Background to this inspection
Updated
6 February 2023
The Willows Medical Centre is located in Bradford at:
Osbourne Drive
Queensbury
Bradford
West Yorkshire
BD13 2GD
The practice also has branch sites at:
Thornton Medical Centre
4 Craven Road
Thornton
Bradford
BD13 3LG
And
Denholme Surgery
Ann Street
Denholme
Bradford
BD13 4AN
We visited all three locations as part of our inspection.
The provider is registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the West Yorkshire Integrated Care Board and provides services to 17,761 patients under the terms of a Personal Medical Services (PMS) contract. This is a contract between general practices and NHS England for the delivery of services to the local community.
The practice is part of a wider network of GP practices under the provider Affinity Care, this is a partnership of practices who work together to focus care on the needs of the local population. These practices have come together to form one single partnership with the aim of working more efficiently and effectively.
Information published by the Office for Health Improvement and Disparities, rates the level of deprivation within the practice population as 5, on a scale of 1 to 10 . Level 1 represents the highest levels of deprivation and level 10 the lowest.
According to the latest available data, the ethnic make-up of the practice area is 95% White, 3% Asian and 2% originating from black, mixed or other non-white ethnic groups.
Care at the practice is provided by a team of 6 GP Partners, 4 salaried GPs, 5 Advanced Clinical Practitioners, 2 practice nurses and a care co-ordinator/health care assistant. The clinical team is supported by a patient services manager and a team of reception and administrative staff. Other wider support is available from the central Affinity Care provider organisation. This includes a pharmacy team, and core functions such as human resources.
The practice is open from 8am until 6pm Monday to Friday. The practice offers a range of appointment types including book on the day and telephone consultations.
Extended access is provided locally by Affinity Care, where late evening and weekend appointments are available. Out of hours services are provided by Local Care Direct via the NHS 111 service.
Updated
6 February 2023
We carried out an announced comprehensive inspection at The Willows Medical Centre on 30 November, 21 and 22 December 2022. Overall, the practice is rated as good.
Safe - requires improvement
Effective – good
Caring - good
Responsive - good
Well-led - good
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities. This was the first inspection of this provider since they registered with the Care Quality Commission.
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 in person and using video conferencing.
- Staff questionnaires sent to staff ahead of the inspection
- Speaking with patients by telephone
- 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 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 found that:
- There were systems in place to safeguard children and vulnerable adults from abuse. Staff we spoke with knew how to identify and report safeguarding concerns.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence based guidelines.
- There was a strong focus on quality improvement, this included clinical audit and whole practice projects aimed to improve services for patients.
- Staff had the skills, knowledge and experience to deliver effective care.
- We received positive feedback from staff regarding support available to them following the merge with Affinity Care.
- The practice had a good understanding of the needs of the local population and delivered services to meet these needs.
- The segmented care model adopted by the practice had established some dedicated teams designed to meet the needs of the local population. For example, the complex health care teams delivering care to vulnerable to housebound patients and those in residential care.
- The practice had a strong focus on community engagement and the delivery of wider population health and wellbeing in conjunction with other partners and stakeholders.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients (refer to requirement notice at the end of the report for more detail).
In addition, the provider should:
- Fully re-establish staff annual appraisal processes.
- Establish and embed the role of Freedom to Speak Up Guardian within the practice.
- Improve documentation of learning events to record identified learning and changes made as a result of events.
- Establish systems to share findings from learning events and complaints with the wider practice team and across the organisation to enable themes to be identified and promote shared learning.
- Continue to monitor and improve patient satisfaction regarding access to services.