The Mill Hill 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 assessed all quality statements for this key question and found that the practice was providing effective services. 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 as good.

This service scored 71 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Staff checked people’s health, care, and wellbeing needs during health reviews. For example, we found that 97.9% of triage requests were dealt with within 24 hours of being received. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Feedback from people using the service was 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. Staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice 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. Clinical records we reviewed demonstrated care was provided in line with current guidance.

The practice worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of 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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support. Patients had access to a social prescriber, which helped them improve their health, well-being, and social welfare by connecting them to community services.

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, including stopping smoking and tackling obesity.

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

The practice performed below national targets for screening and immunisations. NHS England data showed the practice was performing below the 80% national target for cervical cancer screening uptake as of June 2024. It showed it had achieved 67% coverage for women aged 25-49 and 75.4% for women aged 50-64.In addition, UK Health Security Agency data showed between April 2024 and March 2025, the childhood immunisations data for the practice were all below the World Health Organisation target of 95% (practice uptake ranged between 67.5% - 87.1%.

The practice was aware of this and informed us they were actively call-and-recalling patients, they offered a range of appointments including out-of-hours, patients received automated text messages, and the nurse and staff offered opportunistic immunisations and smears. Leaders informed us that weekend appointments at the local hub helped to increase uptake and presented unverified data that showed the practice was performing higher within the Primary Care network (PCN) compared with other local practices. In addition, the practice had an outreach project with the local mosque to educate members of the Muslim community (as the practices data showed this patient population group declined immunisations). There was an 8.6% uptake from the community following this outreach project and the practice continue to encourage its patients.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.Clinicians supported patients in making decisions. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check. Posters were displayed in the practice informing people this was available to them.