The Willows Medical Centre Also known as Affinity Care

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

People were protected from abuse and avoidable harm. Improvements had been made since people the last inspection of the service in December 2022 where the provider was rated requires improvement for the provision of safe services. This was due to concerns regarding the review and monitoring of people in receipt of high-risk medicines and medication for long term conditions, and the failure to fully action safety alerts.

At this assessment we saw that the provider had made improvements, this included establishing processes for the review and monitoring of people in receipt of high-risk medicines and for those with long term conditions. However, we noted issues with the robustness of systems and processes in some areas. The provider had put processes in place to assess and action patient safety and medicines alerts. The provider had also been making significant progress in establishing the vaccination and immunisation status of staff that were involved in the care and treatment of people. Safety issues were managed effectively and the provider had high level oversight via a Quality and Safety Group which reported to the Board of Directors. We saw the provider had developed and implemented comprehensive clinical supervision processes and they had improved their approach to learning after incidents and significant events.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Staff told us they knew how to identify and raise significant events and incidents, and they felt that when they raised any concerns these were investigated and actions taken. Staff told us any learnings were regularly shared in team meetings. Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. The whole team could access the system for reporting and were able to update incidents and learning events as the investigation progressed. This showed how incidents, concerns or learning events were recorded, actions taken and the overall outcome. We saw in the last year there had been 70 learning events recorded, and these had either been actioned or were currently under investigation; the completed records had been shared with staff.

The provider had a Quality and Safety Group in place, which enabled them to have oversight into learning events, incidents and complaints. The Quality and Safety group had quarterly meetings and reported to the Board of directors.

We saw that over the last year the provider had recorded 66 complaints, these were a mixture of verbal and written complaints. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. People received a full response to their complaint and the practice responses included details of the Parliamentary and Health Service Ombudsman.

Complaints and learning events were shared with staff when applicable and process and policies changed when needed.

The service worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. The practice-maintained policies and procedures to enable safe systems, pathways, and transitions for people.

The provider had measures in place to monitor referrals, more specifically those relating to 2-week waits. This was to ensure they kept track of the referrals process and to ensure these referrals were sent quickly and without delay. They had recently identified a learning event were a referral had been missed, this was discussed with the team and the required action taken. Additional steps had been taken to ensure this did not happen again. Referrals and test results were managed in a timely way.

The service collaborated with people and healthcare partners including district nurses, social workers and the palliative care team to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

The provider had an overall safeguarding lead as well as multiple leads and deputies for each site. The staff were able to identify who their practice safeguarding leads were, they could identify concerns and were comfortable to raise these concerns.

Safeguarding policies were in place and known to staff. They were able to locate information regarding safeguarding concerns easily. We saw evidence all staff were appropriately trained in safeguarding and they understood the reporting procedure. As well as online safeguarding training, the provider’s overall safeguarding lead provided bitesize learning sessions which contained case studies as well as other relevant information to support their learning. The safeguarding lead was working to identify the best ways to ensure staff were kept up to date and comfortable reporting their concerns. They evaluated all training sessions and adjusted these sessions based on staff feedback.

The practice had procedures in place to follow up any people who failed to attend appointments. They had a dedicated team for vaccinations and immunisations to ensure everybody was contacted when required. When a parent or guardian notified the practice to say they did not want their child vaccinated, they signed paperwork to confirm this. This was then noted on the patient record; this meant they would not keep receiving calls and contact from the vaccination and Immunisation team.

Safeguarding was regularly monitored and any concerns discussed at practice meetings. The provider took a proactive approach to Safeguarding issues and were constantly looking at ways to improve their approach.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained well. This equipment was checked on a regular basis to ensure all emergency medications were in date and equipment was working. These checks were recorded on a practice compliance portal, which showed when items were due to expire and when equipment had been checked. It stored the information indefinitely so the practice could identify any reoccurring issues and feedback to staff if required. All staff we spoke to were able to identify where emergency equipment and medications were kept.

Staff could recognise a deteriorating patient and knew of action to take. During their annual basic life support training, steps to take when presented with a deteriorating patient were discussed and staff trained on this. The staff were able to signal they needed help through their computer software, this would indicate to the rest of the team where help was needed.

Leaders, managers and staff reported that, in delivering care, they collaborated closely with people to enhance their understanding and management of risks, ensuring that their needs and care decisions were more effectively addressed. The practice had a duty doctor available to support emergencies and those who had acute needs.

People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Leaders and management reported they implemented health and safety management processes to ensure the safety and well-being of people, staff and visitors. We received and reviewed evidence which supported these claims; this demonstrated that necessary risk assessments had been completed. We queried what happened when a risk assessment came back with recommendations or action to be completed; the provider was able to explain, and evidence changes or remedial work that had been completed.

Both the main location and both branch sites were in good structural condition. Although there was an area of carpet in the Willows which was stuck down with adhesive tape. This had been noted, and this was currently being reviewed. Based on evidence provided and observations made during our visit, we noted that equipment was regularly maintained serviced, stored safely and deemed suitable for use. For example, the fire extinguishers had been serviced in line with guidance.

The provider had management processes in place to ensure compliance with health, safety and well-being requirements. A Health and safety risk assessment had been carried out in February 2025 as well as a Legionella risk assessment in September 2024. This Legionella risk assessment highlighted some remedial work for Denholme surgery, this work was carried out and we were shown evidence of the completion.

The practice was conducting regular fire drills and weekly fire alarm tests.

Staff had undertaken mandatory training, such as annual fire safety training. There was a business continuity plan in place which was monitored and reviewed.

There were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

New induction procedures were underway, which included training and supervision as well as a personalised learning plan.

Staff had received regular appraisals, which included their objectives for the year and mandatory training was up to date. Staff had received their required vaccinations and immunisations, however for some staff records were unavailable. This had started to be addressed following feedback.

The provider had also developed processes to manage clinical supervision. Their approach provided strong assurances to demonstrate non-medical prescribers, newly appointed GP’s and other relevant staff received the necessary support, supervision and assessment to ensure that the care they delivered was competent, safe and effective. Additionally, a GP was available daily to ensure appropriate support and oversight.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had an infection prevention policy (IPC) in place and training was up to date. The practice had an IPC audit in September 2024 which had highlighted areas for action. We could see these had been actioned during our assessment.

We observed four clinical rooms and found appropriate standards of cleanliness and hygiene. There were arrangements for managing waste, and sharps bins were managed in line with guidance.

Overall, the building was clean and tidy

Staff were comfortable to report any issues to the IPC lead and had confidence they would be addressed.

Staff understood how to handle clinical specimens safely. The provider had contracts with external companies, such as a cleaning contract, this was monitored by the management team and any issues address with the cleaning company.

Staff had access to an adequate supply of personal protective equipment to carry out their roles.

Risk assessments and audits were completed, and actions taken to mitigate risks.

The provider had systems to manage and respond to safety alerts and medicine recalls and we saw that these had be discussed in staff meetings. Staff confirmed to us they were kept informed of changes to guidance, and key issues. However, our clinical searches identified issues with action taken for a number of people in response to a safety alert search for teratogenicity. Teratogenicity is the ability of a substance to cause developmental abnormalities in a foetus or embryo.

The service had implemented systems and processes to support safe monitoring and prescribing of medications. However, our clinical searches identified issues with the robustness in some areas.

We saw evidence staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or if they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines prescribing and staff managed prescription stationery appropriately and securely.

Staff followed protocols to ensure they prescribed medicines safely, and took steps to ensure people received all recommended medicines reviews and monitoring.

Medicines and vaccines were stored securely and at appropriate temperatures, although it was noted that one vaccine fridge needed a seal replaced, the provider had noted this, and they were in the process of getting this replaced. However, it was having no effect on the fridge temperature, and this has remained in normal range.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Medical gases, such as oxygen, were stored safely and the required safety risk assessments had been completed.

Support measures were available for individual clinicians through post-session debriefing, and the practice maintained an open-door policy which allowed staff to seek advice from more senior clinicians when needed.

As part of our assessment, a Care Quality Commission (CQC) GP specialist advisor (SpA) undertook searches of patient records on the practice’s clinical system. Medicines were safety managed, where issues were identified, these were addressed.

Findings included:Review of Methotrexate (a disease-modifying anti-rheumatic drug) demonstrated that people were receiving appropriate monitoring. Our clinical searches identified 46 people who were prescribed methotrexate, of these 4 were identified as not having had the required monitoring in the last 6 months. The National Institute for Clinical Excellence (NICE) recommends monitoring should be done every 12 weeks when a patient is stable on the medicine. We looked at these 4 people in detail and found that all had appropriate monitoring under the care of the hospital. However, we found that one patient had not yet had the day of the week that medication was to be taken added to the prescription in line with Medicines and Health Regulatory Authority Agency (MHRA) guidance. Following our assessment, we received confirmation from the provider that this had been added.

