The Mill Hill Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as good. At this assessment, the rating has remained the same. There were clear responsibilities, staff understood their roles and responsibilities. Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles.

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 practice had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff had contributed to the development of the practice vision and strategy, which was kept under review.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Leaders informed us there was an open door policy and staff told us leaders at the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff were in place.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities.

The practice had established governance processes that were appropriate for their service. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously. They acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The practice worked with the local mosque to encourage patients on uptake for screening and also worked with other practices within their primary care network to offer extended access. Staff made adjustments to improve coordination of their service with community healthcare services.

The practice had received acknowledgement from the Royal College of General Practitioners (RCGP) for being part of an active community by reducing sedentary behaviour in staff and patients.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Systems for assessing the quality of the service and outcomes for patients were in place. They actively contributed to safe and effective practice. The practice identified their waiting area required improvements and used feedback from patients and staff to start implementing changes. The practice was working in partnership with Doctors of the World UK and had received accreditation for being a safe surgery for patients in vulnerable circumstances including migrants.