Petroc Group Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There had been some improvements in the delivery of safe care and treatment since our previous inspection. The practice now had systems in place to support learning from patients’ complaints, significant events and national safety alerts. Staff told us they acted on safeguarding concerns and the practice worked as part of a multi-disciplinary team to support vulnerable patients. New recruitment, induction, training, appraisals and recording processes were introduced and followed to ensure safe and effective staffing. Recruitment checks were carried out in accordance with regulations (including for agency staff and locums). Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to role. Staff had access to appraisals, one to ones, coaching and mentoring, clinical supervision and were supported to meet the requirements of professional revalidation. There were systems and processes in place for management of emergency medicines and equipment. The systems for reviewing the care and treatment of patients with long term conditions was not always effective. The practice had not always ensured safe use of medication, and monitoring of patients who were on medication needing monitoring. There were systems and processes in place to assess and manage the risk of infection however, the frequently of audits needed to be as given on the audit forms. The practice had systems in place to ensure Health and Safety of patients using the service and staff. The documentation of patients records required improvement to include test results initiated by secondary care and the practice. We found ongoing concerns in the quality statements for learning culture, safe systems, pathways and transitions, safeguarding, medicines optimisation and involving patients. This resulted in a breach of regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some patients told us they had not always been able to raise concerns with the practice, due to a lack of information from the practice. We checked the practice's website and found information for giving feedback and raising a complaint was provided under practice's policies in small size font in the footer section of the website. Therefore, this information may not have always been easily accessible to all patients in particular to those who needed support with finding information on a website. The Family and Friends forms were available to the patients in the waiting room and online.

Some patients told us when they had raised concerns with the practice, staff attitude had been negative and lacked empathy. Some patients told us that they had not received a response to their complaints.

Staff were aware of what constituted a significant event and processes for reporting a concern. An example of this was when staff had come across a case of domestic violence and followed the process for reporting it. As a result, the practice had organised a training for staff on the subject. Staff confirmed they could attend regular meetings held by the practice on complaints and significant events and that the minutes of meetings were circulated among staff who could not had attend.

The practice had systems, including policies in place for acting on complaints and significant events. We found that these policies had not always been adhered to. Some patients said, that they had not received a response to the complaint and concerns raised with the practice.

Quarterly significant events and complaints meetings were held. Information from complaints was also used to identify significant events. Minutes from meetings were circulated to all staff via email to ensure that those not able to attend meetings in person were informed of any actions that needed to be taken. A debrief protocol was in place to support staff wellbeing and ensure actions had been taken when needed. We found the process given in the significant event policy had not always been followed or recorded in the meetings' minutes. This included the chairing of the meetings which needed to oversee the process, the timescale for change implementation, nominating a person to be responsible for ensuring current practice is changed, record of any amendments being made in protocols and policies where necessary, measuring the effects of any improvements where possible and ensuring review and feedback for future discussions at the next meeting.

Some patients through their feedback to CQC, and complaints made to the practice, said they had experienced delays in referral to secondary care and subsequently delays in receiving treatment for what they described as serious health conditions.

Staff aimed at providing continuity of care for patients with long term conditions or multiple healthcare needs. 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. 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.

We did not receive any feedback from partners about safe systems, pathways and transitions.

Patient records were 'not consistently completed with relevant information in line with current guidance. Some improvements were needed to ensure that there was evidence of patients being involved in their care and treatment. In particular when medicine reviews were carried out and when some care was provided by secondary care. Such as ensuring all blood test results were available on patient records to enable safe care and treatment to be provided. Audits were carried out on clinical records completed by advanced care practitioners, such as paramedics, and we saw that where improvements were needed, support was given to ensure all relevant information had been documented by the clinician. Workflow audits were carried out on handling of tasks, letters requiring action, test results and progress with scanning. A workflow state of play report, provided information on outstanding tasks, referrals, lab reports, letters and emails awaiting to be progressed. The report showed monthly data from the month of September 2023. Work was starting to be embedded into daily activity and the practice had a structure in place to monitor the volume of workflow against staffing levels and factors which might influence delays, such as staff sickness. A log was maintained of all referrals made to secondary care and other services. This included two- week wait referrals for suspected cancer. We saw that a priority rating system was used and all referrals were followed up to check they had been sent, received and acted upon. Patients were given advice on what to do if their condition worsened or they had not heard from the service the referral was made to in the expected timeframe. We found further improvements in existing systems were needed to increase efficiency in making timely and correct diagnosis of patient conditions first time, minimising delays in referral to secondary care, and ensuring better communication and record keeping where patients moved between services.

