Millbarn Medical Centre

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this practice since its registration with CQC. This key question has been rated as GOOD.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. Staff used a range of datasets, population health management and assessment tools to maximise the effectiveness of care and treatment and to ensure people’s needs were reflected and understood.

All staff were aware of the changing needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

To ensure patients had their needs assessed and had effective and optimised health outcomes, the practice had introduced a system based on population segmentation data, to assess needs and prioritise those at greatest risk of deterioration prior to winter. Patients had been scored and categorised based on their clinical complexity and level of healthcare needs with preventive measures implemented.

At the time of the inspection, the practice had concentrated on Patient Need Group 10 “multi-morbidity, multi-complexity” and Group 11 “frailty”, drawing further information from GPs, social care and social determinants of health. There were 279 patients in Groups 10 and 11; staff explained that these groups were updated on a monthly basis.

All clinicians we spoke with raised awareness of a significant cohort of moderately frail patients within the practice population. Staff spoke of the shared goal, such as not solely dealing with acute medical concerns but to assess and improve health outcomes, reducing patients' healthcare needs for the future to reduce demand on the healthcare system. As a result of the management of this cohort of patients, the practice was part of a pilot within the integrated neighbourhood team (INT) to assess and review these patients before they became severely frail.

There was a register of 41 patients aged over 14 with a learning disability. Records showed that all 41 patients (100%) had been offered an annual health check and at the time of our inspection, 23 of the 41 patients (56%) had a completed health check (between April 2025 and February 2026). We saw several patients had health check appointments scheduled and further invites were sent for those patients who had not responded.

Feedback from people using the practice was positive. People felt involved in any assessment of their needs, felt confident that staff understood their individual and cultural needs and patients felt their needs were met. For example, feedback sourced from the National GP Patient Survey 2025 showed:

• 96% of respondents felt their needs were met during their last GP appointment. This was higher when compared to the local average (91%) and the national average (90%).

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

Our review of the clinical record system indicated that patients received care, treatment and support that was evidence-based and in line with good practice standards. The management of patients living with long term conditions was good and our searches did not identify any gaps in the monitoring of patients.

Throughout the inspection, staff described a model of care, based on evidence-based treatment, continuity and long-term relationships to deliver enhanced health outcomes and personalised care. The evidence collected at this inspection including patient feedback indicated this model was being delivered.

The practice worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so patients only needed to tell their story once.

The practice worked with other services to ensure continuity of care and held regular multi-disciplinary team (MDT) meetings. Meeting minutes highlighted a compassionate, proactive and personalised discussion for each patient and their families.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

Staff told us the practice worked well across teams and services to support people. They highlighted leaders had made positive changes and implemented new channels of communication to improve how staff worked and delivered together. This was referred to internally as ‘points of the week’; staff told us, given the largely part time work force, this helped staff and teams work more cohesively with shared timely communication.

The practice had strong relationships with the other practices within the primary care network (PCN). Staff and leaders successfully maintained positive partnership arrangements with many services in the local health economy. This was confirmed in evidence collected during the inspection including feedback from the care home which accessed GP services from the practice.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff used various population health management tools and disease prevalence data forecasting to focus and identify risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. This review had led to the start of a local pilot which aimed to assess and support for those patients with 4 or more conditions (diabetes, hypertension, depression and a high body mass index). We noted that those patients identified would receive accelerated and enhanced care to live healthier lives.

Staff supported local and national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice website and designated areas within the practice contained detailed information and links for health promotion, specific conditions and common questions. For example, at the time of our inspection (February 2026), the practice website promoted and shared information regarding the respiratory syncytial virus, more commonly known as RSV (RSV is a common virus that can make babies and older adults seriously ill). Patients we spoke with, advised they felt the practice website was clear, concise and up to date with health information.

The practice and the patient participation group (PPG) had commenced a series of health education events, these events were designed to educate patients and empower them to manage their own health. The first event was planned for March 2026 and would focus on men’s health with other events proposed for later in the year.

The practice utilised the health and well-being coaches from the PCN to support staff and encouraged staff to consider health promotion activities within the local community.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice met the World Health Organisation (WHO) minimum target of 90% for all childhood immunisations with 1 immunisation uptake over 95%.

The practice had a combined 74% cervical cancer screening uptake rate, which was below the expected 80% target. Whilst below the 80% target, we saw the uptake had slowly increased each year. Staff told us they continued to review uptake and reduce the barriers to potential reasons why patients didn’t attend. This included scheduling human papillomavirus (HPV) catch up programmes to coincide with periods when those eligible were likely to be available. The HPV vaccination dramatically lowers HPV infections and rates of cervical cancer in vaccine-eligible women.

Staff we spoke to described the flags and alerts on patients records to alert when vaccinations, screenings or recalls were due. Clinical staff also highlighted a practice wide approach to ‘make every contact count’ to ensure every opportunity was used to improve outcomes.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff we spoke with demonstrated the importance of ensuring that people understood the care and treatment offered before obtaining consent. Clinical and non-clinical staff had undergone training in the Mental Capacity Act 2005 and clinical staff understood the requirements of legislation and guidance when considering consent and decision making.

We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records. Appropriately completed documents were available and had been shared with other relevant services and alerts had been added to the patient record system.