Penistone Group PMS 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

The service consistently planned and delivered care in partnership with patients, ensuring individual preferences, needs, and values were fully respected and embedded in care planning. Staff demonstrated a strong commitment to person-centred care by tailoring assessments to reflect each individual’s communication, personal, and health needs. The provider had implemented effective systems to proactively identify and monitor vulnerable individuals, ensuring timely support and intervention. There was a clear culture of continuous improvement and evidence-based practice. Searches we ran on the practice’s clinical system highlighted exceptional monitoring of patients with long-term conditions and those prescribed high-risk medicines. The service had exceeded national targets for cervical screening and childhood immunisations, reflecting a proactive and preventative approach to population health. Staff worked collaboratively and effectively with a wide range of external agencies to ensure seamless transitions and optimal outcomes for patients. Staff made sure people understood their care and treatment to enable them to give informed consent. Where patients lacked capacity, staff involved those important to the individual when making decisions in their best interests.

This service scored 92 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. For example, our clinical searches identified 14 patients aged over 65 years had been prescribed Citalopram (medicine for low mood), we reviewed 5 patient records, each of which had been individually assessed, with risks clearly explained and documented.

The service demonstrated a proactive approach in promoting the uptake of annual health assessments for patients with a learning disability. As of August 2025, 50 people with a learning disability were registered at the practice, with a 98% completion rate for annual assessments – significantly exceeding the NHS target of 75%. This represented the highest uptake in primary care across Barnsley. Staff had completed learning disability awareness training and continued to receive annual updates. The local learning disability nurse reported an excellent working relationship with the named GP, who regularly provided support and clinical advice on individual cases. For example, safeguarding referrals were initiated when patients missed essential health appointments ensuring additional support was provided to improve their overall health and wellbeing.

The service collaborated effectively with a residential care home supporting 7 young people with autism and other complex needs to ensure their health, care and wellbeing was supported and their communication needs met. A named doctor was assigned to the home who provided continuity of care through annual health checks, vaccinations, blood tests and home visits as needed. The care home manager told us this consistent approach had helped to build trust with the residents. Additionally, they had allocated a named care co-ordinator who maintained weekly contact with the home to address any medical or medicine related concerns promptly. The home manager told us this proactive support ensured that residents received the best level of care and support in a timely manner.

Feedback from people using the service was largely positive, reflecting a high level of satisfaction with the care and support provided. People felt involved in assessments of their needs. The NHS GP patient survey data showed 92% of patients felt as involved as much as they wanted to be in decisions about their care and treatment (national average 91%). Reception staff demonstrated an awareness of the needs of the local community. The provider had proactively engaged with several charitable organisations to deliver staff education on available community support services. This enabled staff to signpost patients to local initiatives aimed at improving wellbeing, reducing social isolation, and supporting falls prevention programmes.

Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. For example, the service had actively engaged with a local independent charity supporting individuals affected by previous sexual trauma, adopting their ‘Ask the Question’ methodology to help identify patients in need of support or counselling. Since its implementation in April 2025, four patients had been identified and offered signposting to appropriate support services. The GP shared an example where the approach enabled a patient to disclose previously unspoken trauma, leading to a referral for specialist support.

Clinical staff utilised structured templates during care reviews to support a holistic assessment of patients’ wider health and wellbeing. The provider had proactively audited areas for improvement in clinical documentation. Following a review of patients prescribed Sodium-Glucose Linked Transporter 2 inhibitors (SGLT2i) for type 2 diabetes, the provider identified a need to ensure patients were informed of the associated risk of euglycemic diabetic ketoacidosis (EDKA) and this was recorded. As a result, clinical templates were updated to include appropriate coding and documentation of EDKA risk discussions. Additionally, a patient information leaflet was developed and embedded into SMS text messages for automated distribution. Following implementation, of 22 newly initiated patients, 17 had a coded record of EDKA education, demonstrating the effectiveness of the standardised template and SMS text messaging system.

Care co-ordinators had proactively identified potentially vulnerable patients, particularly older people who had not been in contact with the practice for some time. A total of 40 patients were identified, with 39 subsequently engaging with the service. Of these, 7 required additional support, including 2 who were referred for GP appointments following falls. All 7 were referred to social prescribing services, with one also referred to the Health and Wellbeing Practitioner for further support.

Staff referred patients with social needs, such as those experiencing social isolation or housing difficulties to a social prescriber. The provider had effective mechanisms to identify potentially vulnerable individuals. For example, the care co-ordinator identified 11 patients diagnosed with a mental health condition who had attended Accident and Emergency more than two times in the previous 12 months. Following contact, 4 patients were booked an appointment with a GP, one was seen by the clinical pharmacist for a medicine review, ten were referred to social prescribing services, and 4 were referred to the Health and Wellbeing Practitioner for additional support.

