Willow Tree Family Doctors

We carried out an announced focused inspection at Willow Tree Family Doctors on 24 August 2022, with the remote clinical review on 22 August 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective – Requires improvement

Caring – Not inspected, rating of good carried forward from previous inspection

Responsive – Not inspected, rating of good carried forward from previous inspection

Well-led – Requires improvement

Following our previous inspection on 24 November 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Willow Tree Family Doctors on our website at www.cqc.org.uk

Why we carried out this inspection

We carried our this inspection of this practice as it was identified as part of a random selection of services rated Good or Outstanding to test the reliability of our new monitoring approach.

This inspection was a focused inspection focusing on whether:

• Care and treatment was being provided in a safe way to patients.
• There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected.
• Information from our ongoing monitoring of data about services.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as Requires improvement overall.

We have rated this practice as Requires improvement for providing safe services because:

• We found issues with the monitoring of patients on some high risk medicines.
• We found that medication reviews were not always completed in appropriate detail.
• We found that the system for managing and acting on Medicines and Healthcare Products Regulatory Agency (MHRA) alerts was not always effective.
• We found gaps in the training records of two clinical members of staff who had overdue Mental Capacity Act training.
• We found that the practice had robust systems and processes for managing safeguarding concerns.
• The premises were well managed and there were effective systems for managing infection prevention and control.
• We found that emergency medicines and equipment on site were organised, in date and effectively managed.

We have rated this practice as Requires improvement for providing effective services because:

• We identified some issues with the monitoring and management of long-term conditions, in particular in relation to patients with hypothyroidism.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
• The practice uptake for cervical screening was below the 80% coverage target for the national screening programme. We saw evidence that the practice had put in place systems to address the uptake of cervical screening.
• The practice had not met the minimum 90% uptake for four of the childhood immunisation uptake indicators. The practice had not met the WHO based national target of 95% (the recommended standard for achieving herd immunity). We saw evidence that the practice had put in place systems to address the uptake of childhood immunisations.

We have rated this practice as Requires improvement for providing well-led services because:

• The practice had a governance framework, however it was not always effectively managing risks. These included the risks associated with prescribing medicines that required ongoing monitoring and reviewing patients prescribed repeat or multiple medicines in line with guidance.
• The practice was not always keeping comprehensive clinical records, with medication reviews not always being completed in detail, including that monitoring was up to date or requested and that any relevant safety information or advice had been addressed.
• The practice was not always appropriately managing patients with long-term conditions.
• Actions were taken to support the maintenance of the service during the Covid-19 pandemic.
• Staff spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The provided must:

• Ensure that care and treatment is providing in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

In addition to the above, the practice should:

• Take steps to ensure that all mandatory training was completed on time and was kept up to date.
• Continue to address the actions identified in the fire risk assessment report from September 2021.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services