The Care Quality Commission
  • Doctor
  • GP practice

Millrise Medical Practice

Overall: Good read more about inspection ratings

Millrise Road, Milton, Stoke On Trent, Staffordshire, ST2 7BW (01782) 536600

Provided and run by:
Millrise Medical Practice

All Inspections

During an assessment under our new approach

Millrise Medical Practice is a general practice providing general medical services to a patient population of around 8000 patients in Stoke on Trent. The practice is a training practice and is part of the Whitfield Primary Care Network, which consists of 5 practices.

Under our previous methodology the practice was rated good overall at the inspection carried out on 7 June 2023 and rated requires improvement for providing safe services.

We carried out this assessment between 17 May 2024 and 22 May 2024 in response to Care Quality Commission (CQC) receiving information of concern. We looked at a range of quality statements in the key questions safe, effective, and well-led. We followed up the breaches at our last inspection. The assessment was carried out as a mixture of remote and on-site inspection. Following this assessment, the overall rating for Millrise Medical Practice remains as Good overall.

We found that the provider had taken action to make most of the improvements required in the safe care and treatment provided. However, we found there were gaps in some areas of the providers governance systems and processes, for example:

• Gaps remained in the practice’s recruitment processes.

• A lack of a systematic approach to maintain clear oversight on all staff training and appraisals.

• Staff were observed in the late afternoon, leaving the building, and returning without logging in or out of the building, a potential fire log risk.

• Not all staff were aware of the practice mission statement vision/values or the practice organisational structure.

• Although not a regulatory concern staff reported lack of action by the leadership team regarding some human resource concerns.

• Staff reported a lack of clear communication from credible sources.

• The non-clinical staff team were spilt within divisions affecting the whole practice teams working atmosphere.

In this challenging context, access to general practice remains a concern.

7 June 2023

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Millrise Medical Practice on 7 June 2023. Overall, the practice is rated as good.

Safe - requires improvement.

Effective - good

Caring - good

Responsive - good

Well-led – good

Our previous inspection took place on 22 May 2017 when the practice was rated good overall and for all key questions.

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

Why we carried out this inspection.

We carried out this inspection in line with our inspection priorities.

Our focus included:

  • Safe, effective, caring responsive and well led domains.
  • Areas followed up including information provided on improvements entitled ‘shoulds’ identified in previous inspection.
  • Following a significant event in 2022 we followed up on the systems in place at the practice to ensure they had put measures in place in relation to individual care record documentation.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Staff questionnaires
  • External stakeholder feedback such as care homes.

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 found that:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients received effective care and treatment that met their needs.
  • The practice needed to improve staff training oversight to ensure safe systems were in place to provide care in a way that kept patients safe and protected them from avoidable harm.
  • Patients could access care and treatment in a timely way.
  • There were gaps in the practice’s recruitment processes and recruitment checks were not always carried out in accordance with regulations.
  • Evidence that staff vaccination and immunity for potential health care acquired infections was not recorded or risk assessed for all staff.
  • Cleaning schedules were not seen for each room and clinical rooms held no signed or dated information on when cleaning had last taken place.
  • Fire marshall staff training had yet to take place but had been booked.
  • Improvement was needed in the uptake of cervical screening.
  • The newly developed practice strategy and succession plan needed to be ratified, implemented and embedded.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

  • Take steps to improve cervical screening uptake.
  • Consider changes to practice website to ensure it is clear when registering at the practice if homeless that a form of ID would not be required.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

22 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Millrise Medical Practice on 27 July 2016. The overall rating for the practice was good with requires improvement in providing safe services. The full comprehensive report from the inspection on the 27 July 2016 can be found by selecting the ‘all reports’ link for Millrise Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The provider had developed a recorded system to receive and act on alerts about medicines that may affect patients’ safety.

  • The provider had implemented a consistent system for checking that monitoring for patients who took long term medicines on a shared care basis had been provided before issuing prescriptions.

  • An updated fire risk assessment was in place and weekly testing of the fire alarm was undertaken in line with best practice guidance.

  • The provider had improved the identification of patients who were also carers resulting in an increase to 2.4% of the practice population. There was a good range of information available to carers and they were also offered annual health checks.

  • The provider had revised their protocol for requesting home visits. The new procedure ensured that decisions about the urgency of a home visit were made by the on-call GP.

  • Complainants were made aware of the avenues of escalating their complaint within the practice’s response letters should they not be satisfied with the outcome of their complaint. However, not all patients spoken with were aware of how to make a complaint and the complaint leaflets were not readily accessible.

  • Patients commented that they were happy with the service provided. They told us that there were a range of appointments available to them and they could get an appointment when they needed one.

  • Patients felt that staff were helpful and friendly and treated them with dignity, compassion and respect.

  • The practice was actively recruiting clinical staff to fill the vacant GP positions and was open to exploring new ways of working.

However, there was still one area of practice where the provider could make improvements.

The provider should:

Make sure patients are aware of the complaint procedure and ensure complaints forms are readily available to patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27/07/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Millrise Medical Practice on 27 July 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows: [

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by the management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Most risks were well managed, although action was needed in the areas of acting upon alerts about medicines and the practice fire risk assessment in place.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Implement a recorded system to receive and act on alerts about medicines that may affect patients’ safety.

In addition the provider should:

  • Implement a consistent system for checking that monitoring for patients, who take long term medicines on a shared care basis, has been provided before the medicines are issued.

  • Review the fire alarm testing frequency and the fire risk assessment in place to ensure all risks are mitigated and date control the document to demonstrate compliance with legislative requirements over time.

  • Improve the identification of patients who may be carers.

  • Strengthen the procedure for patients requesting a home visit to include consideration to the urgency of which the visit should be undertaken.

  • Include the avenues of escalation for patients in the written response to complaints.  

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice