Petroc Group Practice

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• 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

There had been some improvements in how well-led the practice was since our previous assessment. An improvement plan had been developed following our last assessment and there was a system of monitoring progress against the plan. This required more in-depth work. Staff were supported through a Freedom to Speak up Guardian if they had any concerns. The practice had started to work collaboratively with partners and communities and staff worked as part of a team. However, during our assessment of this key question, we found concerns in the quality statements for shared direction and culture; capable, compassionate and inclusive leaders; governance, management and sustainability; learning, improvement and innovation. We found progress was not consistently monitored to ensure required actions were completed. Some progresses were in planning or early stages, and some appeared isolated, lacked tangible outcomes for patients and therefore with limited signs of sustainability. There were systems and processes in place for staff to be involved and share information and learnings. However, there was a lack of an effective system for obtaining and using staff and patients’ views, feedback and input in a systematic way to improve service delivery.

The staff lacked information on GP partners' collective and individual responsibilities and leading roles they played in the running of the organisation, its services, and compliance with relevant standards and regulations. This resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke positively about the support they had from the management and colleagues and told us they could speak to GP partners or the practice manager for support. Staff told us they felt they worked as part of a team, worked hard and were supportive of each other. Staff spoke of the challenges they faced since their last CQC inspection and told us they were working on making on-going improvements. One staff member felt better communication by GP partners was needed as currently this appeared disjointed. The practice held sessions with the staff on the subject of it’s Statement of Purpose and started to implement an internal quality assurance process. This is in infancy stage. In the view of this assessment, we found more extended work is needed by the leaders to agree and set clear strategic aims and objectives for the organisation with the involvement of patients and staff to ensure effectiveness of people's care and treatment.

Monthly state of play reports were put in place and actioned at each partners meeting to give an up-to-date overview on workflow for decision making purposes. GPs were involved in mentoring, education and supervision for first contact practitioners and medical students. A new rota coordinator was in post who ensured there was allocated time for supervision, appraisals and training. A white board was introduced for staff to share views and comments, and staff were made involved in newly introduced quality improvement planning process. Information about complaints and significant events were available to the staff through meetings and by email. A suite of policies had been developed to support the running of the service. Staff had access to these policies when needed. However, we found a lack of oversight for ensuring policies were adhered to by leaders and staff. The practice had run a workshop with staff on its Vision and Mission statement. However, there were no follow up from that workshop. The practice had not carried out an internal staff survey, patients survey or study of patient population to support with a service improvement agenda and programme. An action plan had been developed following our last assessment, however, this required more in-depth work. The practice lacked a continuous improvement strategy and plan in line with legislation, national guidance and current evidence-based good practice and standards.

Staff said they felt supported by the leaders. Staff also commented that the communication with the GPs needed improving.

Nurses said that since the last inspection some staff had felt unsettled and demotivated, but they considered that all staff had been working hard across the practice to act on the requirements made. The outcomes of the inspection had made them more determined to do a good job.

Leaders had started to gain new skills in developing a managerial and strategic approach to the service planning and delivery.

This was at early stages and further work was needed to ensure sustainable progress in delivering quality care to patients.

In this assessment, we found the practice had worked towards making improvements in areas we had found in our previous inspection to be functioning inadequately. The lead GP had attended the 13 weeks GP improvement programme, commissioned by NHSE which supported the practice with the on-going processes of finding better ways of working and achieving outcomes. We heard from the staff that GP partners were inclusive and available when they needed guidance and support and that they operated an open-door policy. The practice had commenced quality improvement processes with the staff and brought in external expertise to support with this process, for example in relation to putting in place necessary health and safety measures. There were further areas for improvement and the leaders were aware of these, including but not limited to real engagement with patients and having in place an effective system for medication optimisation and improving systems for managing patient care and prescribing. The practice told us they had plans to engage specialists to assist with reviewing current arrangements and putting in place necessary measures. We were provided with a staffing structure. This presented a lack of clarity in relation to the GP partners, their governing responsibilities, accountability and specialist leading roles they played in the running of the organisation. There was no information about staff competencies in relation to the leading roles given. It was also unclear as what support and supervision individuals with leading roles were receiving to ensure good governance overall.

Staff said there were no barriers to speaking up and their views were listened to and acted upon.

The practice had a whistle-blowing policy. The policy provided guidance for staff on the Freedom to Speak Up policy for NHS staff, the lead person’s name, and referred staff to the Whistleblowing training provided as a mandatory training for all staff joining the practice. The practice used a whiteboard where staff could write ideas and provide feedback on service provision. Themes and ideas shared on the whiteboard were discussed at practice meetings and action taken when relevant.

We did not receive any negative feedback from staff on workforce equality, diversity and inclusion. Staff said they felt supported by the management and work as part of a team.

The practice had a Mission Statement, recruitment policy and procedure and an Induction policy for new starters. These documents set out the organisation's vision, position, procedures and learning requirements in relation to its staff and provided reference to aiming to meet the diverse needs of its service and workforce in line with relevant legislations including Equality Act 2010.

