The Millwood Partnership

Updated 30 March 2022

The Millwood Partnership is located in Bradwell at:

Mill Lane

Bradwell

Great Yarmouth

Norfolk

NR31 8HS

The practice has a branch surgery (Falkland Surgery) at:

Falkland Way

Bradwell

Great Yarmouth

Norfolk

NR31 8RW

We visited both sites during this inspection.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites.

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is situated within the Norfolk and Waveney Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 19,680. This is part of a contract held with NHS England. The practice is a training practice for both Medical Students and Registrars.

The practice is part of The Gorleston Primary Care Network (PCN), made up of two GP practices.

Information published by Public Health England shows that deprivation within the practice population group is in the fifth lowest decile (five of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 98% White, with the remainder being Asian and Mixed.

The age distribution of the practice population has a slightly higher older population than national averages and is in line with local averages and slightly lower working age population.

There is a team of 10 GPs who provide cover at both practices. The practice has a team of nurses, health practitioners, healthcare assistants who provide nurse led clinics and phlebotomy services at the main and branch location. There is also a pharmacy team at both sites. The GPs are supported at the practice by a team of reception/administration staff. The practice manager is based at the main location to provide managerial oversight.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, GP appointments were a mixture of telephone consultations and face to face appointment. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.

Extended access is provided locally by Great Yarmouth & Waveney CCG, where late evening and weekend appointments are available. Out of hours services are provided by 111.

Updated 30 March 2022

We carried out an announced inspection at The Millwood Partnership from the 24 to 25 February 2022. Overall, the practice is rated as Good.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

During this inspection we also considered the management of access to appointments.

Following our previous inspection on 26 November 2019, the practice was rated Requires Improvement overall and for providing Effective and Responsive services, and the practice was rated Good for Safe, Caring and Well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Millwood Partnership on our website at www.cqc.org.uk

We have rated this practice Good overall

Safe - Good

Effective – Good

Caring – Good

Responsive – Good

Well-led - Good

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There were clear and effective processes for managing infection prevention and control.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Patient satisfaction results had improved, and patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Leaders and staff working at the practice had a commitment to improve.

Whilst we found no breaches of regulations, the provider should:

• Continue to strengthen the recruitment process.
• Ensure systems to monitor identified workplace risks are regularly reviewed.
• Improve the system for coding and recall of patients to ensure they receive the appropriate care and treatment.
• Strengthen the system for managing and acting on Medicines and Healthcare produced Regulatory Agency (MHRA) alerts.
• Continue to review and improve the uptake for cervical cancer screening continue.
• Review the programme of targeted quality improvement to include second cycle audits.
• Evaluate systems and arrangements in place for advanced care planning, end of life care and DNACPR decisions to ensure they are clearly documented and communicated.
• Restart plans to carry out a patient survey and act on feedback.
• Ensure learning opportunities from complaints are routinely used to drive improvement.
• Consider ways to encourage interactions with the Patient Participation Group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care