Parkwood Surgery

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 looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. We found that the service was not consistently effective in meeting people’s needs. At the April 2025 assessment, there were significant failings in timely assessment, diagnosis and follow up of care. Systems to identify and act on abnormal results, missed diagnoses and overdue monitoring were ineffective, leading to risks of delayed treatment and harm. People experienced difficulties accessing appropriate clinicians, which further impacted effective assessment and continuity of care. Evidence showed long term conditions were not always managed in line with current evidence-based guidance, with gaps in medicines monitoring, disease reviews and follow up of referrals.

Following the assessment, the provider took action to strengthen clinical oversight, increase staffing capacity and implement structured searches to identify missed diagnoses. By September 2025, improvements were observed in some areas, including reduced backlogs, better identification of patients requiring review and early progress in managing higher risk conditions. However, these improvements were not yet consistently embedded and further work was required‑risk conditions. However, these improvements were not yet consistently embedded and further work was required to ensure sustainable, effective care for all patients.

As a result, the service has been rated requires improvement for providing effective services.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our assessment found that patients faced significant barriers in accessing the service, which had an impact on their care needs being assessed and acted upon. The practice did not always check and discuss people’s health, care, wellbeing and communication needs.

Feedback from people using the service was predominantly negative. People did not feel involved in any assessment of their needs and felt staff did not understand their individual needs. For example, patients reported that abnormal blood test results requiring clinical follow up were not acted upon. Staff were working outside of their competency with some patients incorrectly reassured that results were normal when later evidence showed this was not accurate. Patients had carried out home blood pressure monitoring and sent in results which were filed in the patient records, with no action taken to identify or act on any abnormal readings.

Triage systems were weak or ineffective, with little or no risk prioritisation with potential for people to come to harm. We saw examples of this when some patients told us doctors did not even read their online notes before taking up appointments.

One person submitted an online triage request for worsening symptoms but received no clinical response. They were told they could not bypass the triage queue, despite deterioration and that over 200 people were ahead of them. They felt their worsening condition which was not recognised or escalated and described staff as dismissive. No alternative pathways, safety netting or clinical advice were provided.

Other patients described multiple consultations with different clinicians without receiving an accurate diagnosis. One patient reported that their condition was assessed only by a nurse who relayed GP advice without a direct GP review. The patient was directed to accident and emergency, where clinicians confirmed the condition could have been treated in primary care.

When we carried out the clinical record searches of the clinical system we found 45 patients were identified as having a potential missed diagnosis of diabetes. We reviewed a sample of 5 patients and found 4 had blood test results consistent with diabetes and only 1 had been informed of the diagnosis and referred for eye screening but they were not coded as diabetic. Failure to code appropriately placed patients at risk of not receiving appropriate care and ongoing treatment.

Searches also found 85 patients as having potential missed diagnosis of chronic kidney disease (CKD) stage 3-5.

Clinicians stated they were unable to complete tasks safely because assessments and monitoring had not been maintained and each request required contacting patients individually or carrying out full reviews.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns. Further assessment activity in September 2025 found improvements in the numbers of patients with missed diagnoses of diabetes; however, further improvements were still required and formed part of the practice strategic action plan.

For example, our clinical records searches found the number of patients identified as having a potential missed diagnosis of diabetes reduced from 45 to 18. However, improvements were still required as all 5 patient records we reviewed showed the patients had not been informed of the diagnosis, although 1 patient was possibly no longer diabetic. We also found 2 of the patients did not have relevant alerts on their records and the practice had not followed guidance on interval testing of repeating HbA1c above 47 within 2 to 12 weeks. We did see evidence of a patient newly diagnosed with diabetes with an appointment booked to discuss their condition and treatment.

We saw that digital flags within the care records system were used to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Following the inspection, the practice told us that an accessibility policy was now in place.

The service did not always plan and deliver people’s care and treatment with them. Systems and processes to keep clinicians up to date with current evidence-based practice were ineffective as care and treatment did not always follow legislation and current evidence-based guidelines, good practice and standards.

We found significant gaps in national guidelines being followed and clinical meetings were not taking place; therefore, opportunities to discuss evidence based care and treatment were missed. There was no clinical supervision policy in place and no evidence of multidisciplinary team meetings. There was no evidence that staff had access to, or were attending, any external training on the latest guidance.

There was no effective system for monitoring chronic disease reviews. Some patients were significantly overdue monitoring such as blood tests; for example, one patient was overdue monitoring for 5 years. This meant patients were not always prescribed the most appropriate medicines and treatment plans for their condition.

This was consistent with our findings at the April 2025 inspection. We found patients were not being followed up within 48 hours to check response to treatment following an acute exacerbation of asthma, this was not in line with national guidelines. Our searches found 40 out of the 872 patients with asthma had been prescribed 2 or more courses of rescue steroids in the last 12 months. We reviewed a sample of 5 of the 40 patient records and found adequate annual asthma reviews had not been undertaken in the last 12 months for 2 patients. Four or these 5 patients were prescribed steroid doses for asthma exacerbation which were not the adult recommendation according to national guidance.

Two patients were also prescribed SABA inhalers without a concomitant prescription of an inhaled corticosteroid which was against national guidelines.

We found 60 out of 631 patients with hypothyroidism were overdue their monitoring for 18 months. We reviewed a sample of 5 of the 60 patients and found that all of them were overdue monitoring. The last blood test monitoring for 3 of the patients in 2022 and 2023 showed their thyroid levels were outside the normal range and 1 of these patients was also overdue other blood test monitoring.

All 5 of these patients had a recent prescription for levothyroxine but no risk assessment about prescribing was documented. We also found that one of these patient records documented they had declined a blood test; however, there was no further information about informed choice, or risk assessment about continuing to prescribe levothyroxine without blood tests. As monitoring was not in line with guidance, these patients were at risk of under or over treatment with thyroxine.

We found patients diagnosed with chronic kidney disease (CKD) stage 4 or 5 were at risk of poor management of their condition due to monitoring frequencies outside of national guidance. We found 8 out of 68 patients with CKD had not received the required monitoring in the last 9 months. We reviewed a sample of 5 patient records and found 2 patients were at elevated risk as they last received monitoring in 2023 and required an urgent review.

We also found 180 out of 958 patients diagnosed with diabetes had average blood sugar levels above normal range. We reviewed a sample of 5 patients and found 4 of the 5 patients with persistent high average blood sugar levels had already sustained diabetes related microvascular complications and were documented to have retinopathy. One of these patients had not received a follow up since their last HbA1c reading in February 2025 and 4 of the 5 patients had blood pressure levels above the recommended range, for which hypertension is an additional cardiovascular risk factor. These findings were consistent with patient feedback that diabetes checks were not carried out and 1 patient said they were 4 months overdue.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns. Actions included upskilling nurses to manage long term conditions, GP partners were in charge of the running and management of long-term conditions clinics with self-book dedicated appointment slots for long-term conditions and administrative staff, supervised by the practice manager, would ensuring patients were recalled for reviews as required.

We carried out further assessment activity in September 2025. When we reviewed patients with chronic kidney disease (CKD) stage 4 or 5, we found monitoring processes for these patients had significantly improved as there were no patients overdue monitoring in the last 9 months.

However, the practice had not made sufficient improvements in managing other long term‑term conditions. Thirty seven of 837 patients with asthma had received two or more courses of rescue steroids in the past year, and 5 of the reviewed cases we reviewed showed no step‑up of regular treatment after an exacerbation, and 1 patient had not been issued a required steroid card. Two patients were overdue their annual asthma reviews and 3 did not have adequate clinical observations or safety netting recorded, which was unsafe. Although national guidelines changed in 2024 to reduce reliance on SABA inhalers, 2 patients still had repeat SABA prescriptions, contrary to updated recommendations.

