Willow Wood Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Our rating for the well-led key question is requires improvement. This was because we identified a breach of the legal regulations in relation to good governance. Some of the governance processes for assessing, monitoring and mitigating risks were not fully effective. This was particularly in relation to; the management of an environmental risk to staff, the safe management of sharps, the process for managing patient group directions, the process for managing advanced decisions, a lack of assessment of the impact of the current management arrangements in response to staff feedback and a lack of assessment of the risk and impact of a breakdown in communication at a leadership level. We found concerns with communication across the practice and leadership team. Some members of the staff team told us the culture of the service was good whilst others described an unhealthy and negative culture where staff did not feel confident to raise issues and did not feel listened to if they did. There were arrangements in place for clinical governance. However, these were not always clearly set out across all members of the staff and leadership team. There were systems in place for monitoring the service but these were not always fully effective or well communicated or understood by all members of the team. Staff understood their roles and responsibilities but the lines of accountability were not always clear and some staff did not feel well supported in their role. A number of staff and leaders told us that there was a lack of management in terms of day to day running of the service. Leaders demonstrated that they understood the challenges to quality and sustainability. However, poor communication and collaborative working at a leadership level was presenting a risk to this. There were appropriate arrangements for the availability and confidentiality of data and records. Information was used effectively to monitor and improve the quality of care and treatment provided.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke of a shared vision to provide a good quality, patient centred service that was responsive to people’s needs. A number of staff told us in discussions and in feedback forms that they did not feel involved in discussions about the vision for the future or involved in shaping this. Staff demonstrated an understanding of equality, diversity and human rights, and they prioritised good quality and compassionate care. Equality and diversity issues were identified and equality and diversity was actively promoted. Staff gave us mixed feedback on the culture of the service. Some felt it was positive and supportive whilst others felt it was closed and they did not feel well supported.

Regular meetings were held for clinical and non-clinical staff. We noted the attendance of clinicians at clinical meetings for the past two meetings was minimal. Members of the team told us that communication at a leadership level had broken down over the previous months and this was impacting on the shared direction and culture of the service.

Members of the staff team in a range of roles told us that communication issues at a leadership level was impacting negatively on their experience of working at the practice and the support they were receiving in their roles and responsibilities. Not all staff or leaders felt supported by the leadership/management team. Not all staff felt that managers and leaders were visible and approachable.

Regular staff meetings were held but staff did not feel involved in shaping the service, service development or part of the vision and strategy. This included staff in a range of clinical and non clinical roles. Our assessment found that the provider had not always acted upon staff views. The provider had carried out a staff survey in May 2023. The results of this showed that many members of the team felt that communication across the service was not effective and they detailed some of the impact of this. During our assessment we found that this continued to be a concern for members of the team. Not all staff felt included in discussions about the service, or felt that their views were being listened to and responded to.

We received mixed feedback from members of the staff and leadership team with regards to the culture of the service. Some staff told us they would feel confident to speak with members of the leadership team if they had concerns, others told us they did not feel confident to speak up. Some staff felt they had not been listened to when they had raised concerns and they were not confident that concerns were being addressed or appropriate action taken.

There was a dedicated ‘freedom to speak up’ person that staff could approach. There was also a whistleblowing policy. The provider had carried out a staff survey in May 2023. Feedback from staff at that time was negative about communication across the staff team. Some members of the staff team told us that communication was still an area of concern. In addition to this, concerns had been raised more recently about communication challenges/breakdown across the leadership team and the impact of this upon the wider staff team. We saw in the management of complaints that people who used the service had received a timely apology when they had made a complaint and they had been told about any actions planned to prevent a recurrence.

Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs.

Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The provider had an equality, diversity, and inclusion policy and procedure.

Communication issues at a leadership level was impacting on the clarity of staff roles, responsibilities and lines of accountability. Structures, processes and systems to support good governance and management were not clearly set out and understood across the team. Members of the leadership team were managing the service partly on site and partly remote. Staff felt this was impacting negatively on the running of the service. Some staff told us they did not have the level of experience, knowledge or time to deal with issues that arose during the course of the day. Managers were available by phone but staff felt this did not provide sufficient support to the service. Following our assessment the provider told us that a business partner had been designated to manage the practice on site on a full time basis. The provider was in the process of reviewing and updating policies and procedures. A regular suite of searches of the clinal record system were being run to identify patient needs and ensure these were being met. For example, to ensure that patients on high risk medicines underwent the required checks so that the medicines they were prescribed remained safe to take. Information was used effectively to monitor and improve the quality of care and treatment provided to patients. The practice used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems.

There were arrangements for identifying, managing, and mitigating risks and overarching risk assessment for the service was shared with us. However, the assessment and management of risk was not always fully effective. This was particularly in relation to; the management of an environmental risk to staff, the safe management of sharps, the process for managing patient group directions, the process for managing advanced decisions, a lack of assessment of the impact of the current management arrangements in response to staff feedback and a lack of assessment of the risk and impact of a breakdown in communication at a partnership/leadership level. A major incident plan was in place. Systems and protocols were in place to ensure data and notifications were submitted to external organisations as required.

People who used the service were supported by a provider who worked in partnership with commissioners, other stakeholder and local services to increase patient satisfaction, and improve their experience and outcomes. The practice had a Patient Participation Group (PPG) that was supported by the primary care network (PCN). The provider used NHS Friends and Family feedback, compliments and complaints and patient surveys to assess people’s views or experiences of the service and implement change and improvements in response.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. They engaged with local networks to identify new or innovative ideas that could lead to better outcomes for patients.

The provider understood the duty to collaborate and work in partnership with other stakeholders, so services worked seamlessly for people.

The practice worked closed with the local Primary Care Network (PCN) and the Integrated Care Board (ICB).

There was a focus on continuous learning and improvement across the service. Systems for assessing the quality of the service and outcomes for patients were in place. The provider monitored the care and treatment provided to patients and made improvements where these were identified.

There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence. The provider worked collaboratively with stakeholders to improve the experience of the patient population as they worked in partnership to improve services for people within the locality.