We did not review this evidence category.

There was a lead member of staff for safeguarding processes and procedures, staff were aware of this member of staff and could describe the actions they would take if they suspected a patient was at risk of harm. Complex care meeting minutes demonstrated that vulnerable patients were discussed with community staff and specialist clinicians who were able to offer extra support. Staff were able to provide example of instances where they had flagged as safeguarding concern, with positive outcomes for the patient had been achieved as a result of their intervention. People with learning disabilities were provided with advice about contraception and discussed issues around consent and saying ‘no’.

We did not receive any feedback from partners in relation to this quality statement.

Safeguarding policies and procedures contained information on actions staff should take and included relevant contact numbers. We saw contact details for the local safeguarding team on display in the reception area. The practice maintained a safeguarding register and made sure patients and their families were coded correctly, to ensure staff were aware of the situation. Training records demonstrated that all staff had received safeguarding training to the appropriate level for children as required by national guidance. Training on safeguarding adults had also been completed.

Data for GP Patient survey 2024 showed a total of 79% of respondents said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was lower than 91% for National average.

Patients records showed where care and treatment was provided, improvements were needed to ensure patients were involved in their care and treatment.

We received mixed comments regarding patients trying to communicate their needs to health care professionals working at the practice. From patients who contacted us, 33% said they felt they were not listened to, staff had no empathy and patience and had a a negative attitude.

Staff told us that they would call patients with diabetes or pre-diabetes multiple times and encourage them to attend appointments and explain the risks. Staff understood the importance of a holistic approach in managing patients care and worked with secondary and diabetic nurse specialist in supporting patients with the required treatment.

The practice had a referral protocol for GPs. There was a protocol in place for Fast Track Referral including a secretarial protocol for sending, and logging referrals. A priority rating system was used and all referrals were followed up to check they had been sent, received and acted upon. Patients were given advice on what to do if their condition worsened or they had not heard from the service the referral was made to in the expected timeframe. Our clinical searches showed patients with possible diabetes or prediabetes did not always receive timely diagnosis and review of their condition. This was due to patients’ health condition not being always coded and delays in tests and misdiagnoses. Staff did not always made necessary clinical records of patient health conditions, such as patients’ respiratory rates, when reviewing patients.

We looked at the practice’s response to a safety alert about patients being prescribed combination of clopidogrel ( a medicine to stop blood clots) and omeprazole or esomeprazole (medicines used to reduce the amount of acid the stomach makes). The combination of these medicines can lead to the clopidogrel not working effectively and an alternative to omeprazole or esomeprazole should be prescribed when possible. We found that patients had been consulted on changing their medicines and where they had declined to change, then this was documented. The risk of continuing on both medicines had been discussed with patients. However, we also found the practice had not always involved patients in the process of managing their care and risks to their health. Our searches identified a total of 15 patients who had been prescribed clopidogrel and omeprazole/esomeprazole which are contra indicated. We sampled five records which showed that only 1 patient had been informed of the risks. We found that medicine reviews were not always completed with the involvement of the patient.

Staff told us they use systems for ensuring timely care to patients such as colour coding for emergency appointments, having protected time for checking emergency medicines and coding vulnerable patients. Staff and leaders told us there were health and safety systems in place including risk assessments, checks, recording and monitoring. These included legionella, fire safety, spillage, emergency medicine, vaccines and environment.

We observed that both the main location and the branch site were maintained and free from clutter. Emergency lighting was in place and the indicator light showed it would work when needed. There was clear signage to show that CCTV cameras were operational outside the main location and in the internal corridors and waiting area. Staff had two computer screens and headsets to use when calling patients on the telephone. There were spillage kits available on site. Vaccines were stored safely and monitored. There were emergency medicines with relevant medicines in place with checks being maintained.

