Millcroft Medical Centre

On this page

• 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 assessed all quality statements from this key question. The rating given is Good.

Leadership, management, and governance arrangements supported the delivery of high-quality, person-centred care, with clear systems in place to ensure care was delivered safely and effectively. Leaders demonstrated capability, compassion, and inclusivity, with a strong focus on workforce equality. Staff understood their roles and lines of accountability and reported feeling well supported.

The organisation maintained an open and honest culture, with leaders providing clear guidance on raising concerns and ensuring issues were listened to and acted on. Leaders promoted learning and innovation and understood the challenges affecting service quality and sustainability. Information was used effectively to monitor and improve care, although some aspects of record-keeping and data management required improvement. These issues were discussed during the assessment, and the practice responded promptly and positively, taking immediate action to address them and demonstrating action for improvement and development.

This service scored 75 (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 had a shared vision, strategy and culture which was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively. Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. All staff we spoke to felt positive about working at the practice and feedback from staff questionnaires was mostly positive about working at the practice. They described good teamwork and a service that was clear on its function to work in the interests of patients and providing the best patient experience they could. Members of the team told us that communication could be improved to ensure that staff in all disciplines received the right information at the right time in the right way.

The management team was new and included leaders who encouraged an open culture at all levels. They understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

Leaders had the skills, knowledge, experience and credibility to lead effectively. Theymonitored and acted upon data about outcomes for patients and made improvements when required. Feedback from people who used the service was mixed but this was something the leaders and staff were working to improve.

The practice had an appointed Freedom to Speak Up Guardian within the South Cheshire and Vale Royal GP Alliance. There was no designated individual within the practice who held this role. Leaders stated that they encouraged staff to speak up, promoted a culture of openness, and had policies and procedures in place to support this. Although staff told us they knew how to raise concerns, felt confident in doing so, and believed their concerns would be taken seriously, not all staff were aware of freedom to speak up, who their guardian was and what their role constituted.

The provider valued diversity within the workforce and actively promoted an inclusive and fair culture by supporting equality and diversity among staff. Reasonable adjustments were made to help staff carry out their roles effectively. The provider supported staff with caring responsibilities through flexible working arrangements and adjusted schedules to meet their needs. Staff had completed training in equality, diversity, and inclusion and demonstrated awareness of how to support individuals with protected characteristics, such as age, gender, religion, and disability. There were no concerns reported regarding workforce equality at any level, including recruitment. The practice had an established equality, diversity, and inclusion policy in place. 

There were effective arrangements in place for governance, management, and accountability. The provider used data to monitor performance and drive improvement. However, they did not fully demonstrate positive impact on patients due to identified improvement requirements. All staff we spoke with understood their individual roles and responsibilities. Managers held meetings with staff although this required review to ensure consistent messages were being communicated across the whole workforce. A regular programme of clinical system searches was carried out to identify patient needs and ensure these were addressed, and our review of clinical records showed this was mostly effective. Staff were able to access all necessary policies and procedures and demonstrated an understanding of patient confidentiality and information security. There were systems in place for identifying, managing, and mitigating risks, and a major incident plan was in place. The provider had established governance processes appropriate to the service. However, some areas for improvement were identified, including task management, learning from events and complaints, maintenance of records, and medicines management. During the assessment, we were assured that the provider took all identified issues seriously and acted on them immediately.

The provider demonstrated a clear commitment to collaboration and partnership working to ensure services operated seamlessly for patients. They shared information and learning with partners and engaged in joint initiatives to drive improvement. The provider worked with other practices within their primary care network to deliver extended access services and to coordinate flu and COVID-19 vaccination programmes. They also collaborated effectively with external stakeholders, commissioners, and partner agencies to provide and enhance service delivery. The PPG had recently been disbanded because it was not effective and this was something the practice was working on to re-engage.

The provider had a focus on continuous learning and improvement across the service. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.

Leaders told us they maintained strong external relationships that supported improvement and innovation. The practice had been training GPs for several years and nurses were supported to become non-medical medical prescribers. Feedback from the Manchester University and from trainee GPs was positive. The practice had received a silver award for supporting medical students.