The Willow Tree Surgery

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• 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 did not look at all the quality statements in this key question during this assessment. The scores and rating for the quality statements in this key question were based on the previous rating from February 2025 except for safe systems, pathways and transitions; safe and effective staffing. We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment in February 2025, we rated this key question as requires improvement. The service was in breach of regulation in relation to safe care and treatment. At this focused assessment, the rating remained the same.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

In our assessment in February 2025, this quality statement was scored as 1. In June 2025 we found the service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Referrals and test results were managed in a timely way from our review of pathology inbox. The Locum GP who had clinical oversight in the absence of the responsible individual ensured all test results were reviewed and acted upon where necessary. The social prescriber, a member of the additional roles reimbursement scheme (ARRS) staff, ensured all referrals were escalated to the relevant teams.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

In our assessment in February 2025, this quality statement was scored as 1. In June 2025 we found the service did not always make sure there were enough qualified, skilled and experienced staff on site to support the team. During the site visit, there were newly employed staff at the reception desk. One of them had only been in post for one month and another member of staff was undergoing shadowing without risk assessment completed by the management. The other reception staff was only 6 months into the role. There was not a more senior member of the administrative team on site at the time the assessment team arrived at the location. The reception staff made a phone call to the practice manager to inform on the presence of CQC’s assessment team. The practice manager arrived 22 minutes after the call and explained to us she had been on a break. There was no clinical staff on site when CQC arrived on site, however, we were informed that the Locum GP, who had oversight in the absence of the principal GP, lived very close and could attend very quickly to any emergency that might arise. Recruitment checks for additional roles reimbursement scheme (ARRS) staff were completed by the Primary Care Network (PCN) and evidence of these were shared with the assessment team.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.