Millfield Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was mostly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs and staff checked people’s health, care, and wellbeing needs during health reviews.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The National GP Patient Survey results showed that 95% of patients felt that the healthcare professional they saw had all the information they needed about them during their last GP appointment. This was above the local and national averages of 92%.

97% of patients also stated that they had confidence and trust in the healthcare professional they saw or spoke to during their last GP appointment. This was above the local and national averages of 93%.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

As part of our assessment, a series of patient clinical records searches were completed by a CQC GP specialist advisor. The search criteria used is freely available for practices to access at any time. The records of patients with long-term conditions were reviewed to ensure that the required monitoring was taking place.

Searches of clinical records for high-risk groups - including asthma, chronic kidney disease (CKD), hypothyroidism, and diabetes - found no major monitoring concerns. Minor issue were identified, such as one missed annual diabetic review, two CKD coding errors, two overdue CKD checks, and one asthma patient requiring a steroid card, however, all issues were promptly addressed by the surgery.

The surgery always worked well across teams and services to support people. They made sure patients only needed to tell their story once by sharing thorough assessments of people’s needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The surgery worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

Leaders and staff were working with their local primary care network (PCN) to meet the needs of the patient population. For example, as part of a project to improve the quality of care for their heart failure patients, the surgery held monthly meetings with cardiologists, a lead heart failure specialist nurse and heart failure leads from other practices in the Vale of York to discuss complex cases and get advice on how best to manage the condition. These meetings had resulted in several benefits for patients including expediting treatment, hospital admissions, device implantation and improved coordinated care.

The surgery supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities.

Staff supported national priorities and initiatives to improve population health (such as stopping smoking and tackling obesity).

Since 2019, the surgery had been registered as a Parkrun Practice, actively promoting this form of exercise to patients and staff. They had also raised funds for local charities through initiatives like the York Team Marathon and the National Three Peaks Challenge.

Clinical searches showed that 481 patients had had a medication review within the past 3 months. A detailed review of 5 patients over 75 and on multiple repeat medicines found the overall quality of reviews to be good. Pharmacy-led reviews were comprehensive, covering all medications, while GP reviews appropriately focussed on higher-risk elements.

While the surgery had systems in place to monitor patient outcomes, these were not always applied consistently to drive continuous improvement.

For example: whilst unverified data provided by the surgery showed that it had previously exceeded the 80% national target for cervical screening in 2023 and 2024, the most recent performance data from NHS England indicated that it was slightly below the national target for 50- to 64-year-old women at 76.3% and for women aged 25 to 49 at 79.3%.

Also, as part of our series of patient clinical record searches, we identified 19 patients as having a potential missed diagnosis of diabetes and, when 5 of their records were reviewed in more detail, it was identified that 2 of the patients did have diabetes and had not been coded as such by the practice and 1 had a recent raised result that had been filed as ‘abnormal but expected’.

As a result of our findings, the surgery was asked to review all 19 patients that we had identified. The surgery immediately did this and acknowledged that there was a potential learning need for the surgery.

On a positive note, we saw that patients with a learning disability were offered an annual health check by the surgery and that there were monitoring arrangements in place to ensure that these checks were carried out. Although some patients had declined a check, unverified data provided by the surgery showed that, for 2024/25, 76% of patients on the Learning Disability Register had received an annual health check and for 2025/26, the current completion rate was 67%.

In addition, although the surgery had faced some staffing challenges which had impacted on service delivery, they also continued to offer NHS health checks to patients as part of locally agreed contracts with unverified data showing that historically they had consistently over-delivered against their contractual targets in this area.

Health checks for patients over the age of 75 were also offered to assess physical and mental health; mobility and fall risk; medication use and adherence; and social and environmental factors.

Clinical and non-clinical audits were carried out to improve outcomes for patients. These included an audit on the coding of patients with chronic kidney disease, an audit on patients prescribed an implantable contraceptive and an audit on urine sample collection and dipstick practices in the surgery.

The surgery had met the national minimum target for all childhood immunisations and would follow up on those patients who did not attend their appointments for health checks to ensure they received the necessary care.

The surgery told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Where individuals lacked the capacity to make decisions, staff engaged those who were important to them to act in their best interests.

Several audits had been undertaken by the surgery in 2025 to ensure compliance with their Consent Policy. These included audits for patients with intrauterine devices and contraceptive implants and an audit on consent for ring pessary fitting. No significant issues were identified by any of these audits.

An audit on consent for joint injections carried out by the surgery did identify an area for improvement however as, while all patients had either written or verbal consent documented, it was felt that the entries in patients’ notes needed to be more detailed when verbal consent was taken. This finding was to be discussed by clinicians performing joint injections and the audit was to be repeated in 12 months to ensure improvement.