Pendeen 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 patients in decisions about their care and treatment and provided them with advice and support. Staff routinely reviewed patients care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had systems and processes in place to identify patients’ needs and preferences during the registration process. The practice 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 patients’ health, care, and wellbeing needs during health reviews. Clinicians used templates when conducting reviews to support the assessment of patients’ wider health and wellbeing. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice had effective systems to identify people with previously undiagnosed conditions. Clinical searches identified 31 patients with a potentially missed diagnosis of diabetes. We looked in detail at 5 patient’s records and found that all 5 patients had received the required reviews and had been coded on the clinical system appropriately. The practice had a ‘Diabetes Champion’ who provided care for patients with more complex diabetes.

In addition to the diabetes champion, the practice had a specialist respiratory nurse who provided care for patients with chronic obstructive pulmonary disease and asthma and acted as a resource for colleagues in this area. One of the Health Care Assistants led on providing cardiovascular health checks in the practice which facilitated identifying those with the highest risk of developing heart disease and proactively managing these patients.

The vast majority of feedback from patients using the service was positive. The National GP Patient Survey found 90% of patients felt their needs were met during their last general practice appointment.

There were systems in place to ensure staff were up to date with relevant legislation, evidence-based practice and required standards. Clinicians lunch meetings were in place monthly to keep staff up to date. There was a rotation of days of the week these were held to accommodate clinicians working different days at the practice. For clinicians who were unable to attend this meeting in person, clinicians were able to join the meeting remotely. These meetings were also minuted and disseminated to all clinicians.

The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

For example, we identified 78 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 patient records and found all patients had their diabetes and diabetic medication reviewed following this blood glucose result.

One of our clinical records searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 20 patients and reviewed a random sample of 5 patient records and found all patients had been followed up appropriately and had received an adequate annual asthma review which included providing the patient with an asthma care plan.

For patients with hypothyroidism, our clinical records searches identified 3 patients who had not had thyroid function test monitoring for 18 months and we reviewed these patient records. We found the practice had identified these patients were overdue monitoring and had already taken steps to address this.

For patients with chronic kidney disease stages 4 or 5, our clinical records searches identified 31 patients. We reviewed the patient records of 4 patients and found they had been appropriately monitored.

The practice worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to information they needed to assess, plan, and deliver patients’ care, treatment, and support. Systems were in place to share information about patients electronically with other services.

The practice worked with other services to ensure continuity of care and held regular multi-disciplinary team (MDT) meetings. For example, the practice had a palliative care clinical lead who attended regular palliative care meetings with external healthcare workers. The palliative care lead told us within these meetings they ensure they followed the ‘Daffodil Standards’ which are an evidence-based framework created by the Royal College of General Practitioners (RCGP) and Marie Curie to help GP practices provide consistently high-quality end of life care. Staff told us they had recently introduced a new MDT template which they would use to help to identify areas for improvement.

The diabetes champion attended a monthly diabetes online meeting which facilitated access to a diabetes consultant, a dietician with a special interest in diabetes, and a diabetes specialist nurse. Staff told us the meeting was an opportunity to discuss patients whose care was complex and who would benefit from specialist input without the need to undertake a referral.

The practice had strong relationships with the other practices which made up the Primary Care Network (PCN) and patients had access to services provided by the PCN, including social prescribers.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff supported national priorities and initiatives to improve population health, including stopping smoking, diabetes prevention programme and tackling obesity. The practice website contained information to support health initiatives. Staff told us they had a rolling programme of health promotion displays. We saw evidence of one health promotion display of ‘hanging up our pants’ in the waiting area to promote the importance and uptake of cervical screening. Staff told us the numbers attending for cervical screening doubled following this display.

Staff had lead roles in areas including diabetes, chronic obstructive pulmonary disease, asthma and cardiovascular disease and worked closely with community teams to support patients. Staff had worked to build connections with patients and their carers to ensure a positive response to invites for regular health checks.

The practice routinely monitored patients care and treatment to continuously improve it. Staff endeavoured to ensure that outcomes were positive and consistent, and that they met both the clinical expectations and the expectations of patients. Staff focused 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.

Published national data showed the practice had achieved the World Health Organisation 90% minimum targets for 4 out of 5 childhood immunisations. The percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 80%.

Published national data for the uptake of cervical screening showed the practice had achieved 77%, which was slightly below the national target of 80%. The practice was working to improve the cervical screening uptake and a recent health promotion exercise in this area had seen an increase in patient appointments.

The practice undertook regular clinical audits, and we were provided with evidence of two-cycle audits which demonstrated quality improvement. From the clinical records we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice told patients about their rights around consent and respected these when delivering person-centred care and treatment. A consent policy was in place to ensure appropriate consent was obtained from patients when receiving care and treatment. Staff understood the requirements of legislation and guidance when considering consent and decision making.

Patients were offered a chaperone for care and treatment when this was appropriate. Chaperone posters were on display at the practice to inform patients of this service and staff who provided this service had completed chaperone training.