• Doctor
  • GP practice

The Millwood Partnership

Overall: Good read more about inspection ratings

Mill Lane, Bradwell, Great Yarmouth, Norfolk, NR31 8HS (01493) 661549

Provided and run by:
The Millwood Partnership

All Inspections

4 August 2022

During a monthly review of our data

We carried out a review of the data available to us about The Millwood Partnership on 4 August 2022. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Millwood Partnership, you can give feedback on this service.

24 & 25 February 2022

During a routine inspection

We carried out an announced inspection at The Millwood Partnership from the 24 to 25 February 2022. Overall, the practice is rated as Good.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

During this inspection we also considered the management of access to appointments.

Following our previous inspection on 26 November 2019, the practice was rated Requires Improvement overall and for providing Effective and Responsive services, and the practice was rated Good for Safe, Caring and Well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Millwood Partnership on our website at www.cqc.org.uk

We have rated this practice Good overall

Safe - Good

Effective – Good

Caring – Good

Responsive – Good

Well-led - Good

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • There were clear and effective processes for managing infection prevention and control.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patient satisfaction results had improved, and patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Leaders and staff working at the practice had a commitment to improve.

Whilst we found no breaches of regulations, the provider should:

  • Continue to strengthen the recruitment process.
  • Ensure systems to monitor identified workplace risks are regularly reviewed.
  • Improve the system for coding and recall of patients to ensure they receive the appropriate care and treatment.
  • Strengthen the system for managing and acting on Medicines and Healthcare produced Regulatory Agency (MHRA) alerts.
  • Continue to review and improve the uptake for cervical cancer screening continue.
  • Review the programme of targeted quality improvement to include second cycle audits.
  • Evaluate systems and arrangements in place for advanced care planning, end of life care and DNACPR decisions to ensure they are clearly documented and communicated.
  • Restart plans to carry out a patient survey and act on feedback.
  • Ensure learning opportunities from complaints are routinely used to drive improvement.
  • Consider ways to encourage interactions with the Patient Participation Group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

26 Nov to 26 Nov 2019

During a routine inspection

A fully comprehensive inspection was undertaken at The Millwood Partnership on 9 July 2015 and the practice was rated as good overall and good for all domains. Since this inspection, the practice had merged with another local practice. A focussed inspection was carried out on 2 June 2019 following an annual regulatory review of the practice. The practice was rated as requires improvement overall; inadequate for providing safe services and requires improvement for providing effective and well led services. The previous ratings of good for caring and responsive were carried over from the previous inspection. As a result of the findings, the practice was issued with a warning notice on 15 July 2019 for regulation 12 (safe care and treatment).

The full inspection reports on the previous inspections can be found by selecting the 'all reports' link for The Millwood Partnership on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at The Millwood Partnership on 26 November 2019 to check that improvements identified at the July 2019 inspection had been made and to re-rate the practice.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and requires improvement for all population groups.

We rated the practice as good for providing safe services because:

  • The breaches identified at the previous inspection had been reviewed and systems and processes had been put in place to rectify these.
  • Systems and processes to safeguard patients from abuse were embedded and appropriate.

We rated the practice as requires improvement for providing effective services in line with our ratings aggregation principles because we rated the population groups of people with long term conditions and people experiencing poor mental health as requires improvement due to:

  • 2018/2019 Quality and outcomes framework (QOF) data showed outcomes for some patients with long term conditions was below average.
  • 2018/2019 QOF data showed that for patients with mental health issues, achievement was below average.
  • We noted there was a clear action plan in place to address the lower areas and that achievement for 2019/20 was on an upward trajectory.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services because:

  • Patients did not find it easy to make an appointment and 2019 national GP survey results had lower than local and national average results for access to services. There was some evidence that changes to the appointment system and the emergency on the day team had improved this, but further embedding and sustaining was required.
  • These areas affected all population groups, so responsive is rated as requires improvement.

We rated the practice as good for providing well-led services because:

  • The practice culture and governance arrangements supported the improvements that were required to make changes to QOF achievement and patient satisfaction.
  • Staff reported they were happy and proud to work in the practice.
  • The practice regularly engaged patients in the delivery of the service.