Staff we spoke to told us they had clearly defined roles and responsibilities and knew where to find policies and guidance. Staff told us they attended various meetings for information sharing and learning including significant events and safeguarding. Staff felt supported in carrying out their roles and said there was an audit of their consultation with patients. Staff attended learning opportunities provided to expand their skills and were provided with learning opportunities to get upskilled. We found that the practice had not always adhered to its policies such as medication management, complaint and significant event and we received no evidence of this having been challenged by staff who work directly with the patients and were responsible for implementing these policies in practice. We found this adversely affecting patient care and treatment. Staff told us that the regular clinical and coding searches had not been carried out to identify gaps and take action to address them. Feedback from staff also showed that the practice faced challenges in meeting patients needs for appointments due to lack of time and staff availability.

There was a staffing structure, however, this did not provide necessary information on governance of the organisation, and how different areas of work were overseen for compliance and quality assurance. A suite of policies was in place to underpin governance arrangements within the practice. However, we found that policies in place were not always followed, for example we identified from patient records that medicines reviews were not always completed in the manner required and some patients experienced delays in receiving a response to their complaints.

There have been some improvements since our previous assessment: The leaders met regularly to review the progresses made in recruitment as well as information and data gathered about clinics, workload and admin. The practice held and planned ahead a number of meetings, training and briefing workshops on operational matters such as general admin and clinical workflow, significant events, quality improvement planning and the organisation’s Vision and Mission Statement. A new cloud-based phone system put in place which would assist in collecting call data, including abandoned calls. The practice was planning to include information from that data into quality improvement planning. There were various Primary Care Network (PCN) meetings for information sharing, learning and managing risks, including complex care meetings and multi-disciplinary team meetings. The practice had started the process for auditing staff consultations records with patients. This did not appear to be linked to any service improvement planning including staff training, supervision and appraisals. Further work needed to ensure systems newly put in place are fully embedded in the practice, and that the improvements are sustainable. The practice needs to provide a plan of action to CQC with details of work completed and work in progress, with required evidence.

The Patient Participation Group (PPG) was in the process of developing into an independent patient led group and was already working with the practice to support patients wellbeing.

The practice had a Patient Participation Group (PPG). The group met four times a year. We looked at minutes of three meetings. The group was yet to elect a Patient Chair and agree Terms of Reference and action plan and was in the process of recruiting more members. The practice had allocated a space on the website for interested patients to make contact. The practice is yet to fully involve the PPG in a strategic process of service planning, change and improvements where patients input is of the essence. Staff had established links with nurses in the community when carrying out health checks for people with learning disabilities and there were links in place with secondary care and diabetic nurse specialist. When staff had come across any cases of safeguarding concern, they had flagged those concerns to relevant authorities such as social services to ensure safety measures were put in place. The practice shared the visiting paramedics funded by three networks and the social prescribers for the whole PCN. Staff worked closely with the social prescribing team and made referrals for patients with long term conditions in particular patients with diabetes and pre-diabetes. There were monthly Multi-Disciplinary Team meetings for learning and sharing information. Learning modules were available virtually, allowing those who could not attend to access information online. The practice worked with the PCN on cancer screening, and support was available for patients from mental health practitioners as part of the wellbeing hub run by the PCN in the area for focusing on population health management. 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 social prescribing lead told us about a project they had set up with the aim of supporting patients to eat healthily.  The primary care network had received funding to offer 3 annual subscriptions for patients to collect vegetable boxes from a local grower each week. These subscriptions were divided into four to enable 12 patients to participate in the scheme for 3 months. Patients’ blood sugar level and BMI was monitored prior to starting the project and after they had taken part for 3 months. Recipes were provided with the vegetable boxes for patients to follow. The social prescriber said that all patients who took part in the project experienced health benefits and their Body Mass Index (BMI) and blood sugar level had reduced; and they had been invited to talk about the project at a national conference earlier in 2024.

There were links and processes in place with secondary care and PCN for learning, sharing resources, referring patients with long term conditions and raising safeguarding concerns. Staff were using these links when planning patient care.

Staff told us that they were receiving regular training and were encouraged to learn new skills. Staff had access to information relevant to their work through policies and attending meetings and workshops. Staff and leaders told us further improvements in staff appraisal process, clinical meetings, teaching, medicine reviews and checks for medicine reauthorisation were needed.

The practice had commenced discussions with staff about a new method of gathering clinical and operational data and a new quality improvement plan process for use with various elements of the service provision. The process was at its infancy stage, was not linked to any existing organisational improvement plan and lacked sufficient oversight to provide assurance it would achieve the required outcomes.

The practice had conducted a clinical search of patients on Dapagliflozin (a medicine used to treat type 2 diabetes). The audit was not linked to any plan to improve patient care as a result of its findings. The practice provided us with an audit on treatment and diagnosis of osteoporosis in patients who have been on systemic corticosteroids for more than 3 months. However, no evidence of implementation of the recommendations to make improvement to patient care was provided.

The practice also had completed a quality improvement plan on Antibiotic auditing at end of October last year with the aim of monitoring and auditing the use of antibiotics for the purpose of optimising patient outcomes and reducing the risk of adverse events and antimicrobial resistance. A further review of antibiotics was carried out in April this year with the outcome documented as plan to review trimethoprim and fluoroquinolone prescribing and conducting discussion with the pharmacist. However, the plan does not give specific dates and lead for actioning.