Millfield Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

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

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The surgery made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Home visits were available for those patients assessed as not being able to attend the surgery, providing continuity of care to those patients.

There were established mechanisms for engaging with the community healthcare providers such as the Integrated Neighbourhood Team and the local Primary Care Network (PCN).

Multidisciplinary team meetings were held every 6 weeks attended by members of the Millfield Surgery Team and local mental health and community partners with the aim of ensuring patients with mental health issues received holistic, person-centred and evidence-based support.

In addition, meetings were also held monthly with the Palliative Care Nurse, District Nurse, Occupational Therapist and Frailty coordinator to identify care needs for patients on the Gold Standards Framework. This is a framework used in palliative care to promote advanced care planning and improve the quality of care for patients in their final year of life.

With nearly 30% of their population aged over 65, the surgery had implemented targeted measures to support frail and elderly patients. These included maintaining a housebound list and conducting daily home visits based on clinical need. One of the GPs served as a Frailty Lead, overseeing a frailty register and promoting the use of Rockwood scores to assess patient needs. The surgery had also developed a Community Comprehensive Geriatric Assessment (CGA) Clinic to provide holistic care locally. This initially was a pilot study undertaken at local supported living unit however, following this pilot, funding was secured for a 2-year community CGA clinic which has been running since April 2024.

The surgery supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The surgery website was available in multiple languages and staff had access to interpreter services. The surgery could also provide information in large print or ‘easy read’ format if needed, or through communication support like British Sign Language interpreters or other assistive technologies. There were also several fact sheets on their website for newly arrived individuals seeking asylum which covered the role of GPs, how to register and how to access emergency services.

Arrangements were in place to ensure compliance with the Accessible Information Standard and patients were informed via the surgery’s website as to how to access their care records.

Results from the National GP Patient Survey showed that 96% of patients knew what the next step would be after contacting the practice, which was above the local and national average of 83%.

98% of patients also said that they knew what the next step would be within 2 days of contacting the practice as compared to the local and national average of 93%.

The surgery was exceptional at enabling people to share feedback and ideas, or raise complaints about their care, treatment and support. They always involved people in decisions about their care and told them what had changed as a result.

For example, people could provide feedback or complain online via their website, by email, letter or verbally. People were also encouraged to give feedback online, through the NHS Friends and Family Test.

Results from the National GP Patient Survey showed that 94% of patients felt that, during their last appointment, the healthcare professional was good at listening to them, compared to the local and national average of 87%.

Complaints were managed in line with the practice’s complaints policy and compliments were logged and shared with staff. Learning from complaints was evident and some staff were able to identify changes made because of patient feedback, including complaints.

An example of a change implemented because of patient feedback was the introduction of a total triage system for booking appointments. This stemmed in part from consistent negative feedback about telephone waiting times in 2023/2024 and aimed to offer patients better access and appointment availability. Although officially rolled out in November 2025, the surgery had started encouraging the use of eConsult earlier in the year and publicised it via social media, phone messaging and newspaper advertising. This early roll-out saw positive results in GP Patient Survey data and improvements across several areas such as a reduction in incoming calls, telephone waiting times and callback requests.

A further example of actions taken because of patient feedback were those taken following a dispensary survey in 2023. This survey highlighted the need for a better procedure to notify patients about shortages of medication or out of stock medication and consequently the dispensary team now contact patients if there are issues with their medication and discuss any actions to be taken.

The surgery made sure that people could access the care, support and treatment they needed, when they needed it.

The surgery was open from 8:30am to 6pm Monday to Friday and we saw on the day of our visit that appointments were still available for GP Registrars that day and for nurses and Health Care Assistants, the following day.

Outside of surgery hours, an enhanced access service was available for patients which ensured continuity of telephone access before and after core hours and no gaps in urgent communication.

People could access the service to suit their needs, for example, online, in person and by telephone and the percentage of respondents to the National GP patient survey who responded positively to their overall experience of contacting the surgery was 88%, significantly above the local average of 72% and national average of 70%.

The percentage of respondents who responded positively to how easy it was to contact the surgery on the phone was also significantly above the local and national averages (72% as compared to the local average of 56% and national average of 53%).

77% of respondents also stated that it was easy to contact the surgery using their website (local average 57% and national average 51%); and 76% of respondents also stated that it was easy to contact the surgery using the NHS app (local average 54% and national average 49%).

Telephone response rates were monitored by the surgery, and a patient call-back option was also in place which meant that callers did not need to wait to speak to reception staff.

The development of the new total triage model discussed under the Quality Statement ‘Listening to and involving people’ has significantly reduced telephone waiting times and helped ensure that patients who do not have or are not confident in using online communication can access the practice more easily.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The majority of feedback provided by people using the service, both to the surgery as well as to CQC, was positive.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

The provider had processes to ensure people could register at the surgery, including those in vulnerable circumstances. They did not refuse to register patients who were unable to provide identification or a fixed address and had a policy of registering all patients, unless they lived outside of their designated practice area. No patients had been refused registration in the 3 months prior to our assessment.

The service was an Armed Forces Veteran Friendly Accredited GP practice. This meant that there was a clinical lead for veteran health who undertook regular training to better understand the needs of veterans and support veterans to access dedicated health services.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

Five patient records were reviewed where a ReSPECT (recommended summary plan for emergency care and treatment) form was in place. All patients were flagged appropriately on the patient’s clinical record following notification of the decision. Where ReSPECT forms had been completed by surgery staff, a copy was held on the patient’s clinical record as per best practice.

The surgery was actively involved with the local community hospital and worked with them to provide end of life care within the community, aligning with patient preferences and reducing hospital admissions.