Petroc Group 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 found ongoing concerns in the quality statements for assessing needs and monitoring and improving outcomes.

Systems for assessing the management of patients with long-term conditions and patients on medications needing monitoring, were not fully embedded into practice. We found issues regarding the management of patients with asthma, chronic kidney disease stages 4 or 5, hypothyroidism and diabetes. The practice had not always involved patients in their own care when needed and it had not always ensured good communication and good clinical record keeping when people moved between services. There continued to be limited evidence that clinical audits were being followed up and used to drive improvements in patient outcomes. However, there had been some improvements in the delivery of effective care and treatment since our previous assessment. Staff were working effectively across teams and services to support people. Patients were supported to manage their health and wellbeing and maximise their independence, choice and control. The practice had taken action to improve the uptake of cervical cancer screening and childhood immunisation by allocating resources and running late clinics. Consent from patients for care and treatment was obtained either verbally or in writing and entered on their records.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A patient with long term condition told us, they had experienced 12 weeks delay in the review of their care and treatment. This meant they did not receive the health review

they needed.

Staff told us patients with long term conditions were offered face to face, virtual or phone call appointments. GPs told us they mainly managed the overall care of these patients and worked with other clinicians in the practice, such as advanced nurse practitioners who undertook long term condition annual reviews. Staff said they found prioritising workload was an issue and used special software, (nurse secretary) to prioritise patients whose needs was seen to be more urgent. The practice worked with the primary care network and linked in with learning disability nurses and diabetic nurse specialists and shared information when relevant to provide joined up care. Following our searches we asked the practice and leaders provided assurances that they will carry out checks and follow up with patients who needed follow up.

The processes for reviewing patient care and treatment were not always effective. We found a lack of oversight in management of patients with long term conditions (Asthma, hypothyroidism, Chronic Kidney Disease (CKD) and Diabetes) and patients who were on medication that needed monitoring. Patients’ health condition was not always being coded correctly and there were misdiagnoses and delays in conducting tests. Staff had not always made necessary clinical records of patient health conditions, such as patients’ respiratory rates, when reviewing patients. The processes of medication review did not always ensured patients involvement when needed, correct coding for all medicines were reviewed and details of monitoring checks needed being recorded. Patients were not always advised of the risk associated with the medication, when prescribed. We found patients who were prescribed medicines and combinations of medicines that could cause GI (gastrointestinal) ulceration and bleeding without proton pump inhibitor (PPIs) being prescribed. We also found medicines reviews were not effective in identifying patients who needed PPIs. One patient, was missed diagnosis and was not coded and recent result identified this patient as possible diabetes and requested to make appointment with diabetic nurse in April 2024. Two patients with possible diabetes but 2nd tests not being done to confirm diagnosis. One patient had blood taken for other tests in April 2024 but hba1c was not done and other patient was told he was prediabetes when his hba1c was in diabetic range, therefore at risk of not having been diagnosed appropriately and not having being referred for screening, appropriate education, prescribing appropriate medication and necessary follow up. Some patients were not appropriately coded with prediabetes or diabetes. One patient had not had regular monitoring of prediabetes to ensure not progressing to diabetes with last hba1c had been in November 2022.

The data from GP Patient survey 2024 showed 88% of participants felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment. This was lower the 92% national result.

Nurses were responsible for reviews of patients with long term conditions with doctors overseeing their work in meetings. Staff attended staff meetings, clinical and multi-disciplinary meetings as well as workshops for information sharing, learning about necessary guidelines and discussing cases. Staff told us they contacted patients to discuss their care and treatment with them and provided them with advice and options and signposting to other services when needed. Staff told us they were aware of and planning to start on making further improvements in relation to current coding issues for patients with prediabetes and diabetes and conducting regular audit of clinical records for patients with long term conditions.

Since our last inspection, the practice had made improvements in relation to the safe management of patients on some medicines that required monitoring and people with long-term conditions. There were systems in place for carrying out monthly Disease-Modifying Antirheumatic Drugs (DMARD) searches. In this assessment we completed a series of searches on the practice’s clinical system to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance. Our clinical searches showed, the practice needed to make further improvements. These included involving patients in the processes of their medicine review when needed and following national guidance for the purpose of monitoring, assessment and review of patients with long term conditions and management of patients on medicines that required regular monitoring.

Patients told us that they did not always have a positive experience where referral to other services was needed. This included delays in making a referral and lack of communication by the practice with the patients. Some patients and relatives of patients with mental health needs told us, these patients did not always receive timely and sympathetic care and referral to appropriate services, when needed.

The practice carried out weekly ward rounds at two care homes in the area. They also linked in with the community matron in the frailty team to respond to patients with acute needs. The practice worked in line with primary care network (PCN) strategy for improving the population’s health. There was joint work with cancer screening, mental health, social care, district nurses, social prescribing team, physio, diabetes and learning disability specialist nurses. There were multi-disciplinary, cross network monthly meetings for sharing information and learning. Learning modules were available virtually and those that couldn’t attend were able to access information online. Appointments and follow up with GPs for children with Asthma were made when referred by accident and emergency (A&E). The medical secretary had created a ‘bible’ of information.

We spoke with PCN social prescribing team lead who gave us positive feedback on joint work with the practice staff for supporting patients, in particular patients with pre-diabetes and diabetes.

There were multi-disciplinary care meetings attended by the practice and other professionals for sharing information and supporting patients with complex needs. The practice was part of three networks who funded and shared services provided by visiting paramedics and social prescribers for the whole PCN. There were working processes and links in place with other services in the community for referral, joint work, information sharing and overall supporting people’s health and wellbeing.

Further improvements were needed to minimise delays in referral to secondary care, and in record keeping where patients moved between services including ensuring all blood test results were available on patient records to enable safe care and treatment to be provided

We did not receive any negative feedback from patients about this evidence category.

Staff explained ways in which they accessed a social prescribing service that worked across the network. The team provided support to patients with long term health conditions in particular patients with diabetes and pre-prediabetes. The social prescribers lead told us, they were planning to develop a bespoke health education programme consisting of three sessions run by specialists covering medicines, treatment, health risk, lifestyle, exercise and diet. Both face to face appointments and online information was available for people referred to the programme. The team was able to track patient blood test results and would remind patients to get blood tests done. The team members were attending a drop in hub once a month, in Padstow, alongside the foodbank, to talk with patients and offer support. Patients had support from a disability advisor from the department for work and pensions (DWP), who was attending the hub. The team was arranging wellbeing walks at lunchtime, including one at Newquay Zoo. New staff were shadowing social prescribers when they joined as part of their induction to understand what their role was.

There were processes in place to support patients with long term conditions, complex needs or other social needs to access services in the community which supported independence and living a healthier life. The process supported individual choice and preferences. There was a team of staff, consisting of two social prescribers and two wellbeing coaches providing advice, running a programme of health focused activities and signposting for patients. The team was working closely with other services and specialists to ensure a holistic approach to patients needs and support provision. There was face to face or online appointments available for patients. The team had developed a library of resources which was made available on the Watergate PCN website. Between the years 2022 and 2023, the practice had made 560 referrals of patients with diabetes and pre-diabetic to social prescribing service run by Watergate primary care network. (PCN). The service had reported 79% of all diabetic and pre-diabetic patients referred to the programme, had lower blood sugar level results after having had used the service. The service’s internal survey showed that 97% of patients had said they were extremely satisfied or very satisfied with their engagement with the programme and 100% would recommend it to a friend or family member.

We did not receive any feedback from people about this quality statement.

Staff told us they were continuing to work on improving cervical screening uptake, but were aware more work needed to be done. Most patients who required screening had to book 3 months in advance, as there were difficulties with getting appointments sooner. The practice offered evening appointments to 7.30pm, but this came out of the number of appointments already available. Staff said they would undertake opportunistic screening, e.g. when a patient comes in for a pill check and take time to explain the

process if the patient was nervous. A new member of staff was assigned in order to increase the number of appointments offered to patients.

The practice had processes in place to monitor and review patients care. We found these processes were not always effective and had not followed National Institute for Health and Care Excellence (NICE) guidance for best practice in patient care. Therefore, patients had not always received timely review of their care and treatment including monitoring of their medicines when needed. An audit of Ciprofloxacin (an antibiotic) prescription was carried out. The audit was not sufficiently comprehensive and the results showed that patients were not consistently followed up for signs of serious adverse reaction in order for the treatment to be discontinued. The audit also did not include information about patients having had been advised of risks and reporting side effects following start of the treatment. The practice had started the audit of its clinicians’ consultation records. This was not linked into individual clinician personal development plan or a practice wide learning programme, aiming to improve the overall quality of patient care and treatment.

Patient care were not always reviewed and monitored in an effective and timely manner, with the accuracy needed and with the involvement of patients when needed. The practice had not always followed national guidance in the process of monitoring and reviewing patient care and treatment and prescribing.

Data from GP national survey 30/06/2023 showed that of patients eligible for cervical cancer screening who were screened adequately was 70.5%, which was below the target of 80%. The practice had met the 90% target for childhood immunisations, achieving 95%. The practice had not always followed NICE guidance for the treatment and reviews of patients who had experienced an exacerbation of asthma. We found patients who were not routinely followed up within 48 hours and a patient who was on separate clenil and salmeterol inhalers instead of combination inhaler. Patients’ respiratory rates were not always recorded during examinations. Some patients had not receive medicine reviews and spacers were not issued when needed. We found from 56 patients with chronic kidney disease in stages 4 or 5, there were 9 who did not have their U+E (Urea and Electrolytes) monitored. There was one patient who was overdue for monitoring since 2019. The medicine reviews did not identify that monitoring was overdue. There were 566 patients with hypothyroidism. We found 13 patients who had not had their thyroid function test monitored for 18 months. There were 19% of patients with diabetes with poor diabetic control, showing their tests had not been repeated in a timely manner when needed and after the patient had started treatment to monitor the response. The practice had not always carried out monitoring of patients who were prescribed Disease-Modifying Antirheumatic Drugs (DMARDs). We found from 23 patients who were prescribed Azathioprine, 3 had not had monitored in the 6 months. From 64 patients who were prescribed Aldosterone Antagonist, 18 patients had not had the required monitoring.

We have not received feedback from people about consent to care and treatment.

Consent from patients for care and treatment was obtained either verbally or in writing and entered on their records. Staff said that if a patient attended with a family member or friend that would ask whether the patient wanted them to be in the consultation with them.

Nursing staff used structure templates on their computer systems when carrying out reviews and consent was part of the template. When patients had specific communication needs then arrangements were made for appropriate support such as interpreting services or written information in a format accessible to the patient.