The Willow Tree Surgery

On this page

• 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 looked for evidence that the service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment in 2018 using the old methodology, we rated this key question as good. At this assessment, the rating has changed to requires improvement because we identified issues with safe care and treatment and good governance.

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.

The practice staff understood the practice’s mission; however not all staff could inform us of the shared direction, vision or goals of the practice, for example, a member of staff when asked what the values/ mission statement of the practice was responded “priority for vulnerable patients” while another informed us “not involved in the values planning”. Staff informed us that they could share concerns with the management. The leadership did not always monitor and review the risks to service delivery.

The practice leadership did not always exemplify high- quality leadership seen by the evidence of the quality of care delivered to the patients and the effectiveness of the systems used by the practice in service delivery including the recruitment process. The leadership at this practice was not always alert to risks that affected the quality of people’s care and the impact it would have on the practice staff such as staff not being made aware of learning from incidents and changes made as a result. However, staff spoken to during the assessment informed us that the leaders were supportive and approachable. The practice worked together with the local PCN in the development of primary care services within the local area.

The practice said they encouraged staff to speak up and there was whistleblowing policy, however, this did not include a named Freedom to Speak Up Guardian. The operational manager informed us that there was a named person within the local PCN, and an external person separate to the practice whose name was not shared with us or recalled during the interaction with CQC. The whistleblowing policy we reviewed on the practice computer system did not include specific contacts for the practice staff to approach that were external to the practice. We requested for the practice to share a copy of its whistleblowing policy, but this was not provided. Following the site visit, the practice shared posters highlighting who staff can go to externally when they have concerns. However, the whistleblowing policy shared with CQC during the review of the draft report showed the policy contained out of date information, such as the named confidential contact within the practice that the practice staff could go to who was no longer the practice manager, but it contained contact details of external professionals that could help with matters relating to speaking up.

The practice trained staff on equality and diversity, however, not all staff had evidence of its completion and only 3 out of 8 staff file records we checked showed completion of equality and diversity training. Following the site visit, the practice shared additional evidence that staff had completed the training. Documents collated by the PCN during the staff temperature check at this practice and we reviewed on site showed that staff felt that more needed to be done to promote fairness and equity at the practice.

Staff we spoke to informed us that they understood their roles and responsibilities. Staff told us that on some days there was no management presence at the practice. When we raised this with the practice they provided a document to show there was senior cover onsite; however, the document was redacted so we were unable to verify it showed such cover.The staff we spoke to said they could call the GP on the phone if there were any issues. Staff appraisals were not up to date or complete. The practice leadership did not ensure effective systems were in place for suitable background checks, recruitment, staff performance monitoring and induction processes. Action plans from staff meetings and clinical meetings were not clearly recorded. The leadership did not have any record of the supervision completed with the ARRS staff working within the practice. Following the site visit, the practice shared completed supervision notes with the GP assistant, one of the ARRS staff. The completed clinical supervision notes did not include a comprehensive detail of what was discussed and a measurable action plan.

The practice worked closely with other healthcare professionals collaboratively to promote seamless service delivery. The practice shared information with the mental health team, district nurses, community palliative care team and the PCN social prescriber and other community health care services.

The principal GP informed us that the practice ran a Saturday clinic to increase the uptake of cervical screening, but this information was not included on the practice website. The practice after the site visit informed CQC that the Saturday clinics occur opportunistically and communication about it passed to the patients. The practice said lessons learned from complaints and significant events were shared with the staff for improvement work, however there was little evidence of this sharing in meeting minutes and other records we reviewed. There was no evidence of effective quality improvement work, such as multi-cycle audits, to drive up patient outcomes.