We also found more effective measures were required for searches and medicines reviews of patients diagnosed with hypothyroidism, to identify issues of overdue monitoring and non-ordering. Whilst we found the number of patients with hypothyroidism that had not had their thyroid function tests monitoring for 18 months had improved to 10 out of 613 patients, we reviewed 3 records and found that 2 patients had outdated or incomplete thyroid monitoring dating back to 2019, with one no longer registered at the practice and another lacking an up to date review despite recent prescriptions.

We also found a slight improvement with 162 out of 988 patients diagnosed with diabetes having average blood sugar levels above normal. We reviewed 3 of the 162 patients with elevated results and found appropriate follow up and timely interventions. Overall, the practice improved its management of these patients, with repeat blood tests now carried out within the national recommended timeframes as standard practice, which was previously not always being followed. We saw evidence of good reviews from the 3 records we reviewed.

While adherence to evidence-based guidance had improved, there were still no systems in place to ensure staff were kept up to date with current guidance or legislation. No clinical meetings or multidisciplinary team meetings were taking place and we found no evidence of structured learning opportunities for clinicians.

Staff did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Prior the assessment in April 2025, we received concerns that the relationship between the partners had broken down and people described a poor staff culture and ineffective partnership working. Staff had no directive or clarity on their roles and as a result, there was no effective teamwork between staff and their teams and there was a high turnover of clinical and non-clinical staff which left remaining staff overstretched and unsupported.

This was consistent with our findings during the April 2025 assessment where we found that teamwork across the practice was significantly impaired due to longstanding partnership conflict, poor communication and unclear lines of accountability. Staff described a fractured working environment where partners frequently contradicted one another, creating divisions rather than collaboration. We found longstanding partnership conflict, poor communication and unclear lines of accountability.

We also found the redeployment of staff into other roles left gaps in necessary resources. Staff told us the lead GP worked limited clinical sessions and was not consistently available to support allied health professionals when they sought guidance. This created friction and a lack of collaborative working. Staff reported they were rarely available and avoided supporting colleagues and this placed additional strain on already overstretched teams.

Locum GPs were not given adequate induction or guidance, which contributed to errors and disjointed working. For example, we saw evidence that they were not aware of how to process safeguarding referrals as they had not been shown on induction.

There was mixed staff feedback about communication. Some staff made efforts to ensure their respective teams helped each other out and worked together, however meetings were no longer taking place. The absence of regular meetings, shared learning forums and clinical supervision meant there were limited opportunities for teams to coordinate care, discuss risk, or improve processes collectively.

We saw evidence that secondary care providers also raised concerns that their correspondence was ignored, leading to gaps in continuity of care and how services worked together. We received several complaints from patients that their secondary care letters were not being actioned by the practice, showing poor interteam and interagency collaboration. One patient also reported waiting 5 months to obtain information required by the Drivers and Vehicle Licensing Agency (DVLA), only for the form to contain insufficient detail, resulting in the patient being asked to attend a face-to-face review.

The effectiveness of out of hours communication, escalation to rapid response or social care teams, virtual ward step-up and stepdown access was significantly compromised by the widespread operational failures in the practice. Severe backlogs in results, referrals and documents meant urgent information was often delayed or missing, while poor communication and inconsistent triage processes led to unsafe or inappropriate decision making. Staffing shortages, high turnover and lack of supervision meant clinicians and non-clinical staff were unable to reliably identify or escalate risk and vulnerable patients including children and those with complex needs were sometimes turned away or not followed up.

These systemic issues collectively prevented the practice from coordinating timely, safe and effective responses across all these pathways, contributing to delays, clinical risk and poor patient experience. For example, the practice did not act on a young person’s referral for over 12 months and at the time this feedback was provided, they had not heard back from the practice.

The practice had an active Patient Participation Group (PPG) who sought to bring together collective thoughts and ideas to help improve the practice through collaboration with patients.

The practice told us they promoted health and provided diet and lifestyle advice and this was displayed on their website. NHS health checks were also offered to those aged between 40 to 74 years of age and we saw evidence of this.

