The Mill Medical Practice

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 patients in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed patients’ care and worked with other services to achieve this.

Leaders inspired a culture of improvement, where understanding current outcomes and exploring best practice was a deeply embedded part of the culture, and learning was widely shared and acted on.

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in patient’s care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. Staff involved those important to patients and considered capacity and legal power of attorney when decisions were being made.

At our last inspection, we rated this key question as outstanding. At this inspection, the rating remains the same.

This service scored 92 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice always made sure patients’ care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing, and communication needs with them.

Feedback from patients using the practice was positive. Patients 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, such as the requirement for longer appointments or for an interpreter to be present. Staff checked a patient’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of patients’ wider health and wellbeing. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

All staff had completed learning disability and autism training, and patients with complex health needs were given longer appointments to review their needs.

The practice had recognised an increase in referrals for those patients with neurodiversity. However, it was also recognised the difficulties patient and parents/carers had in ensuring the practice had the correct information to make the referrals. In response the practice created a ‘pack’ for patients to take away with a step-by-step guide as to what to do. The pack consisted of ‘a do list’, a breakdown of ‘Right to Choose’ providers, the questionnaires required, FAQs and a letter to complete so the patient could list their provider of choice.

The practice proactively used population health management tools to improve treatment for those patients whose health needs had changed, and their care needs evolved. For example, the practice had highlighted a cohort of 424 patients who were persistent attenders. The patients had an alert on their patient record to encourage care navigators to book these patients with their usual GP and for GPs to ‘dig a little deeper’ into reasons for attending. By analysing patterns of presentation, flagging persistent attenders and by re-allocating persistent attenders to the GP they see most often, the proportion of appointments taken by this group had reduced by 24% over a 12-month period.

Feedback from patients using the practice was very positive. The results of the GP patient survey 2025 showed that 96% of practice respondents felt their needs were met during their last appointment (national average 90%).

The practice always planned and delivered patient’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 best practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. There was a strong emphasis on learning within the practice and regular meetings were held to support the sharing of information. Clinical supervision was in place. A clinical lunch meeting was held one day a week and was an opportunity for doctors, the practice managers, lead nurses and allied role professionals to meet. Discussions included clinical care and management of patients, which were aligned with the practice vision, culture and values. Standing agenda items included significant/learning events and the review of appointments for the current week and the two weeks to follow. The minutes from these meetings were shared with all clinical staff. Audits were also presented and discussed.

The practice also held a quarterly breakfast clinical meeting which provided protected time for learning. Staff we spoke with told us that a clinical staff member would present a topic of clinical relevance.

The remote clinical searches we undertook included reviewing the monitoring of patients with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed. Clinical records we saw demonstrated care was provided in line with current guidance.

The practice always worked well across teams and services to support patients. They shared thorough assessments of patients’ needs when they moved between different services, so patients only needed to tell their story once.

We saw evidence of regular meetings taking place including, clinical, nurse, and partner meetings. There was also a monthly full Primary Health Care team meeting with all members of staff. This ensured direct engagement of all staff and an opportunity for all voices to be heard. It was also used as an opportunity to share strategy and vision, and to guide staff into achieving the objectives of the practice. Significant / learning events were standing agenda items. These meetings were also used for staff development, and face-to-face mandatory training. For example, annual fire safety, basic life support, infection prevention and control, and health and safety training. Staff we spoke with told us these face-to-face training sessions ensured they felt confident in the training subject and supported their online training.

The practice had strong relationships with the other practices that made up its Primary Care Network of local practices Staff and leaders successfully maintained positive partnership arrangements with many local providers and charities.

The practice worked with other services to ensure continuity of care and held regular multi-disciplinary team (MDT) meetings. For example, the practice held regular palliative care meetings with the lead frailty GP, clinical and non-clinical palliative leads, and information provided from the local hospice and a charity who was supporting some of the palliative care patients and their families with emotional and practical support. Meeting minutes highlighted a compassionate, proactive and personalised discussion for each patient and their families. The practice reviewed information of all deaths of patients on the palliative register quarterly, to identify what went well and any areas for improvements.

The practice followed the ‘Daffodil Standards’ which are an evidence-based framework created by the Royal College of General Practitioners (RCGP) and Marie Curie to help GP practices provide consistently high-quality end of life care.

Referrals to other services were monitored to ensure that appointments were booked for patients in a timely manner, for example, when patients were referred for suspected cancers.

The practice ran a yearly flu clinic which patients could self-book through Accurx (NHS-approved communication tools for healthcare professionals to connect with patients). Pneumococcal and shingles vaccine had also been included in the invite where required. Due to the whole practice working closely together as a team, 1838 patients were vaccinated in one morning. The practice also ran a separate children’s flu clinic. Staff told us that 2 members of staff had dressed as children’s TV characters, and we saw patients had sent feedback saying how their children had enjoyed the experience.

Staff had access to the information they needed to appropriately assess, plan, and deliver patient’s care, treatment, and support.

The practice always supported patients to manage their health and wellbeing to fully maximise their independence, choice, and control. The practice supported patients to live healthier lives and where possible, reduce their future needs for care and support.

There was a system that ensured all the patients with a learning disability were offered an annual health check including appointments with a variety of reasonable adjustments available. For example, early or late appointment times, a quiet waiting space or waiting in a car, and the use of visual aids (laminated pictures related to medical conditions, procedures, and pain scores to facilitate communication during the consultation).

The learning disabilities register was reviewed annually in collaboration with the local learning disabilities liaison nurse for primary care to ensure its accuracy and to include all newly eligible patients. The learning disabilities liaison nurse also reviewed a percentage of patient records to provide feedback and advise on any further training requirements that were related to undertaking the annual health review.

The practice worked closely with a range of local organisations to support patients’ health and wellbeing. The practice had developed a wide range of tailored patient resources and had created a dedicated digital platform (The Mill Medical Portal) to ensure patient information and local support was easily available. This included topics such as mental health, men’s health, and menopause. The practice had also designed and built a collection of printable, easy-to-understand resource packs which could be shared with patients according to their condition or support needs. These included local services, self-care information, and national resources. These were reviewed and updated regularly to reflect new services and best practice. For example, ADHD (attention deficit hyperactivity disorder) and autism, end of life care and bereavement, as well as resources for the elderly.

The practice published monthly newsletters which included health promotion, seasonal health advice, general information and charity groups offering support. For example, staying hydrated in Summer, free meals for children over school holidays and a charity that supports men who may be struggling with their mental health or experiencing social isolation.

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. Individuals living with long-term conditions were regularly monitored and, where appropriate, referred or signposted to local services offering information, education, and tailored support. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice routinely monitored patients’ care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of patients themselves.

Staff identified opportunities to refer patients to improve their quality of life. GPs followed up patients who had received treatment in hospital and acted on information received in discharge summaries.

The practice exceeded the World Health Organisation (WHO) national target of 95% for childhood immunisations.

We saw evidence of an established culture of audit activity to monitor the quality of care offered to patients. There had been a wide range of clinical audits undertaken in the last year, for example, transgender patients requiring medication monitoring and appropriate screening, paediatric adrenaline auto-injector prescribing and cancer referrals. We also reviewed a range of 2-cycle audits demonstrating improvements and actions plans for continued improvements. For example:chronic kidney disease and antibiotic prescribing audits both of which demonstrated improvements.

As part of preventative care and tackling health inequalities, the practice had undertaken a targeted weight management project from January to February 2025. The practice used a set of criteria to identify eligible patients. We noted that 255 patients were sent a proactive text message offering support and inviting them to access a free NHS weight loss programme. In total 162 patients were referred; 72 patients were referred to NHS Digital and 90 patients referred to One You Surrey. We noted that 14 patients were also identified as pre-diabetic and were referred to the diabetes prevention programme. We reviewed the results of 9 patients referred and saw an average weight loss within the first month of between 3-10%.

The practice had taken part in a pilot project which provided 14-day continuous ECG monitoring in the community. The project was designed so patients could avoid long waits for hospital cardiac monitoring, increase detection rates, improve patient experience, and reduce unnecessary hospital referrals.

From the clinical notes we reviewed, we found that patients who used the practice experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice always carefully explained to patients what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

Staff we spoke with demonstrated the importance of ensuring that patients understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. Clinical and non-clinical staff had undergone training in the Mental Capacity Act (MCA) 2005and clinical staff understood the requirements of legislation and guidance when considering consent and decision making.

We looked at a sample of ReSPECT plans (recommended summary plan for emergency care and treatment), to record agreed recommendations for a person’s clinical care in future emergencies if they were unable to make the decision. This included do not attempt cardiopulmonary resuscitation (DNACPR) decisions where appropriate. We observed clinical flags were on patient’s records when they had a completed ReSPECT form and plans had been made in line with relevant legislation.

We saw evidence of a cycle of audits for ReSPECT forms to ensure forms were well completed and demonstrated thoughtful clinical reasoning and patient-centred discussions. We reviewed audits completed where a random sample of forms were selected for each audit (June 2024 - 31 respect forms reviewed, January 2025 - 30 respect forms reviewed and June 2025 - 39 respect forms reviewed). The same 5 areas for compliance were assessed each time, this included clear guidance and decision about resuscitation and the patient’s wishes for care in an emergency situation. The GP assistant and paramedic team had developed suggested phrasing which had effectively reduced ambiguity and provided valuable guidance for clinicians regarding patients' care planning wishes. Findings showed a continued improvement with recommendations discussed at the doctors’ meetings. The last audit showed that completion quality against recommended standards was very high.

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.