Mill View Surgery

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this service since its registration with CQC where this key question has been rated. This key question has been rated as requires improvement.

The practice had established systems and processes, however, these lacked adequate oversight. Governance systems required enhancements to ensure that processes for the management of risk, safe prescribing, transparency and adherence to training and competence levels and patient choice were in place.

The service was in breach of legal regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The service understood the challenges and the needs of people and their communities.

The majority of staff reported a positive experience working at the practice, describing strong teamwork, and supportive leadership and a shared commitment to delivering high quality patient centred care. However, staff shared that on occasions they had raised concerns which had not been considered or acted upon. All staff had contributed to the development of the practice vision and strategy.

The service dispensary had the electronic prescribing system switched off, restricting patient choice, the surgery told us they would give patients a paper prescription to go elsewhere if they requested this. However, this would mean the patient would have to come and collect the paper prescriptions which could be avoided using electronic prescribing.

Leaders understood the context in which the service delivered care, treatment and support; however, they did not always embody the culture and values of their workforce and organisation. Leaders did not lead with integrity, openness and honesty. We observed that significant event and near miss spreadsheets did not have comprehensive outcomes and actions taken and dated. Informal complaints were recorded on their clinical system within patient notes, which did not easily allow for complaints to be reviewed, or themes identified and were not recorded on the complaints register as stated on their website. Complaints should not be included in patient records to avoid any future prejudice, to maintain patient confidentiality as only those involved should have access and due to data protection as patient’s records are for life whereas complaints have a retention record.

We observed a lack of transparency when leaders were questioned on findings during the inspection, for example the CQC ratings poster shared on a noticeboard had inaccurate information. We identified a staff member was undertaking tasks that were outside of their formal training and competency having been asked to undertake this duty by senior leadership. While the provider may have intended to ensure service continuity, this approach did not reflect safe practice and posed potential risks to both staff and people using the service. We identified concerns with the provider’s management of controlled drugs, including balance checks not being undertaken weekly as per national guidance. When questioned, senior staff provided conflicting accounts regarding the re use of controlled drugs and why this was occurring. When this was followed up with NHS England the staff member who had been involved in discussions about the reuse of controlled drugs did not agree with the leadership team’s account of events. The lack of clarity and consistency in leadership responses did not provide us with assurances that systems may be operating as described.

A member of Senior leadership was available on site each day, however, there was lack of succession planning in place.

We did not look at freedom to speak up as part of this inspection.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place.

The service did not always have clear responsibilities, roles, systems of accountability or good governance and sustainability. The service did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Several systems such as significant events and dispensary near miss spreadsheet, staff competencies and controlled drug processes required further review and embedding to ensure resilience and consistency and learning.

Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks.

Patient confidentiality and information security was not always taken seriously, informal complaints were stored within patient clinical records which could leave the patient open to future prejudice, lack of confidentiality and data protection issues as patient’s records are for life whereas complaints have a retention record.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access and other services such as a social prescriber, physiotherapy and mental health practitioner.

The service offered coffee mornings and had planned a “meet the staff” (including clinician’s) open day in October 2025.

The service did not always focus on continuous learning and improvement across the organisation and local system. Significant events, and near miss log did not have clear outcomes from investigations and the dates when actions were taken. There had been no formal complaints, and informal complaints were recorded in patient records, not on the complaints register as stated on the service website, so could not be reviewed for trends or outcomes.

The service had a patient representative who attended the Patient Participation Group (PPG) meetings with a group of surgeries in Burton. We received positive feedback from this group about the practice. The GPs and staff were helpful, and supportive and the GPs were caring and listened to what patients had to say. However, there was no specific group or meetings held within the practice itself. Management told us they were trying to re-establish refresh their local PPG and were considering contacting several new members.