The areas where the provider should make improvements are:

  • Review the system for Patient Group Directions to ensure they are signed when new staff join the practice authorising their use.
  • Review and improve the system for sharing learning from significant events.
  • Continue to embed the action plan in relation to the performance in the Quality and Outcomes Framework to improve outcomes for patients.
  • Continue to embed the plan to improve patient satisfaction, particularly in relation to access.
  • Review and follow up patients identified as potentially at risk of diabetes.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth

BS BM BMedSci MRCGP
Chief Inspector of General Practice

02 Jul to 02 Jul 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at the Millwood Partnership on 2 July 2019. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions; are services safe, are services effective and are services well-led.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall.

We have rated the practice as inadequate for providing safe services because:

  • We found four GPs did not have the appropriate level of safeguarding training. After the inspection, the practice provided a spreadsheet with details of completed training We noted training had been completed on the day of or after the inspection.
  • We found three members of clinical staff who did not have their immunisation status recorded.
  • We found a defibrillator that had not been calibrated since November 2017. There was another defibrillator on site that had been calibrated.
  • The practice were unable to provide a recent fire risk assessment for the Millwood site. We were provided with a fire risk assessment for the both sites after the inspection. A fire risk assessment had been completed for the Falklands branch site in 2017, however this was due for review in 2018 and it was not evident a review had been completed.
  • The practice did not have an effective system for the management of safety alerts. We ran three alert searches from February and March 2019 and found these had not been actioned for all patients. Following the inspection, the practice sent us an action plan detailing how they would address this.

We have rated the effective domain as requires improvement overall. We rated the population groups of older people, families, children and young people, working age people and people whose circumstances make them vulnerable population groups as good. We have rated the people with long term conditions population group as requires improvement because:

  • Outcomes relating to people with long term conditions were below local and national averages.

We have rated people experiencing poor mental health (including people with dementia) population group as inadequate because:

  • Outcomes relating to mental health were significantly below average and unverified data from 2018/19 was still significantly below average.

We rated the practice as requires improvement for providing well-led services because:

  • We found the practice did not have appropriate oversight of some risks within the practice, including the immunisation status of staff, safeguarding training, patient safety alerts and fire risks.
  • There was a plan in place to address lower than average QOF performance for 2019/20, however there had been limited oversight and low outcomes for 2017/18 and 2018/19, particularly for mental health indicators.
  • The governance systems in place did not assure the practice that appropriate action had been taken when required.
  • The Millwood site had not had a fire risk assessment since 2015, and the practice had not reviewed the previous risk assessment. There was no assurance system in place to alert staff when the risk assessment was due. We were provided with a fire risk assessment for the both sites after the inspection. A fire risk assessment had been completed for the Falklands branch site in 2017, however this was due for review in 2018 and it was not evident a review had been completed.

We did not inspect the practices caring and responsive services at this inspection and have used the previous ratings of good in making our judgement.

We found the provider must:

  • Ensure care is provided in a safe way to patients.
  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

We found the provider should:

  • Review staff immunisation status to ensure staff are appropriately protected.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BS BM BMedSci MRCGPChief Inspector of General Practice

9 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Millwood Surgery on 9 July 2015. We found that the practice provided a safe, effective, caring, responsive and well led service. The overall rating for this practice is good.

We examined patient care across the following population groups: older people; those with long term medical conditions; families, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health. We found that care was tailored appropriately to the individual circumstances and needs of the patients in these groups.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, report incidents and near misses. These were all investigated and learning was identified and acted upon. These included incidents where things had gone well, so that positive practice was shared too.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Information was provided to help patients understand the care and treatment options available to them.
  • The practice was friendly, caring and responsive. It addressed patients’ needs and worked in partnership with other health and social care services to deliver individualised care.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • High standards of patient care and service were promoted and owned by all practice staff with evidence of effective team working across all roles.
  • The clinical and managerial leadership at the practice was forward thinking and supportive.

However, there were also areas of practice where the provider needs to make improvements. the provider should:

  • Improve the security of access to emergency medicines and the documentation of the amount of emergency medicine held in stock.
  • Ensure the legionella management policy is completed.
  • Ensure the practice is correctly registered with CQC to provide the regulated activity of surgical procedures.

We saw one area of outstanding practice:

  • One of the GP partners completed the annual appraisal with each member of staff. There was a proactive culture of learning and support between all members of the practice. Staff spoke positively of the support they received and told us they felt valued by having a GP undertake their annual appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice