The Willows Medical Centre Also known as Affinity Care

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.