South Milford Surgery

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

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. Some of the facilities needed some modernisation but met the needs of people, they were clean and equipment was well-maintained, and risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. The practice had introduced technology to mitigate errors and improve patient experience in dispensing of medicines.

This service scored 72 (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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During clinical leadership meetings, there were arrangements for the clinical team to discuss and learn from clinical incidents.

Staff felt able to report incidents and managers promoted an open culture, which was reflected by staff feedback. The provider had processes for staff to report incidents, near misses and safety events.

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. For example, it was identified that staff had not followed practice policy for dealing with a potential emergency situation. Further training was provided to staff on identifying red flags symptoms and how to manage subtle presentations and emergency situations.

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

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care when patients moved between services.

Staff understood their roles and had systems in place to manage tasks and test results. Through searches on the practice’s clinical system, we saw that referrals and test results were managed in a timely way and included contacting the patient following referral to other services to ensure they had received an appointment.

The practice had introduced new artificial intelligence (AI) document management software to assist in the administration work for the practice.

The service 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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

We found that staff had a good understanding of safeguarding and how to take appropriate action. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. All staff we spoke with were able to inform us who the practice’s safeguarding lead was. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

During the assessment a review of documents relating to accident and emergency (AE) attendance highlighted patients who had attended AE multiple occasions over the last year. As a result of this, the practice implemented a search on their clinical system to identify and review patients who had multiple visits to AE in the last 12 months.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained across all sites. Following additional training, staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Staff had received training in sepsis awareness and basic life support and were able to explain how to act safely in an emergency, including alerting clinical staff and the emergency services.

The service did not always detect and control potential risks in the care environment. They had mostly made sure equipment, facilities and technology supported the delivery of safe care. Portable appliance testing (PAT) testing of equipment was overdue but scheduled for December 2025. Some of the clinical rooms were in need of refurbishment as there were some cracks and plaster missing. There was carpeted flooring in the GP’s room at the Thorpe Willoughby branch site . The practice had a risk assessment in place to mitigate risks. This included all treatments and procedures being completed in the nurse’s room as this had appropriate laminate flooring.

There was a plan for refurbishment but some of the work required was not scheduled for completion until 2035. During assessment the practice confirmed they would review this timeframe.

Health and safety risk assessments and audits had been undertaken and most risks identified had been addressed. For example, on assessment the cleaning cupboard at Micklefield Surgery had flammable items such as cardboard boxes stored in it. The fire risk assessment dated 6 August 2025 had identified this, but it had not been actioned. This was immediately addressed by the practice when it was highlighted to them.

There was a business continuity plan in place which was monitored and reviewed. Staff had completed mandatory training in fire safety.

The service 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.

The practice had recently undertaken a review of the number of clinical appointments offered per week and made the decision to recruit a new GP to increase capacity.

There were a range of clinical and non-clinical roles within the practice. Training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

As part of this assessment, we looked at recruitment files of 4 members of staff, this included administrative and clinical staff members. All files recorded that appropriate recruitment checks had been completed, and staff had received annual appraisals.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the practice to be clean and tidy throughout except for a few clinical rooms that had plaster missing from the walls. One clinical room did not have a sink which had elbow operated taps, there was also carpeted flooring. The practice provided a risk assessment with the anticipated refurbishment completion time of 2035. The practice reassured us that these would be reviewed earlier.

The service 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 received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

As part of our assessment, 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 a sample of medicines that required monitoring, as well as a review of prescribing, including the effectiveness and quality of medicine reviews and usage.

Searches ran on the practice’s clinical system showed that all patients prescribed warfarin (medicine to thin the blood) had received appropriate monitoring. Searches also identified 5 patients over the age of 65 on a high dose of citalopram or escitalopram (medicine to treat depression). A review of all 5 patient records showed that they had not received the required monitoring. The provider immediately reviewed these patients.

Searches identified 1526 patients prescribed an ACE Inhibitor or Angiotensin (medicine to reduce blood pressure). A review of these patients showed that 99.3% of patients had received the required 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 stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

The practice provided a dispensing delivery service for the over 65s. The practice had a dispensary at the main site and the Micklefield branch site. There were suitable processes for staff to follow when dispensing medicines. The practice used an electronic dispensing system. This system checked the correct dispensing of medication via bar code scanners. During assessment we observed the system in action and how this helped eliminate dispensing errors. This system was appropriately monitored and audited.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages.

There was a programme of regular clinical audits of medicines prescribing that focused on improving care and treatment.