The practice had systems in place to ensure Health and Safety of people using the service and staff. There were contracts in place for health and safety, for example, for legionella testing; equipment testing and calibration; and fire drills and logs. When needed, action was taken to maintain safety. Fire drills had been carried out at the main location and the branch site, the time taken to evacuate the buildings had been recorded. There were risk assessments with action plan and policies and procedures in place and the practice had carried out regular reviews to ensure actions are completed by due date. A key holder policy was available for staff to read on the shared drive. The key holder log and employee files were kept and managed separately by the practice manager and human resources manager, and held within the HR server with limited access.

Data for the GP Patient survey 2024 showed 87% of respondents had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. This was lower the 92% national average.

A patient said “I attended the practice 3 times in the last 2 months and have been treated very well. The doctor was very thorough and took great care of me”. There were also negative feedback from patients about the attitude of some of the staff they had had interaction with.

Staff said the practice experienced difficulties with recruiting GPs and high turnover of admin team. They were liaising with the local integrated care board and other stakeholders across the area to attract new staff. The practice was also a training practice and said they were in a position to offer jobs to newly qualified GPs.

Staff with leading clinical roles had clear duties allocated to them. Staff felt supported by managers and GPs who had an open-door policy and worked together effectively as a team. They received induction, supervision and appraisals and had protected time for study and training.

The skill mix had been reviewed and more allied health professionals such as pharmacists and a physiotherapist had been employed by the primary care network and had been allocated to work in the practice either on a permanent basis or for a specified number of sessions per week. Training and development opportunities were offered to staff employed at the practice. This included an apprentice practice manager, paramedics provided with opportunity to do advanced care practitioner training and physiotherapist learning about joint injections. The practice planned to deliver specific Oliver McGowan Mandatory Training on Learning Disability and Autism, but had not updated the training policy to reflect this. One staff member said communication with GPs needs improving as at times it could be disjointed.

The practice had a structured induction and training process in place. Training considered mandatory by the practice consisted of 18 modules and additional training according to the member of staff’s role. Mandatory training was delivered via a 12 month rolling programme which included refresher training. Training completion was monitored during supervision and appraisal sessions and action taken if a member of staff had not completed all required training. Appraisals carried out covered clinical work as well as staff performance and development.

The recruitment process of new staff was monitored using a spreadsheet, which detailed areas such as when disclosure and barring service checks had been made; interviews; and requests for evidence of satisfactory conduct in previous employment. Checks of entry on professional registers were made and when staff had revalidated, to ensure they were fit to practice.

The practice had recruited rota coordinators who looked at staffing needed against planned appointment availability to develop rotas in advance, this work was relatively new, as the coordinators were recruited in March 2024. Urgent requests were always looked at on the day they were received.

Visiting paramedics and social prescribers were shared across the GP practices across the primary care network.

We did not receive any concerns about infection prevention and control from people using the service.

Staff said they had received training in handling specimens safely and infection control. Training records confirmed this.

We saw there were supplies of personal protective equipment in consulting rooms and handwashing facilities. Spillage kits were available for use. The premises at both sites were visibly clean and tidy. An isolation room was available if a patient was suspected of having an infectious disease, and this could be accessed via a separate entrance.

There were systems and processes in place to assess and manage the risk of infection. Regular audits were carried out of the environment and staff infection control practices. Routine checks were maintained on the water systems to ensure there was no sign of Legionella (a bacteria which can cause breathing problems) and the temperature of hot and cold water was tested and we saw that temperatures were within recommended ranges to prevent Legionella occurring. Single use instruments were available for clinical procedures, such as coil fitting. NHS Environmental cleanliness Audit were completed for March/April 2024. According to the information given on the audit form, this was required to be completed on a weekly basis. Where areas of improvement identified, required action(s) and completion with dates were not always given.

Safe management of the care environment audit was completed for April by Infection control coordinator. According to the information given on the audit form this should had been completed on weekly basis. Infection control policy was reviewed on 29 November 2023. It lacked the approving person’s signature and details of local IPC specialist team.

From September 2023 to March 2024, CQC received 30 feedbacks from patients of which 3 related to challenges patients faced with obtaining prescriptions.

Staff were able to tell us where emergency equipment and medicines were kept and said they had protected time for checking them. A member of the nursing team said they were responsible for managing vaccines and ensured that stock was correctly stored and rotated. They also had oversight of vaccination clinics and ensured that the required vaccines were available for these to be carried out. The manager for the dispensary had responsibility for coordinating activity across the main location and the branch surgery.

As a result of findings from our clinical searches, leaders told us they will conduct regular clinical searches in order to ensure, patients’ medicines being prescribed appropriately and national guidance being followed, for instance when the doses of medicines needed to be changed due to interaction with other medicines.

Following findings from our clinical searches, the practice, also wrote a new standard operating protocol for patients who had an exacerbation of their asthma, to ensure they were followed up appropriately and were prescribed relevant medicines and had information on what action they needed to take. This protocol was going to be discussed with all staff at the next practice meeting to ensure all staff were aware of the process.

Weekly checks were carried out on emergency medicines and equipment. We found that dates of expiry were noted, so that new supplies could be ordered and medicines and equipment was stored securely with relevant signage in place where needed. Emergency medicines included those for medical emergencies, such as cardiac arrest, severe allergic reactions and suspected infections, such as meningitis. There were also defibrillators at both surgeries. We saw fridges used to store medicines in had data loggers and daily temperatures were taken, records showed that medicines were stored at the correct temperature. We saw that vaccines were stored safely and monitored. In addition regular checks were carried out on controlled drugs and these were recorded. Room temperatures of the dispensaries were taken daily and recorded; we saw these were within recommended temperature ranges. All paper prescriptions were printed in the dispensaries and taken to the duty GP to sign. None of the consulting rooms had paper prescriptions in them and clinicians would either send requests to the dispensary or electronically to pharmacies.

Medication reviews were not always carried out with the involvement of the patient or their representative. Monitoring and annual health reviews were not aligned to occur at the same time. Patients who were prescribed medicines which could cause bleeding were not always prescribed appropriate medicines which reduced stomach irritation. Medication reviews that were carried out on these patients did not highlight the need for medicine to protect the stomach. Patients who were on medicines which needed regular monitoring and were under the care of secondary services did not always have their blood test results downloaded from the hospital system when the practice was responsible for issuing prescriptions. We found some patients on medicines needing regular monitoring had not had this carried out prior to a prescription being issued. Steps had been taken to encourage patients to attend for monitoring, such as sending text messages or letters. However, the practice had not taken any other action such as reducing the timeframe between prescription requests. We shared details of patients we had identified in our searches with the practice and they provided us with information on what actions they had taken as a result, which included reducing the length of time between repeat prescription.

The practice had a medicines management policy. However, the policy had not always been adhered to. We found that the practice had not always followed National Institute for Health and Care Excellence (NICE) guidance and recommendations including those related to high risk drugs such as opioids.

This included pre-prescribing agreement and treatment strategies plans for end of treatment with patients, policies and procedures for safe prescribing and co-prescribing and a system of warning flags at recommended intervals. The practice since had put measures in place and introduced changes.

Prescribing data from the period 01/07/2023 to 31/12/2023 showed that prescribing of medicines such as antibiotics and strong painkiller were managed appropriately. Prescriptions of antibiotics was broadly in line with averages. However, two patients out of the 17 reviewed in Oct 23 were on long term trimethoprim and had not been reviewed. We found duplication of missed diagnosis in our clinical searches which the provider said that they would only be able to remove at the end of the quality and outcomes framework year in March 2025.

The practice told us that they had plans for carrying out regular clinical and coding searches, but due to absences, they had not managed to carry these out. The practice aimed at restarting this process and carrying out regular clinical searches to identify gaps and take actions to address them. The practice had also planned to engage an external consultancy company to undertake a thorough review of all medicines processes, in particular medicine reviews and prescribing. This work was due to commence in the weeks following this assessment. The external company would be set to review all standard operating protocol and procedures used and ensuring they were up to date and in line with relevant guidance.