Aldosterone antagonists (potassium sparing diuretic): Our clinical searches identified 8 people with heart failure who were also prescribed aldosterone antagonists. We reviewed 5 patient records in detail and found that all 5 people were overdue monitoring. We saw 3 people had already had appointments booked into to attend for monitoring or had been contacted by the practice to attend for monitoring. However, we found 2 people were overdue monitoring, and we could see no evidence in the patient records to demonstrate the practice was aware of this or checks regarding monitoring would be carried out prior to prescriptions being issued. When we discussed this with the provider, they explained they had systems in place to ensure people would be invited for appropriate monitoring. The review dates for medication were now set for 6 months instead of 12 months. There was a recall system in place which was manged by clinical care co-ordinators at the practice. These coordinators would alert the pharmacy team if a patient was not responding to calls to book an appointment, and the pharmacy team would reduce the prescription to encourage people to book. The practice confirmed that both people had been identified as a result of this and had appointments booked for monitoring.

Potential missed diagnosis of diabetes: We identified 44 people that potentially had a missed diagnosis of diabetes. We reviewed 5 patient records in detail and found that 2 contained appropriate coding to identify the people as prediabetic and were being monitored appropriately. However, we found issues with 3 patient records, for example, no coding to identify the patient as having diabetes or prediabetes, no information contained on problems or summary and delayed referral for eye and foot checks. When discussing this with the provider they explained they had a Diabetes lead who ran audits monthly to ensure that no new diagnosis is missed therefore, all people identified in our searches would be picked as part of this process. They also confirmed that action had been taken to address the issues identified by our clinical searches.

Medication reviews: It should be noted that while performing the other clinical searches we a number of people overdue their medication reviews. The practice had undertaken 939 medication reviews in the previous 3 months. We looked at 5 medication reviews in detail and found that 2 were well documented and covered all required areas. However, we found issues with 3 of the medication reviews we looked at. For example, a structured medication review had been done without the patient being present, not all reviews covered all medications that the people were taking, not all reviews made it clear that monitoring was checked to ensure it was up to date, risks of taking medicines were not always discussed with the patient and sometimes a medication review code was added without any detail.

Gabapentoids- Our clinical searches identified 10 (of 281) people who were prescribed gabapentoids and had not had a review in the last 12 months. We looked at 5 patient records in detail and found that 3 people were managed appropriately. We saw evidence of discussions around reduction of dosages in some cases. However, there were issues with 2 of the patient records we reviewed. For example, medication reviews were overdue, and people had not always been informed of the potential adverse effects of taking pregabalin on an unborn child and the need for effective contraception. The provider explained that as an organisation they were currently looking at pregabalin and gabapentin deprescribing and they are discussing this with people at medication review appointments.

Overall, the systems and processes for management of people with long term conditions were effective. Our clinical searches identified 947 people with chronic kidney disease stage 4 or 5 and all people had attended for monitoring in the last 9 months.

There were 615 people with hypothyroidism, and all had received thyroid function test monitoring within the previous 18 months

Asthma: We identified there were 2334 people on the Asthma register; of these, 92 people had been prescribed 2 or more courses of rescue steroids in the last 12 months. We looked at 5 patient records in detail and found some issues. For example, documentation of the clinical assessment had not always been comprehensive, people had not always been examined appropriately, and people had not always been followed up in line with NICE guidance. We received feedback from the practice following our assessment to confirm a protocol was in place, which triggered an information page when acute prednisolone was prescribed. The information page requested the clinician booked an asthma follow up. It also detailed information which is expected to be in reviews and triggers a task to the reception team to check review appointments have been booked.

Diabetes – People with diabetes who’s latest HbA1c was 75mmol/l or above: We found there were 1343 people with diabetes, of these 199 had a latest HbA1c of 75mmol/l or above. We reviewed 5 people records and found that 2 people were generally being well managed. However, we found some issues which included overdue annual diabetes reviews and foot checks. We received feedback following our assessment to provide further information regarding attempts to engage with people regarding monitoring. Additionally, we were advised annual reviews had in some cases been incorrectly coded as diabetes review.

Summary of findings for safety alert search for teratogenicity in women of childbearing age prescribed Topiramate (a medication used to treat seizures): We identified 62 people and checked 5 records. Of these 5 records no people had signed risk acknowledgement forms in their notes and none had a Pregnancy prevention plan (PPP) in place. We also found that 2 people were overdue their medication reviews.

We spoke to the practice about the lack of pregnancy prevention plan (PPP) being completed and they informed us they now had a plan in place to ensure this was completed and people received the required information.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.