Willow Wood 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

Feedback from people who used the service indicted that they felt they received safe care and treatment. The provider received few formal complaints but when they did they learned from these and made improvements to the service in response. Safety events were investigated, and lessons were learnt to identify any shortfalls, prevent a recurrence, and embed good practice. Members of the staff team provided mixed feedback about staffing levels. Some told us they felt there were sufficient numbers of staff across a range of both clinical and non-clinical roles whilst others told us they felt the staffing was insufficient. There had been changes to the staff team as a result of staff turnover. Systems and procedures were in place to safeguard patients who may be at risk of abuse. Staff had undergone checks to ensure they were suitable for the role and they had been provided with safeguarding training at a level appropriate to their role. Staff were not always clear as to who the responsible safeguarding lead was and alerts were not always added to the patient record system for relevant others. Overall, staff had been provided with training to meet their roles and responsibilities. Procedures for managing health and safety were in place. The premises were safe for people who used the service. However, staff had use of an office area that had a leak in the ceiling and buckets were being used to capture the water. Infection prevention and control measures were in place. However, the management of sharps was not appropriately risk assessed and appropriate control measures were not in place to prevent the risk of injury to staff. There were processes for monitoring patients’ health in relation to the use of medicines including medicines that require regular review.

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.

People who used the service were listened to and their feedback was acted upon and used to drive improvement. Lessons were learnt when people had had cause to make a complaint or had been the subject of an incident or significant event. Complaints were appropriately investigated whether they were formal written complaints or verbal. Complainants were provided with an explanation as to the findings of any investigation and an apology if this was required. At the time of our visit to the service there was no information on display to inform patients of the complaints process. The provider took action to address this following the visit. There had been no particular feedback about the management of complaints made to the provider and no feedback about the complaints process shared with CQC generally or in the ‘give feedback on care’ link shared on the provider’s website where people were invited to share their experience of the service with CQC.

Staff knew how to identify and report concerns, safety incidents and near misses. Safety events were investigated, and lessons learned to identify and embed good practice and prevent a recurrence. The provider was in the process of aligning information about safety events and key policies and procedures to ensure these were fully accessible at this location. Staff gave us mixed feedback about the support they received to identify their training needs and for protected learning time to undertake training and professional development. Some felt training opportunities were appropriate and others felt they were not well supported with their training needs.

Information and learning from complaints, incidents and significant events was shared across the team to improve patient experience. The provider held a log of significant events and complaints which they used to identify themes and trends. Regular meetings were held with standing agenda items on matters such as incidents and complaints. The learning from these were discussed and shared across the staff team. The provider worked alongside other stakeholders and worked within the Primary Care Network (PCN) to develop services.

The experience of people who used the service as gained in patient feedback was positive regarding timely and appropriate referral to other services and signposting to other relevant support. Patients felt involved in decisions about treatment pathways and reported prompt follow up care. There were no particular themes of complaints linked to how people are supported when using other services made to the provider and no particular feedback of this nature shared with CQC generally or in the ‘give feedback on care’ link shared on the provider’s website where people were invited to share their experience of the service with CQC.

Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health. Reception staff had been trained in care navigation to direct patients to the most appropriate service or services to meet their presenting needs. This may include specialist statutory or community services and local health and wellbeing services.

The provider worked with patients and other agencies to ensure safe systems of care and treatment when patients were being supported by other services. Regular multi-disciplinary meetings were held at a local primary care network (PCN) level. These provided an opportunity to discuss and arrange to meet the needs of patients with complex needs. Not all members of the clinical and leadership team were aware of how information about patients discussed at these meetings was documented and shared.

There were no backlogs of work that could otherwise result in delays for patient care. Referrals to secondary or specialist care were made promptly, and patients referred under the two week wait rule for suspected cancer were followed up to ensure they had undergone the required investigations. This demonstrated that staff managed patient care proactively and effectively. Correspondence from secondary care such as discharge letters/summaries were up to date. The system of tasks (to identify follow up actions) used within the clinical record system was up to date, which indicated prompt action was being taken to support patients in their treatment pathways. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. Clinicians followed care and treatment pathways for treating and referring patients to other services.

Feedback from people who used the service did not include any concerns with regards to safeguarding. There had been no particular themes of complaints linked to safeguarding made to the provider and no particular feedback of this nature shared with CQC generally or in the ‘give feedback on care’ link shared on the provider’s website where people were invited to share their experience of the service with CQC.

Staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. This is intended to provide staff with an understanding of how to recognise safeguarding issues, raise alerts and manage safeguarding concerns. Staff told us they were confident about what action to take if they had concerns about a patient’s safety and to report safeguarding concerns. However, a number of members of the team were not aware of who the responsible lead for safeguarding was.

A register of patients for whom there was a safeguarding concern was held, reviewed and updated on a regular basis at a primary care network (PCN) level.

Alerts were added to the patient record system when a patient was subject to a safeguarding concern so that all relevant members of the staff team could readily identify this. We noted that alerts were not always added to the records for immediate household/family members. Regular meetings were held within the practice where safeguarding was a standing agenda item for discussion. There were systems, processes and practices to respond when it was suspected that people may be subject to abuse or neglect. Reports to the local Multi Agency Safeguarding Hub (MASH) were prepared by designated members of the PCN and reviewed by clinicians prior to submission. Systems were in place to ensure staff were appropriate to work in the service. Recruitment checks had been carried out prior to employment and staff were required to show proof of an up to date Disclosure and Barring Service (DBS) check at the required level.

Feedback from people who used the service indicated that they were provided with a good level of information about their condition, enabling them to make informed decisions about treatment and risks. There had been no particular themes of complaints linked to involving people to manage risks made to the provider and no particular feedback of this nature shared with CQC generally or in the ‘give feedback on care’ link shared on the provider’s website where people were invited to share their experience of the service with CQC.

Staff worked proactively to support patients with the prevention of ill health, for example, recalling patients who were at risk of developing diabetes or referring patients for dietary advice or smoking cessation. Staff were trained in areas to support people who lived with long term health conditions, for example, diabetes. Patients were called in for regular checks on their health when they were living with a long term condition or managing a health issue. When people did not attend they were followed up. Health reviews for these patients included reviewing their current health and providing advice, care and treatment to improve or maintain this and prevent a deterioration. The service encouraged patients to attend for health screening. Parents of children who had not attended for childhood immunisations and people who had not attended for cancer screening were followed up and encouraged to attend.

Our review of a sample of consultation records showed that patients were informed about risks and how to keep themselves safe through safety-netting advice (advice given to patients when the cause of their symptoms, or how their illness will progress, is uncertain and about the actions to take if their condition fails to improve, changes or if they have further concerns about their health in the future) should their condition not improve or worsen. Patients were referred to services that could provide them with specialist advice to manage their condition and the risk of deterioration. For example, referral to a dietician or to a diabetes education course. Patients who were prescribed high risk medicines were called for regular checks. There was a system in place for dealing with patient safety alerts and patients had been made aware of particular risks with regards to medicines in response to these.

Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. Staff told us in discussions and feedback forms that overall they were satisfied with the health and safety arrangements in the service. We noted one area of the building were a leak was presenting a risk to staff. Buckets were in situ in the main administrative office and staff told us they were awaiting repair to the ceiling. This had not formed part of the provider’s health and safety or premises risk assessment.

The service was located in a purpose built building that provided the required facilities such as safe and appropriate access for people who are disabled. There were sufficient rooms available to accommodate/host additional services. The premises were clean and contained the appropriate facilities to support infection prevention and control. Staff told us there had been a period of weeks when they were required to undertake cleaning duties in the absence of a cleaner but this had since been addressed with the appointment of an alternative cleaning company. We noted that a sharps disposal bin was not signed, dated or stored appropriately. Medicines and vaccines were stored securely and they were readily accessible to staff who required them.

Regular checks were carried out on the premises, facilities and equipment provided. Equipment used to deliver care and treatment was suitable for the intended purpose and checked regularly. A fire risk assessment was in place and actions identified for improvement had been addressed. Fire fighting equipment and an alarm system were in place and serviced/checked regularly.

Patient feedback in the National GP Patient Survey indicated that patients were satisfied with the care and treatment they received from the staff team. For example, patients felt that they were listened to and treated with care and concern. Feedback we received directly from patients was very positive and patients comments indicated high levels of satisfaction with members of the staff team and the care and treatment they had received.

Staff gave us mixed feedback about staffing levels. Members of the staff team told us they felt there had been a high turnover of staff over the past 12 months. Details of staff turnover provided to us confirmed this. Staff told us that as a result there had been occasions when they felt that there were not sufficient numbers of suitably experienced staff on duty and that this was compounded by the absence of a designated manager on site. A number of staff told us they did not feel well supported in their day to day work and in managing challenges when they occurred. Members of the clinical team also cited concerns regarding staffing and a lack of seniority or day to day manager on site. Members of the team told us they had raised these concerns but there had been no action taken to date in response. Following our site visit the provider told us that a business partner would be based in the location and responsible for the day to day management of the service with immediate effect.

Staff gave us mixed feedback on how well supported they felt in their role. Some gave examples of how they were encouraged to develop as individuals and as a team, for example by attending training to support them in additional roles and support team work. Others felt their training was not sufficient and they did not have the necessary skills or experience to be fully confident in their role. Staff gave us mixed feedback on the levels of communication across the staff team. Staff in a range of roles felt there was an absence of a designated person with overall responsibility for the day to day management of the service. Some staff told us that members of the leadership team were approachable and supportive, others told us that this was not the case for all members of the leadership team. Business partners were responsible for managing the service. However, they were only based at the practice for a number of sessions per week and available by phone for the remainder of the time. There was no designated person in a day to day management capacity based at the practice and no designated senior on site and staff felt the lines of accountability were not always clear. Following our findings the provider designated a business partner to be on site at the practice and manage the service on a full time basis. We looked at the recruitment records for a sample of staff. These showed recruitment practices were carried out in line with requirements. All new staff underwent an induction programme. Some members of the team told us the induction process was basic. The provider shared a copy of the induction checklist with us and this was not well detailed. We also noted that mandatory training for a newer member of staff was outstanding at the time of our visit. There was a system of appraisal and these were up to date across the staff team.

There have been no complaints linked to infection prevention and control made to the provider and no particular feedback of this nature shared with CQC. People who used the service were protected from the risk of infection because the premises and equipment were kept clean and hygienic. Patients therefore experienced a clean environment with a good standard of hygiene and appropriate infection prevention and control measures in place.

There were clear roles and responsibilities around infection prevention and control with a dedicated lead person. Staff had been provided with training in infection prevention and control and they told us they were aware of their roles and responsibilities in this.

The facilities and premises were appropriate to support cleaning and the spread of infection. Personal protective equipment was in good supply and located appropriately around the premises. Cleaning schedules were in place and cleaning audits were carried out on a regular basis. Cleaning equipment was stored securely and in line with best practice. We noted that the arrangements for the disposal of sharps was not in line with best practice. A sharps disposal box was not dated and the location of the box could present a risk of needle stick injury to members of the clinical team.

Audits of infection prevention and control procedures were carried out and actions identified for improvement in the last audit had been completed.

Feedback we received from people who used the service did not include any concerns related to the management of medicines. There had been no particular pattern of complaints linked to medicines made to the provider.

The provider commissioned a pharmacy service to manage repeat prescribing, medicines reviews and changes to people’s medicines as directed by secondary care.

During our on-site assessment we saw that medicines, including vaccines were stored safely. Staff were aware of what to do if a fridge temperature was out of range and the requirement to investigate any anomalies. Staff had access to emergency medicines and equipment including oxygen and a defibrillator. These were regularly checked for stock availability and to ensure they were in date. We noted that Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients in planned circumstances for example vaccinations) were not always in good order and correctly authorised.

The arrangements for medicines prescribing ensured that people who used the service were invited in for required health checks. Our review of a sample of patient records showed a small number of people had failed to attend the service to undergo the required checks when they had been invited. Regular medicines reviews were carried out for people who used the service to ensure their medicines were appropriate to their needs and safe. A protocol was in place for managing the repeat prescribing of medicines. The majority of prescriptions were sent electronically to the patient’s dedicated pharmacist. There was a process in place for managing patient safety alerts linked to medicines and appropriate action had been taken for the medicines alert we looked at.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that medicines were managed safely overall and the approach to medicines reflected current and relevant best practice and professional guidance. Regular searches of the clinical record system were carried out for all patients who were prescribed high risk medicines. A small number of areas for improvement were noted. These included ensuring all patients attended for required health checks prior to providing repeat prescriptions and ensuring the most up to date results were available when patients had undergone checks in secondary care. Prescribing data for the practice showed no particular variation when compared to national averages.