During an assessment under our new approach
Date of Assessment: 29/07/2025 to 05/08/2025. Mill View Surgery is a GP practice and delivers service to 1984 patients under a contract held with NHS England. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. The surgery has its own dispensary. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had established systems in place to support the delivery of safe care. The facilities and equipment met the needs of people, were clean and well-maintained and risks were generally mitigated. However, there were areas that required strengthening including learning from significant events, complaints and near miss events. There was not always enough staff with the right skills, qualifications and experience, which meant staff had completed tasks outside their training and competence. Systems around recruitment checks and staff vaccinations required strengthening. There was a lack of transparency around fridge temperatures and the displayed CQC ratings poster. Systems around safe prescribing required strengthening and patient choice had been restricted by not using electronic prescribing.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Managers worked with the local community to deliver the best possible care and were receptive to new ideas. However, governance processes within the practice lacked adequate oversight and required enhancements to ensure transparency and that systems for the management of risk, safe prescribing, safe recruitment process and adherence to training and competence levels were in place.
We found breaches of regulation in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.