The Care Quality Commission
  • Doctor
  • GP practice

Willowbrook Medical Practice

Overall: Good read more about inspection ratings

Brook Street, Sutton In Ashfield, Nottinghamshire, NG17 1ES (01623) 440018

Provided and run by:
Willowbrook Medical Practice

All Inspections

4 October 2023

During a routine inspection

We carried out an announced comprehensive inspection at Willowbrook Medical Practice on 4 October 2023. Overall, the practice is rated as good.

Safe - good

Effective – good

Caring – good

Responsive – requires imrovement

Well-led - good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Willowbrook Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The focus of inspection included a review of all key questions.

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 face to face and by 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 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 and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. This included safeguarding systems, safe recruitment, infection prevention and control and the management of the premises and associated risks.
  • Our review of clinical records found safe management of medicines, in particular those that required ongoing monitoring due to adverse risks.
  • Systems were in place to support the practice to learn and make improvements when incidents and complaints occurred.
  • Patients received effective care and treatment that met their needs. Our review of clinical records found appropriate follow up of patients with or at risk of long-term conditions.
  • Uptake of childhood immunisations were above the national target and national average.
  • Uptake of cervical screening was below the national target and national average.
  • Patient feedback from various sources was mixed about the way staff treated and involved them. Results from the GP national patient survey on some questions relating to patient experience were lower than local and national averages.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. There was a strong emphasis of working with partners to tackle health inequalities.
  • The practice provided a supportive culture with clear direction for the future of the service.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve cervical screening uptake.
  • Continue to identify and implement changes to improve the GP national patient survey results.

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 Health Care

2 March 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 Willowbrook Medical Practice on 18 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Willowbrook Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 2 March 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 18 August 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:

  • The practice had a formalised process for staff meetings including governance issues.
  • Actions and outcomes from legionella testing had been followed up and work was ongoing.
  • Patient safety alerts, including estates and facilities alerts were received in practice. There was an effective process for dissemination and evidence to show these were acted on were applicable.
  • There was an effective process for reporting and recording significant events, incidents and near misses. All staff were aware of this and all analysis was shared with all staff.
  • Policies such as complaints policy and prescription security had been reviewed and updated were required. Staff understood the process and it was been followed.
  • Fridge temperatures were recorded and any outside the required range were reported and investigated as an incident. The practice were checking that drugs and vaccines were safe and fit for use.
  • Feedback from the national patient survey had been discussed with all staff and with the PPG to identify any areas for improvement.
  • The practice had reviewed processes and methods for identification of carers and the system for recording this. The practice had a carers champion who was responsible for maintaining the list and contacting them to offer support and advice for those that required it.
  • The registration of the regulated activity of maternity and midwifery services had not been completed on the day of inspection, however this was in the process of been actioned following the new registered manager application.

The areas where the provider should make improvement are:

  • Ensure regulated activity of maternity and midwifery is added when registered manager is in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Willowbrook Medical Practice on 18 August 2016 . Overall the practice is 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 a system in place for reporting and recording significant events however not all incidents were reported or shared with all staff.
  • Some risks to patients were assessed and well managed however several identified actions had not been completed.
  • 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.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

  • Patients said they found it difficult to make an appointment with a named GP however they could get an appointment on the day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management.

  • The practice was sponsoring a local scheme that provided meals at a susbidised cost using supermarket surplus. The practice had agreed to pay for 100 meals per month that would be given to the very underprivildeged and homeless.

  • The practice proactively sought feedback from staff and patients, which it acted on. However the results of the July 2016 national patient survey had not been fedback to the PPG or the GPs.

  • The provider was aware of and complied with the requirements of the duty of candour.

  • The practice did not have a process in place for identification and support for carers.

  • At the time of the inspection the provider was not registered for maternity and midwifery services. The provider said that they would rectify this.

  • The practice had a number of policies and procedures to govern activity however not all the policies were being adhered to.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care.

  • The practice proactively sought feedback from staff and patients, which it acted on

The areas where the provider must make improvement are:

  • Embed a formalised process for staff meetings including governance issues.
  • Ensure actions and outcomes from legionella testing are followed up and rectified.
  • Ensure patient safety alerts, including estates and facilities alerts received in practice are disseminated and acted on were applicable.
  • Ensure robust processes for reporting and recording significant events, incidents and near misses. Ensure all staff are aware of this and that all analysis is shared with relevant staff.
  • Ensure registration includes the regulated activity of maternity and midwifery services.

The areas where the provider should make improvement are:

  • Ensure policies in practice such as complaints policy and prescription security are followed and understood by all staff.
  • Ensure the registration is updated and applies for the registered activity for maternity and midwifery services.
  • Investigate errors with fridge temperatures and ensure that drugs and vaccines are safe and fit for use.
  • Review feedback from the national patient survey with all staff and identify any areas for improvement.
  • Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice