Millbarn Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

This service scored 84 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff told us the leaders welcomed feedback and encouraged them to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

As a training practice, all staff were committed to learning; they organised and implemented educational activities to share learning across the practice. For example, a GP partner had created a virtual learning club for all clinicians across the building (including the co-located GP practice) to share articles, reviews, journals and ‘hot topics’ about primary care and general practice. Feedback regarding the learning culture and the learning club was positive, highlighting the virtual club was accessible, provided peer learning, social interaction and team collaboration.

Staff told us learning and improvement was integral within the practice and where possible learning opportunities were acted upon. For example, the practice was aware of the increased use of online and digital platforms used by patients. To support patients to navigate these platforms, the practice worked with and signposted patients to a monthly drop-in session, known as the ‘Digital Café’ to support their individual learning and increase their knowledge and confidence of using the new tools. Feedback highlighted the digital café had helped patients learn how to use the NHS app, navigate NHS referral systems and also helped patients for non-health related digital concerns.

The learning culture within the practice and the local primary care network (PCN) was recognised and had recently been an approved PCN Learning Environment, supporting workforce education, development and sustainability across the local health system.

Representatives from the patient participation group (PPG) felt leaders took concerns, suggestions and ideas seriously and proactively made improvements to the service.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were innovative systems in place for processing information relating to new patients and staff had embraced new technology to improve communication and information sharing within the practice. Following the introduction of systems and protocols for example, workflow optimisation processes, supported by new technology, we saw the practice had improved the efficiency of new patient registration which had reduced the time taken to register with the practice and also liberated over 470 staff hours. Further impact was demonstrated in workflow correspondence systems including communications from secondary care, such as discharge summaries. We saw before the workflow optimisation protocol was introduced, the average number of results each month was on average 1,854 (March 2023) Following the introduction of the protocol, this had reduced to 1,071 (a 42% reduction reported in November 2024) and following the introduction of new technology, this had further reduced to a monthly average of 711 reported in July 2025. This was a 61% reduction despite a growing list size. Staff feedback was positive about the use of new technology, advising it supported their role and created more time to spend with patients. We saw the use of technology, including Artificial Intelligence (AI) tools was approved by a Data Protection Officer, rigorously tested and under constant review to ensure safety and secure transfer of information.

A review of the practice’s clinical system, which formed part of this inspection, indicated people’s test results were being managed in a timely manner to support transition through services.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Safeguarding registers for children and adults were reviewed and discussed during monthly multi-disciplinary team (MDT) meetings, where any trends were monitored and updates made. The practice acted on concerns and worked in partnership with other organisations. For example, they followed up children who attended Emergency Departments (formally referred to as Accident and Emergency) and those that failed to attend secondary care appointments.

The practice worked with people to understand and manage risks by thinking holistically whilst using accurate performance and data metrics. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff could recognise signs of high-risk, red flag symptoms and the deterioration of patients, this included both physical and mental deterioration. Emergency equipment was available and maintained. Staff were knowledgeable regarding the appropriate action to take. Receptionists received training on emergency symptoms including sepsis. A duty doctor was available to support receptionists.

As part of this inspection, we visited the practice (which was located within a modern purpose-built building). We saw the practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Facilities and the environment were well maintained and there were systems to ensure equipment was safe to use.Millbarn Medical Centre worked with the other co-located GP practice to jointly manage the facilities, estates and the environment.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

There was a business continuity plan in place which was monitored, reviewed and contained information to manage unforeseen emergencies.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were also followed.

Staff told us they could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. There were daily slots available for clinicians to seek support with the on-the-day duty GP. This enabled staff to discuss individual cases, reflect on their practice and identify any changes to improve outcomes for patients.

Appraisals were completed on a regular basis to support professional development. Staff felt supported with their professional development, and we saw examples of staff developing in their role. The practice had supported staff to gain additional qualifications resulting in career progression. For example, staff members from the admin team had highlighted ambitions to become phlebotomists through their appraisals. The practice saw this opportunity and provided the training and opportunities for those 2 members of staff to work in a hybrid admin/phlebotomist role.

We saw data which demonstrated the additional 2 phlebotomists had increased the capacity of the in-house phlebotomy service, thus reducing patient wait times and the need for patients to travel to the local hospitals for this service.

As a training practice, we reviewed feedback the practice had received from trainees who had completed placements at the practice. This feedback was highly positive and praised the support, mentorship and development opportunities they had received.

There were processes for providing all staff with the development they need. This included appraisal, career development conversations and staff were supported to meet the requirements of professional revalidation where necessary.

The practice was proud of their reputation in training and mentoring the next generation of primary care clinicians. They hosted medical students and trainee paramedics for brief placements, alongside GP registrars (fully qualified doctors in the final stages of training to become a General Practitioner). At the time of the inspection, there were 2 GP registrars, supported by 2 GP trainers.

The GP registrars were offered extended appointments, had access to a named senior GP throughout the day for support alongside support from the wider practice team. They were also encouraged to become involved in clinical audit activity and developmental projects within the practice.

Leaders were highly committed to continuous development of the staff members skills, competence and knowledge. The recognition of meaningful development was seen as integral to ensuring safe and high-quality care.

Staff praised the learning culture within the practice, notably the mentorship and coaching from the 2 GP trainers and the wider support of the practice team.

The practice identified, assessed and managed the risk of infection, with an infection, prevention and control (IPC) lead who had training and led IPC audits and activity within the practice. The IPC lead supported staff and worked together to detect and control the risk of IPC concerns. Staff had received training relevant to their roles.

Cleaning schedules were in place, and regular IPC and cleaning audits were conducted to maintain standards. Cleaning equipment was stored safely and according to best practice. Waste, sharps, and clinical specimens were managed carefully to keep everyone safe. Staff vaccinations were kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. There was a clear system for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff managed prescription stationery appropriately and securely. Prescribing staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. For example, we saw a recent 2 cycle clinical audit (repeated to ensure continuous improvements) regarding the prescribing of Benzodiazepines (a medicine used as a sedative). Following a review and changes within the prescribing policy, the 2nd cycle of audit (August 2025) highlighted a 56% reduction in new prescribing of this type of medicine.

As part of our inspection, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found patients had received monitoring in line with guidance.

As part of this inspection, we also reviewed 6 additional national prescribing data sets and saw mixed levels of prescribing achievements when comparing the practice’s prescribing levels to local and national averages. For example, there was negative variation for the prescribing of 1 group of antibiotics, whilst there was positive variation for the prescribing of opioids (medicines to treat pain).