The Willow 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. At our last assessment using the old methodology in 2018, we rated this key question as good. At this assessment using the assessment framework, the rating has changed to requires improvement because we found issues with medicine management, long term conditions were not monitored and managed timely to mitigate the risks to the patients. The service was in breach of regulation related to safe care and treatment. The service did not always ensure safe recruitment and staffing oversight. The service did not always monitor staff training to ensure compliance and effectiveness. The service did not always ensure patients were aware of risks involved with their care and treatment.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The significant event analysis (SEA) report did not always contain comprehensive analysis of the occurrence of event, learning outcome and action plan within a specified timeframe. Discussions during the staff meetings did not always show a robustness of learning and action plan to prevent a recurrence of events/complaints.

The service did not always work well with people and health system partners to establish and maintain safe systems of care which led to some of the patients not being monitored for their conditions or referred for appropriate tests needed for review of medications. They did not manage or monitor people’s safety. They did not make sure there was continuity of care and appropriate actions taken when there were drug safety alerts. For example, Asthma patients not being followed up for acute exacerbation of asthma (NICE recommended within 48 hours) for their conditions and steroid cards issued. This left the patients at risk of future attacks and life-threatening complications. Female patients on topiramate did not have pregnancy prevention plan which posed a risk of abnormalities or birth defects for any child conceived by the patient.

The service worked with people and healthcare partners to understand what being safe meant to them and how best to achieve it. Safeguarding policies were in place and known to staff. Staff were not appropriately trained in safeguarding procedures for their roles until we pointed it out and corrections were made. After the site visit, the practice shared the evidence of safeguarding training completed at the correct level by the staff. The practice maintained a list of vulnerable people and worked in partnership with other organisations such as the local safeguarding board.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do things that mattered to them. Emergency equipment was available but not always maintained as there was no oxygen tubing in the emergency equipment bag during a check on the site visit. A daily check was completed by the practice and all items attested as available a day before the site visit. This showed that the systems in place needed further strengthening to ensure effectiveness in an emergency.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The practice had contract in place to ensure the premises was cleaned and maintained. Health and safety risk assessments and audits were carried out but did not always identify the risks or actions to mitigate risks. Some risk assessments were not completed such as Legionella assessment, wheelchair access, waiting area and night security to protect staff who may work very late or during the winter months. For example, on completion of the site visit, the main door opened out into the dark night without security light to show the walk path posing a health and safety risk to staff and patients. The opening or closing of the door is not easily managed for patients in wheelchairs or using walking trolleys. Since the site visit, the practice completed a risk assessment for wheelchair access and shared with us. The practice after our site visit, shared plan to make amendment to the security light at the premises.

The Legionella risk assessment document provided by the practice was a one-page job completion report with a line stating that “the above work has been undertaken and completed” and 7AC Legionella Samples written above it. This report did not conclude if the practice was at risk of legionella or not and if any actions were taken. A business continuity plan was shared with us, but it contained information that seemed out of date indicating it was not monitored and reviewed. The immunisation records of staff were not always correctly checked and recorded. We referred the practice to its own policy regarding staff immunisation which was not followed. The premises was old and there was not a free flow of air during the site visit.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always ensure that staff received appropriate training and induction as some of the newly employed staff did not have induction record in their staff files. We found that 2 members of staff did not have induction completed as there was no record of its completion. For example, the interim practice nurse recruited in January 2025 did not have any record of induction. The operational manager who was recruited to the post in May 2023 did not have any record of induction. Following the site visit and feedback, the practice claimed that the records were missing and of a malicious intent of which the practice was investigating independently.

The reception staff did not always understand the patient needs due to language barriers on the part of the reception staff. There were clinical and non-clinical roles within the practice with more utilisation of additional roles reimbursement scheme (ARRS) staff. We found most of the trainings were only completed after the assessment was announced. Safe recruitment practices were not followed as 2 of the staff recruited did not have any employment references having worked at the practice for example since 2022 and 2023. Disclosure and barring services checks were not always completed appropriately and relevant risk assessments recorded and reviewed. Following the site visit and feedback given to the practice, the practice shared completed DBS staff self-declaration. Staff appraisals and supervisions were not always robust with comprehensive details and action plans with measurable goals as demonstrated by the clinical supervision note of the ARRS staff completed and shared with CQC following the site visit.

The service assessed and managed the risk of infection. The practice had a designated lead for infection prevention and control (IPC). The practice had a comprehensive policy that was specific to it. IPC audits and action logs were completed. Cleaning schedules were in place and followed. The IPC policy also identified the IPC lead at the integrated care board (ICB) level to aid in sharing concerns with appropriate agencies promptly.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medication reviews for patients were not always consistent in triggering drug safety alerts as only text messages were sent to the patients and no record of discussion was seen in patient records checked during this assessment (for example, we examined 5 patient records with only 1 out of 5 female patients of reproductive age on Topiramate had a highly effective contraception and none of them had any pregnancy prevention plan recorded). Patients living with Asthma and Chronic Obstructive Pulmonary Disorder (COPD) did not have care plans as revealed during our clinical searches. The practice shared evidence of the care plan after the site visit and the written care plans were not personalised to the patients. The consultation notes however appeared to be of an acceptable standard.

Staff did not always follow protocols to ensure medicines were prescribed safely and reviewed appropriately. For example, the 48 hours follow up guidelines for asthmatic patients on steroids to be reviewed. Patients living with Asthma did not have steroid cards issued to them. The principal GP said follow ups were done after 7 days at this practice. Patient group directions (PGDs) were not always up-to-date and authorised. The authorisations for patient specific directions (PSDs) were not seen during the site visit as the staff informed the assessment team that it was shredded. The rationale behind the shredding was not satisfactorily explained. The practice was signposted to the relevant guidance regarding PGDs and PSDs. Following the site visit, the practice shared an email document of a message between the health care assistant (HCA) and the operational manager stating that the PGDs are now up to date, printed and signed. However, the actual PGDs which were signed, and current were not shared with CQC.

The prescribing data reviewed as part of our assessment showed that the practice prescribed antimicrobials at a level that is not varied from national and local averages. Clinical audits completed were not always comprehensive as the descriptions of actions taken and action plans were not robust or detailed. The audits did not show comparison of previous data to measure improvement.