The Willow Tree Surgery

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• 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

We did not look at all the quality statements under 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 governance, management and sustainability. At our last assessment in February 2025, we rated this key question as requires improvement. At this focussed assessment, the rating remained the same.

This service scored 54 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

In our assessment in February 2025, this quality statement was scored as a 1. In June 2025, we found staff who were present during the unannounced site visit did not assure us that they fully understood their roles and responsibilities. Most of them were new to their roles and to get support and assistance required them to call a more experienced member of staff who was not on site. However, clinical cover was provided by the Locum GP who was available to staff on the phone in any emergency and lived very close to the practice.

The service did not ensure that household members of patients on the safeguarding register were coded, and the safeguarding policy required a review and update to reflect this, we informed the service about our findings and following the site visit, the service informed us that all household members have been added to the safeguarding register. However, the service did not share the updated safeguarding policy with CQC to demonstrate this was now part of the standard process.

Not all tasks created and completed on the clinical system used by the service were marked as completed on the system which the service informed us was caused by multiple individuals being assigned same tasks. The service did not inform us how this would be prevented in the future.

The principal GP was on annual leave and not at the practice when we visited. We reviewed the arrangements made for clinical cover and oversight during this absence and were satisfied it was adequate. The arrangements included some remote working by the principal GP whilst on annual leave. The Locum GP was always contactable when off site and could get to the location within a few minutes in any emergency and the staff on site had received basic life support training should an incident occur. The Locum GP provided clinical oversight while the principal GP was on annual leave and reviewed incoming correspondence and test results on a daily basis.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.