Staff supported national priorities and initiatives to improve the local population health, including stopping smoking and offered appointments with a First Contact Physiotherapist (FCP) for problems related to muscles, joints, bones and soft tissues. There were 2 primary care network (PCN) social prescribers working in the practice. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to the social prescribers. Designated staff told us they were trained to be smoking cessation advisors. Nurses led the well woman clinic and offered contraceptive advice. They could refer patients to their website for health and information section including the NHS health screening and sexual health advice and support. When compared to the practice website, we found the PPG website contained significantly more information and advice for patients and useful links to signposted services.

However, we were not assured that the service effectively supported people to manage their health and wellbeing as the gaps we identified in access, continuity of care and the provision of timely health information meant people were not always given the advice or interventions required to support healthier living. For example, we were not assured that palliative care patients received timely care. One palliative care patient had unactioned tasks dating back to November 2024, indicating ineffective oversight. Although we saw evidence the patient was seen since, such delays limited the practice’s ability to support people to live healthier lives, where timely symptom management and follow up were critical.

Patient feedback was predominantly negative, with some patients raising concerns about the accuracy and reliability of clinical observations. One patient reported having their weight and blood pressure recorded incorrectly and on one occasion, their blood pressure was entered into their record despite no measurement being taken. These inaccuracies directly affect the service’s ability to support people to live healthier lives due to unreliable measurements, missed opportunities for early intervention and poorer long-term health outcomes.

The practice did not meet the national cervical screening uptake target of 80%, achieving 70% at the time of assessment. While leaders acknowledged the lower than average uptake and recognised the need to strengthen recall and engagement processes, they had not implemented any actions or system improvements to address this gap.

The practice did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Prior to the April 2025 assessment, the practice had carried out 62 out of 71 learning disability reviews. However, the practice did not meet national targets for screening and immunisations. For example, the cancer prevention data for 2023/24 showed that 75% of patients aged between 53-70 years had received breast cancer screening and this was above the national average of 70%.

Data also showed 74% of patients between 60 to 74 years of age had received bowel cancer screening and this was above the national average of 72%. The number of new of new cancer cases treated resulting from an urgent suspected cancer referral for 2023/24 was 48%, which was lower than the national target of 56%.

The practice did not meet the national targets for childhood immunisations in 3 of the 4 indicators, with the lowest indicator for children aged 2 years old who had received their measles, mumps and rubella (MMR) immunisations at 86%, just below the 90% minimum target and 95% expected target. The practice had reviewed the low childhood immunisation uptake and took steps to improve engagement. Reminder messages were sent to parents prompting them to book vaccinations or contact the practice if declining. Follow-up telephone calls were also made. Their data showed that a small number of children, 5 out of 82, had received none or only one of their required immunisations. Parents expressed hesitancy and raised concerns about vaccines and feedback from telephone discussions with parents was generally negative.

People did not always feel their care and support was planned proactively in partnership with them. Some patients reported that their conditions deteriorated following encounters with the practice where their symptoms were missed, whilst a small number of patients felt involved in their care and were happy with the outcomes of appointments.

From the clinical notes we reviewed, we found that people who used the service did not always experience positive outcomes as set out in evidence-based clinical guidance. For example, we received concerns that the practice did not consistently recognise or act on raised blood pressure readings. Although a system existed to manage these results, it was not functioning effectively. When patients were asked to submit home blood pressure readings via their Accurx messaging system, these were often saved into the record without any follow up action and it remained unclear who was responsible for reviewing and responding to these results.

At the April 2025 assessment, the practice had not carried out any quality improvement work, including clinical audits. This meant they could not demonstrate that they were monitoring quality and improving outcomes. By the September 2025 assessment activity, audits had begun but none were 2-cycle (repeated audits to measure improvement), therefore the practice was unable to demonstrate that improvements were sustained.

Staff were not up to date with their mental capacity act (MCA) training. For example, only 2 clinical and 3 non-clinical staff had completed this training out of 31 staff.

Some patients reported that during appointments with the clinicians, another individual was present in the room but their identity and role were not explained. Patients said they were not asked for consent for this person to be present.