The service consistently planned and delivered care and treatment in partnership with patients, ensuring that individual preferences and priorities were respected. Care was provided in accordance with relevant legislation and clinical guidance. Clinical search results were exceptional and demonstrated total compliance with best practice. For example, our clinical searches identified that 20 out of 1,926 patients may have been overprescribed short-acting beta-agonist (SABA) inhalers, which are used for rapid relief of asthma symptoms. A review of 5 clinical records confirmed that all patients had been reviewed within the previous 12 months, received education on appropriate SABA use, and were included in a recall system for high SABA usage, in line with recommended guidance.

The service also demonstrated a commitment to developing evidence-based good practice. Clinical searches showed that 32 of the 1,162 patients diagnosed with asthma had received two or more courses of rescue steroids in the past year. A review of 5 of these records confirmed that all patients had been issued with a steroid card and were appropriately treated and monitored in accordance with national guidelines.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation and clinical records we saw demonstrated care was provided in line with current guidance. For example, 163 of the 1,026 patients diagnosed with diabetes whose last HbA1c (blood test to measure blood glucose levels) was over 75mmol had all received a diabetic annual review and had appropriate monitoring arranged in line with recommended guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care. The provider had established a women’s health service at the practice to provide intra-uterine device fitting as a hormone replacement therapy treatment in collaboration with the local sexual health service. Patient feedback received by the provider on the service showed 100% of patients reporting that the overall service was excellent with 97.5% being very satisfied with the information provided.

The service supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. The provider had very effective systems in place to identify individuals with previously undiagnosed conditions. A clinical search identified 17 patients with a potentially missed diagnosis of diabetes. A review of 5 patient records confirmed that all had been appropriately coded as pre-diabetic, informed of their diagnosis, and scheduled for annual reviews to monitor their condition.

Staff actively supported national priorities and initiatives aiming at improving population health, including smoking cessation and obesity reduction. One example of this was the service’s collaboration with the Health and Wellbeing Practitioner on the ‘Pathway to Remission’ programme for patients with type 2 diabetes. This initiative involved a structured 3 month dietary plan designed to support weight loss and potentially lead to diabetes remission. The programme was extended to neighbouring practices, with the provider identifying approximately 100 eligible patients within their own practice and 20 at a nearby practice. The first cohort included 18 enrolled participants, 3 of whom were from the neighbouring practice. Five patients recently completed the programme, achieving a combined weight loss of 48 kg, while 13 remain actively engaged in the process. The provider plans to run another cohort next year to continue supporting eligible patients on their remission journey.

Patient feedback from the national Friends and Family Test was mostly positive, with many individuals expressing that they felt supported by the service. Comments received included: ‘treatment was fast and efficient and I left with a clear plan and understanding of next steps’, ‘they listened to my concerns and adjusted my care accordingly – very responsive service’, ‘fantastic service from the reception team to the nurses and GPs, always feel supported’.

The service monitored people’s care and treatment to continuously improve it. For example, they carried out regular medicine reviews to ensure patients’ repeat prescriptions were appropriate. Our clinical searches showed 1,854 medicine reviews had been completed in the previous 3 months. We reviewed 5 clinical records, and all had received a structured and well documented review. The provider ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves. They had excellent recall systems in place and named care co-ordinators who actively contacted people to arrange their appointments. For example, our clinical search identified 5 of the 623 patients diagnosed with hypothyroidism (underactive thyroid) had not had a monitoring blood test done in the previous 18 months. All 5 clinical records we reviewed showed multiple invitations to attend had been made and some had been put onto weekly prescriptions to encourage to book in for monitoring.

The practice exceeded national targets for cervical screening and childhood immunisation uptake. We saw the practice had continuously met the 95% World Health Organisation (WHO) target for achieving childhood immunisations. We also saw that the practice had continuously achieved more than the national 80% standard for the uptake of cervical cytology with 80% of patients aged 25 to 49 years having been tested and 84% of aged 50 to 64 years. The GP told us that the care co-ordinators actively contacted patients who failed to attend for their appointments, and the GP would telephone the parents of children who had not attended for their immunisations.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Our clinical searches identified exceptional monitoring processes. For example, 61 patients had been diagnosed with chronic kidney disease stage 4 and 5, of those 2 patients had not had a blood test to monitor function in the previous 9 months as per recommended guidance. On review both were being monitored by secondary care. Our clinical searches identified of the 86 patients prescribed medicine to treat autoimmune conditions, 5 were identified as not having the required monitoring tests in the previous 6 months. We reviewed all 5 clinical records and saw all had either been contacted on numerous occasions by the provider or were under hospital review for monitoring.

Our clinical searches showed that 2,242 patients were prescribed ACE inhibitors (medicine used to treat high blood pressure, heart failure and certain types of kidney disease), of those patients, 8 did not have a record of monitoring review. All had been actively contacted.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.