The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Willow Surgery

Overall: Good read more about inspection ratings

Hill House Road, Bristol, BS16 5FJ (0117) 970 9500

Provided and run by:
The Willow Surgery

Important: The provider of this service changed. See new profile

All Inspections

27 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Willow Surgery 28 July 2016. The overall rating for the practice was good however the safe domain was rated as requiring improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for The Willow Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 27 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

We found in the areas where the provider must previously make improvement that:

  • The provider had ensured that the blank prescriptions held by the practice were fully recorded and maintained an auditable record.

  • The provider had ensured that the systems for monitoring and recording the stock of medicines and emergency equipment used at the practice provided an auditable record which ensured an in date supply was available.

  • The provider had ensured that patient specific directives were explicit to the staff member who administered the medicine.

  • The provider had ensured the new system for monitoring refrigerator temperatures was sustained by the staff team.

  • The provider had ensured the appropriate Disclosure and Barring Service checks for GPs were undertaken as part of the recruitment process.

  • The provider had reviewed the audit documentation used for infection control to ensure the tool used encompassed a whole audit of the practice and its environment.

  • The practice had obtained a risk assessment of the premises which controlled any risks associated with Legionella.

  • The provider had devised systems which ensured the processes for checking test results was robust and fail safe.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Willow Surgery on 28 July 2016. Overall the practice is rated as good with the safe domain rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Clinical risks to patients were assessed and well managed. The practice had a continuous quality improvement policy which listed the type of processes the practice used to improve patient experience.

  • We found the system for the management of medicines and emergency equipment was not failsafe and did not ensure an in date supply was available; records of blank prescriptions were incomplete and not auditable should a security incident occur.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available and easy to understand.

  • Patients said there were urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The practice had an active patient participation group who contributed ideas for improvement and was valued by the practice. The group had suggested the practice introduce a list of frequently asked questions entitled ‘A conversation with the Willow Surgery’ into the waiting room so that patients were better informed about what to expect when making an appointment.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • The provider must ensure that the blank prescriptions held by the practice are fully recorded and maintain an auditable record should a security breach occur. Also the provider must ensure that the systems for monitoring and recording the stock of medicines and emergency equipment used at the practice provided an auditable record and ensured an in date supply was available.

The areas where the provider should make improvement are:

  • The provider should ensure that patient specific directives are explicit to the staff member administering the medicine.

  • The provider should ensure the new system for monitoring refrigerator temperatures is sustained by the staff team.

  • The provider should ensure the processes for checking test results is robust and failsafe.

  • The provider should ensure they undertake the appropriate recruitment checks for GPs.

  • The provider should review the audit documentation used for infection control to ensure the tool used encompasses a wider audit of the practice and its environment.

  • The practice should obtain a copy of the risk assessment to control any risks associated with Legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 October 2013

During a routine inspection

We were welcomed by patients and all members of staff when we visited. The inspection was announced to the service 48 hours prior to our visit. The GP's, practice manager and staff had considered a programme of events for our visit so that we had a useful variety of patients and staff to speak with. We also attended a 'baby clinic and treatment room nurse consultation'.

The practice received positive, constructive, comments and feedback from their patients when they had completed surveys. Comments included 'Nothing is too much trouble', 'Attentive, kind and efficient', 'Would prefer waiting times advertised' and 'I like the internet appointments system'.

Staff were happy to share their experiences about their individual roles and how they supported patients who used the service. It was evident that all the staff we met with were' proud' to work at the practice and for the services they provided to patients.

Staff clearly supported the practice and their commitment to the delivery of quality services in a manner that significantly improved patient experience, their health and wellbeing.

The practice considered the community they were supporting and were always thinking of innovative ways to improve and expand services for patients so that patients could have access to new care and treatment services within their local community.