Improvement and Disparities shows that deprivation among the practice population group is in the 4th decile (4 out of 10). The lower the decile, the more deprived the practice population is relative to others. The Willow Tree Surgery is registered to deliver the following regulated activities: diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.
Safe: The practice did not always have a good learning culture. When significant events analysis (SEA) reports were completed, they were not always detailed with clear action plans to prevent a recurrence. The SEAs and complaints were discussed at team meetings; however, the minutes did not always show the details of the discussion in clear terms and there was no action plan to prevent a recurrence or mitigate risks. Managers did not always understand the oversight responsibilities to complete them effectively. Staff recruitment and induction process were not always fit for purpose. The infection prevention and control (IPC) policy and system were specific to the practice with IPC audits completed appropriately.
Effective: The systems put in place to monitor and improve the health and care needs of the patient were not always effective. The practice offered health check reviews to some of the eligible patients, but not all eligible patients were offered the health checks. Patients did not always get the information needed to make an informed decision about their health.
Caring: People were treated with kindness and compassion; however, the dignity and privacy of patients were compromised due to the structure of the leased premises. The patient satisfaction at this location was significantly lower than the local and national averages. There was an action plan to improve the wellbeing of staff following a recent staff survey which showed the level of staff morale and concerns and there was an action plan to improve the experiences of care for the patient population.
Responsive: People were not always provided with information about their health needs to make informed decisions. People complained about not getting appointments to suit their needs and that it was difficult to get to see doctors face-face as telephone appointments were offered. Patient feedback we received highlighted that people did not always feel information provided to them was relevant to their needs. Complaints were dealt with and recorded appropriately. However, lessons learned from the complaints and action plans were not always clearly defined and recorded in complaints log and in staff meeting minutes.
Well-Led: Leaders and staff at this practice did not have a clear understanding of their roles and responsibilities. There was a lack of clinical and administrative oversight to ensure patient safety. Most of the responsibilities were delegated to the additional roles reimbursement scheme staff (ARRS) or allied health care staff without adequate oversight of activities provided by them. There were no adequate systems in place to identify, monitor and complete administrative and clinical activities at this practice.
We found breaches of regulation 12 (safe care and treatment), 17 (good governance), and 19 (fit and proper persons employed). We took civil enforcement action against the provider, and we published the information on our website. All representations were concluded, and an outcome was reached. We served a warning notice on the provider for the breach in the provision of safe care and treatment.