All inspections: The Willows Medical Practice

We carried out an announced assessment at The Willows Medical Practice on the 12 February 2025.

The Willows Medical Practice is a GP practice and that delivers a service to approximately 7,670 patients under a contract held with NHS England. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment was carried out to review the improvements made following the previous CQC assessment in June 2023 where there was a breach of the Health and Social Care Act 2008. The assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. The assessment reviewed the key questions for safe, responsive, well led and two quality statements from effective.

The overall rating for this assessment is Good.

We carried out an announced responsive focused inspection at The Willows Medical Practice on 14 June 2023. Our focused inspection looked at the key questions of Safe and Well-led. Overall, the practice is now rated as requires improvement. At this inspection dated 14 June 2023 we rated the key questions of safe and well-led as follows:-

Safe - Requires improvement

Well-Led – Requires improvement

Following our previous focused inspection held on 20 July 2022, the practice was rated good overall except for key question responsive which was rated as requires improvement.

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

Why we carried out this inspection.

We carried out this focused inspection on 14 June 2023 to follow up on concerns reported to the Commission relating to the provision of care and governance management at this location.

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:

Requesting evidence from the provider in advance of our site visit
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 had established systems and processes that kept patients safe and protected them from avoidable harm, but these were not always implemented.
Patients received care and treatment that met their needs.
Not all staff had the skills and knowledge to carry out their role effectively.
The practice had a system in place to manage and mitigate risk relating to the practice.
There was a system and process to learn and improve from incidents/events that occurred at the practice.
Supervision of staff undertaking clinical duties was not evident.

We found one breach of regulations. The provider must:

Ensure that care and treatment is provided in a safe way.

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

Following our previous inspection on 19 and 26 May 2021 the practice was rated Good overall and for all key questions with the exception of responsive which was rated requires improvement:

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

At this inspection the practice remains rated as Good Overall.

Responsive – Requires Improvement.

Why we carried out this inspection

We carried out an announced focused inspection at The Willows Medical Practice on 20 July 2022 to review the service provided requires improvement rating for providing a responsive service.

The inspection consisted of a review of information without undertaking a site visit to follow up on:

Areas where the practice could improve such as conducting in house surveys, and how the practice improved access for patients by telephone.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

Requesting evidence from the provider.

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.

Our findings

We found that:

The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However, patients could not always access care and treatment in a timely way.

We found the following breach of regulations, the provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

We carried out an announced inspection at The Willows Medical Practice on 19 & 26 May 2021. Overall, the practice is rated as good.

The ratings for each key question is as follows:-

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires Improvement

Well-led - Good

Following our previous inspection on 11 March 2020, the practice was rated Requires Improvement overall and for all key questions. At the March 2020 inspection, breaches of regulatory requirements were identified, and the practice was issued with requirement notices under Regulation 17 (Good governance) of the Health and Social Care Act (Regulated Activity) 2014.

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

Why we carried out this inspection

This inspection was a comprehensive inspection which included a remote clinical records review and a site visit to follow up on breaches of regulations or ‘shoulds’ identified in previous inspection

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:-

Conducting staff interviews using video conferencing
Completing clinical searches on the practice’s patient records system and discussing findings with the provider
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 and
information from the provider, patients, the public and other organisations.

We have rated this practice as Good and RI for all population groups.

We rated the practice as good for the key questions safe, effective, caring and well-led. Key question responsive has been rated as requires improvement due to continued low national GP survey results relating to patient access by telephone to the practice.

We found that:-

The practice had systems and processes in place to facilitate the delivery of good quality care.
The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Patients did not always feel they could access care in a timely way.
The way the practice was led and managed promoted the delivery of good quality, person-centre care.
Quality improvement activity led to the practice reviewing and improving on exisiting systems in place.
There were processes in place to manage risk, issues and performance.

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

Continue with programme of recall to improve on the uptake of childhood immunisations.
Monitor antibiotic prescribing with the aim of reducing the numbers of antibiotics prescribed.
Increase efforts to allow patients to access the practice by telephone in a timely manner.
Update links on practice website to show local carers support service.
Conduct further in-house patient surveys on a regular basis to ascertain current patient concerns.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at The Willows Medical Practice on 11 March 2020 as part of our inspection programme. This inspection was a full comprehensive inspection in line with our inspection programme of re-inspecting practices who were rated requires improvement at their last inspection.

The practice was rated as requires improvements overall at their last inspection held on 11 March 2019. The March 2019 inspection occurred as the practice was rated requires improvement overall following a previous inspection held in October 2017.

At the March 2019 inspection, breaches of regulatory requirements were identified, and the practice was issued with requirement notices under Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act (Regulated Activity) 2014. At this time we identified that the practice had

Incomplete staff training records for fire, child protection and safeguarding
Above average prescribing of antibiotics
No process to ensure security of prescription pads
An unclear significant events process

At this inspection we found that the practice had satisfactorily addressed all but one of our previous concerns, that relating to prescribing of antibiotics.

The reports for all the previous inspections for The Willows Medical Practice can be found by selecting the ‘all reports’ link for The Willow Medical Practice on our website at . The previous inspection history covers the period between 2016-2019 for this provider.

This inspection was an announced full comprehensive inspection undertaken on 11 March 2020.

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.

This provider remains rated as requires improvement overall. At this inspection we rated the practice as requires improvement for all key questions because:

The most recent National GP Patient Survey results revealed mixed scores for the practice and there was limited evidence of a plan of action to address the low scores.
Not all staff files we viewed were up-to-date with information relating to training, qualifications and immunity status.
The practice had good monitoring of patients on high-risk medication, however antibiotic prescribing for the practice was still above local and national averages.
There was a lack of formal oversight of some clinical staff at the practice.
There was no documented evidence of learning gained from complaints received at the practice.
Some QOF indicators showed the practice performing lower than both local and national averages.

These areas affected all population groups, so we rated all population groups within the key question of responsive as requires improvement and all population groups with the key question of effective as requires improvement, except working age people which is rated inadequate.

The areas where the provider must make improvements are:-

Put in place effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

Continue with programme of recall to improve on the uptake of childhood immunisations.
Continue to monitor antibiotic prescribing with the aim of reducing the numbers of antibiotics prescribed.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at The Willows Medical Centre 11 March 2019 as part of our inspection programme.

At the last inspection in October 2017 we rated the practice as requires improvement for providing safe services because:

The practice could not evidence what specific or core training the HCA had undertaken to administer flu vaccines and B12 injections.
The practice did not have systems in place for monitoring uncollected prescriptions.

At this inspection we found the provider had satisfactorily addressed these areas, however we also found:

Incomplete fire, child protection and safeguarding training, above average prescribing of antibiotics, no process to ensure security of prescription pads and unclear significant events processes.

At this inspection we rated the practice as requiring improvement for providing an effective service because:

Results for some clinical indicators were below local and national averages, achievement for childhood immunisations was slightly below target, there was limited evidence of recent dementia awareness training, there was no systematic programme of quality improvement or learning and development.

At this inspection we rated the practice as Good for being caring because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

At the last inspection in October 2017 we rated the practice as requires improvement for providing responsive services because:

Results from the 2017 national GP patient survey showed that patients' satisfaction with how they could access care and treatment was considerably below the local CCG and national averages.

At this inspection we found:

Results from the 2018 GP patient survey showed below average results for telephone access to the practice and an incomprehensive complaints process.

At this inspection we rated the practice as requiring improvement for providing being well led because:

Action taken to address poor areas of performance had yet to produce demonstrable and verifiable improvement, there was no comprehensive, systematic programme in place to support effective risk and performance management, there was no comprehensive staff training process in place and a limited comments and complaints management process.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

Review performance in childhood immunisations.
Review staff training to ensure they completed the necessary training for their role.
Review procedures for replenishing stocks of emergency medicines.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Willows Medical Practice on 13 October 2016 and rated the practice as requires improvement for caring and inadequate for safe, effective, responsive and well-led key questions. This led to an overall rating of inadequate and the practice was placed in special measures. Breaches of legal requirements were found and requirement notices were issued in relation to patient safety, staffing and governance. The full comprehensive report can be found by selecting the http://www.cqc.org.uk/location/1-572070226 link for The Willows Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection which we undertook on 11 October 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 13 October 2016. This report covers our findings in relation to those requirements. The overall rating from this visit was 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.
The arrangements for managing medicines, including emergency medicines and vaccines, in the practice minimised most risks to patient safety, however the practice could not demonstrate all staff who administered vaccines had received the appropriate training.
The practice had systems to keep all clinical staff up to date.
Data from the Quality and Outcomes Framework showed patient outcomes were below CCG and national averages.
Clinical audits now demonstrated quality improvement.

Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
Results from the 2017 national GP patient survey showed patients felt they were treated with compassion, dignity and respect.
Patients rated the practice below local and national averages on how they could access treatment and care.

The practice had good facilities and was well equipped to treat patients and meet their needs.

The area where the provider must make improvement is:

Ensure care and treatment is provided in a safe way to patients.

In addition the provider should:

Continue to monitor its national GP patient survey results, as these showed patients satisfaction on how they could access treatment and care were below local and national averages.
Monitor and record the usage of blank prescription forms.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Willows Medical Practice on 13 October 2016. Overall the practice is rated as Inadequate.

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

There was a lack of managerial oversight and the leadership had failed to mitigate identified risks. Governance systems were informal and ineffective.
Patients were at risk of harm because systems and processes were not in place to keep them safe. Our inspection identified concerns in relation to safeguarding, chaperoning, infection control, medicines management, fire, health and safety, recruitment and emergency procedures.
There was minimal monitoring or benchmarking of performance to improve patient outcomes. The practice was not aware of data demonstrating where performance was poor comparatively to other practices and there was no ongoing programme of clinical audit.
The practice did not ensure that all staff had the skills, knowledge and experience to deliver effective care and treatment. Staff were performing duties outside of their responsibility and competence.
There were gaps in staff understanding of their roles and responsibilities in obtaining consent. There was no monitoring in place to ensure consent to treatment was obtained in line with legislation and guidance.
The practice did not maintain a carers register and had only identified two carers (0.03% of the practice list).
The practice continued to receive negative feedback about its appointment system and accessing the service despite making changes to it.
The practice was unable to provide assurance its complaints policy and procedure were in line with recognised guidance and contractual obligations for GPs in England. The practice was unable to demonstrate how it had shared learning and made improvements as a result.
The practice did not proactively seek patients' feedback in order to improve the quality of service provided. They had been unaware of some low satisfaction scores from the national patient survey and the PPG raised concerns about the practice’s lack of responsiveness to their suggestions. Patients were not always positive about their interactions with staff and said they felt they were not always listened to or involved in decisions about their care.

The areas where the provider must make improvements are:

Care and treatment must be provided in a safe way for patients. Risks should be assessed, mitigated and monitored. This includes introducing systems and processes for addressing concerns identified in relation to medicines management, infection control, environmental risks and medical emergency procedures.
Ensure recruitment arrangements include all necessary employment checks.
Ensure staff are appropriately supported and their training needs identified to ensure they have the necessary skills and competencies to be able to carry out their roles safely and effectively.
Review its governance arrangements to ensure performance is monitored and fully understood so improvements are made to patient outcomes and the quality of the service provided. This includes reviewing its policies and processes to ensure they are relevant to the practice and accessible to staff.
Establish an effective system for identifying, handling and responding to feedback from complaints, patient surveys and the PPG. Learning should be identified and shared amongst staff.

The areas where the provider should make improvement are:

Establish an effective system for identifying and supporting carers.
Advertise within the practice the provision of the translation and bereavement services for patients and provide patient information in different languages.
Consider how to improve communication with patients who have a hearing impairment.
Monitor the practice website so patients receive up to date information.

Improve processes for making appointments.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We spoke with people visiting the surgery on the day of our inspection. People told us they were happy with the service provided by the doctors at the practice. One person said 'they've done wonders for me here. The reception staff are fantastic and are always polite. The GP always listens to me.' Another person told us 'they try and do their best for you here.'

People told us that the GPs were approachable and they could ask questions if they needed to. We found that people's care was planned and delivered in a way that met their individual needs and that the practice co-operated with other healthcare professionals and services.

We also found that people were protected from the risk of abuse because the provider had procedures in place for safeguarding vulnerable adults and children and staff we spoke with were aware of these procedures.

People we spoke with on the day told is that they were always able to get an appointment and did not have problems getting an emergency appointment.

We found that people's privacy and dignity was respected.

The provider had effective recruitment procedures in place to ensure only suitable staff were employed at the service.

The Willows Medical Practice

All Inspections

During an assessment under our new approach

14 June 2023

During an inspection looking at part of the service

20 July 2022

During an inspection looking at part of the service

19 & 26 May 2021

During a routine inspection

11 March 2020

During a routine inspection

11 March 2019

During a routine inspection

11 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

13 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field CBE FRCP FFPH FRCGP

10 October 2013

During a routine inspection