Ringmead Medical Group

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

During the assessment we reviewed evidence remotely, spoke with staff, completed remote clinical searches of the practice’s clinical system and undertook observations while on site. We found the following: Medication reviews did not always contain complete information about what had been reviewed and it was not always clear whether the patient had been involved in their review. We found evidence of patients with diabetes that had not been informed of their diagnosis or that patients at risk of poor asthma control had not been informed of the risks. This lack of information did not support those patients to maximise their health. Our remote clinical searches found examples of patients taking medicines requiring monitoring that were overdue routine monitoring tests in accordance with national guidance. We found evidence of a system to determine staffs’ skills and knowledge and all staff we spoke with were clear of their scope of competence and told us they felt supported to only practice within the boundaries of their professional competence. Staff we spoke with told us how they worked effectively across teams and other services outside the practice to ensure that patients were supported effectively when they needed specialist services. We found clear examples of how the practice identified vulnerable patients that required additional support and found evidence of the support the practice offered. We found evidence of a system of audit to ensure that urgent referrals were not missed.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We asked the practice to share details of our Give Feedback on Care process on their website and we received 35 pieces of feedback. The feedback included a variety of positive, mixed and negative feedback about patients’ experiences of care at the practice. The positive feedback that relates to this quality statement included 4 pieces of feedback reporting patients felt they had received good quality care. Three pieces of feedback specifically praised the support a clinician had given the patient during their treatment and 5 pieces of feedback stated that triage had worked well for the patient. There were also 5 pieces of negative feedback about specific experiences, but these did not relate to this quality statement. We reviewed the results of the GP Patient Survey. We found there was no statistical variation between the practice and the national average about how involved patients felt in decisions about their care and treatment at their last GP appointment. However, we found there was a negative variation between the practice and the national average when reviewing results about whether the patient felt the healthcare professional at their last appointment was good or very good at listening to them.

All staff we spoke with had clear scopes of competence to determine the conditions they could treat. Despite hearing that the practice had shortages of staff, particularly in clinical roles, no staff reported feeling pressured to consult with patients outside of their scope of competence. A member of clinical staff we spoke with told us their scope of practice was being increased incrementally as their confidence and experience grew. This made them feel supported by the practice. For example, they were currently treating older patients, but it was planned that they would begin treat younger children, with incremental reductions in the ages they saw. We heard there was a clear triage process to ensure patients were treated by the most appropriate member of staff. We saw evidence of the policy and process and, heard from staff that it was followed by the reception team. We heard from staff that in the event a consultation was incorrectly assigned, for example, a matter that was not initially mentioned or was outside of the scope of the clinician, the appointment would either be assigned to the supervising GP or would be rebooked. We heard that where carers accompanied patients to appointments, staff were always observing for opportunistic ways to support them with their own health. For example, reminding them of eligibility for vaccinations and signposting them to support or community services.

The practice supported care homes in the practice boundary and had a dedicated care coordinator for the care homes along with a resources document which detailed all the support the practice offered, including priority access. We also saw evidence of how the practice supported vulnerable patients such as patients with a learning disability. We found there was a dedicated care coordinator and recall letters were sent in an easy-read format, text messages or annotated invitations. The practice scheduled appointments at a time that was convenient for the patient and called the day before to remind the patient of their appointment. The practice shared evidence which showed they had completed 91% of their health checks for this group of patients. However, we reviewed a random sample of 5 patients that had received medicine reviews by several staffing roles within the practice. We found medicine reviews did not always provide assurance that medicines continued to be prescribed appropriately or safely. Three reviews included a single coded entry, of which 2 did not provide evidence the patient had been involved in the review and 1 review was coded during a consultation for another matter. The reviews also did not always document whether all repeat medicines had been reviewed or that the reviewer had checked routine monitoring of the patients’ condition was up to date. The remote clinical searches also found examples of patients with diabetes and at risk of poor asthma control that had not been informed. This did not support those patients to maximise their involvement in their own care and posed the risk they did not know of the risk factors associated with their condition.

We asked the provider to share details of our Give Feedback on Care process on their website and although we received 35 pieces of feedback, none were specific to this area.

Staff we spoke with gave clear examples of how they followed current guidance. For example, the practice provided a copy of national guidance for the schedule of routine immunisations and staff spoke of using the guidance during interviews. We also heard about guidance referenced by staff when prescribing. Regarding our findings of 63 patients with a potential missed diagnosis of diabetes, the practice gave feedback during interview that when they had merged with another practice in July 2023, they had found a group of patients that required follow up tests to confirm diagnoses of diabetes. The practice reported those patients were in the process of being tested but did not provide an action plan at the time of the assessment to demonstrate they were aware of the finding and acting. Regarding the findings for patients prescribed disease-modifying anti rheumatic drugs (DMARDs) we heard that staff had asked for appointments to be longer to allow them to complete all the monitoring tests in a single appointment. As an alternative the practice had purchased blood pressure monitoring equipment for all 5 sites so patients could complete this monitoring test themselves. While explanations for the findings of the remote clinical searches were provided, we were not assured the practice had complete oversight over the issues and the scale of the patients affected.

Our remote clinical searches identified 15 patients prescribed a disease-modifying anti rheumatic drug (DMARD) that were potentially overdue monitoring. These medicines are used to treat autoimmune conditions and require regular monitoring to ensure that complications are identified early. We reviewed a sample of 5 patients and found blood tests were all up to date, but all 5 patients were overdue blood pressure monitoring. We saw 4 of the patients had received reminders in the 2 weeks before the remote searches were undertaken. We also reviewed a sample of patients taking a medicine to treat heart arrythmia which requires ongoing monitoring. The search indicated 13 of 21 patients were overdue monitoring tests. Our GP specialist advisor reviewed 5 patients’ records and found all were overdue monitoring, however, we found 3 patients had received a reminder they were overdue but had not yet attended their monitoring appointment. Our remote clinical searches identified 63 patients with a potential missed diagnosis of diabetes. Our GP specialist advisor reviewed 5 patients’ records and found 3 of the patients’ test results had been identified as abnormal and had been coded as requiring a follow up consultation but we found no evidence this had been acted on. This posed the risk that the patients did not know of their diagnosis, placed them at risk of worsening symptoms and complications related to a lack of education, treatment, monitoring and follow-up. We were not assured the practice had effective systems to code patient’s diagnosis or to follow-up abnormal tests results to ensure patients treatment was optimised.

We asked the practice to share details of our Give Feedback on Care with their patients during the assessment. We received 35 pieces of feedback and of these, 2 patients told us their experience had been of prompt triage and, in their opinion, allocation to the correct clinician for the consultation. We also reviewed the feedback received from patients dating back to July 2023 and of the 8 pieces of feedback received, none related to this quality statement.

Staff told us there were a range of meetings throughout the practice to ensure staff and teams worked effectively together. These included a clinical meeting every 2 weeks which could be attended in person or remotely to promote access for staff working across the 5 sites. There were also meetings for the nurse and MDT teams where information could be shared and updates disseminated. During our interviews with staff we found the practice held a monthly safeguarding meetings attended by partners including health visitors, community midwives and social services. There was also a meeting to discuss vulnerable patients in the community, including those patients at the end of their lives. These meetings ensured information was shared between teams and services so patient’s needs could be assessed and care planned effectively with partners. Staff we spoke with told us they believed the practice had good working arrangements with partners including the tissue viability service, podiatry and lower limb services.

We asked for feedback about the practice from partners, but they had no specific feedback to share about this area.

We reviewed the process to make urgent referrals, for example when the practice suspected a diagnosis of cancer. We found there was a clear process to triage and prioritise referrals between urgent and non-urgent. Staff we spoke with told us there were clear timescales for referrals to be made. When we reviewed the teams’ inbox which received requests for referrals we found these timescales were being met for urgent referrals but there was a backlog for non-urgent referrals. The cause was explained to be staffing shortages within the team but a system to prioritise and monitor referrals was demonstrated. We found there was a clear process to triage request for care by patients. These were triaged by a clinician who categorised the request based on urgency and determined the most appropriate type of consultation, for example face to face or remote, and which clinician was suitable to complete the consultation. The triage system maximised the skillsets of staff in the practice and was intended to ensure the patients saw the most appropriate clinician first time. The practice had clear systems and processes to identify patients that may be vulnerable or benefit from additional support. For example, patients with dementia, that were homeless, patients that did not speak English as a first language, pregnant women, and veterans. Documentation reviewed explained these patients’ clinical records were coded to identify them. Tailored support to the needs of each group was offered, for example signposting to community support and referral to weight management services. We found that when a patient was at the end of their life the practice clearly thought of the patients’ and family’s needs and how to support them best at that time.

We asked the practice to share details of our Give Feedback on Care process and received 35 pieces of feedback from patients. None of the feedback related specifically to this quality statement, however, 3 pieces of feedback specifically referenced individual clinicians and how well supported the patient had felt during their care. We also reviewed the feedback we had received from patients prior to the assessment dating back to July 2023. This included 8 pieces of feedback, however none directly related to this quality statement.

During our interviews with staff we heard an example of how the practice had recently supported a patient that had become homeless. The practice explained there was a care coordinator that maintained the register of homeless patients. When the practice heard of the patients’ circumstances they searched the system and found a telephone number for the patient. The care coordinator was able to contact the patient and explained all the services the practice offered and how they could support the patient to maintain their health and make referrals to support them. We also heard how the practice was proud of their achievement for completing health checks for patients with a learning disability. The practice reported they had been commended for their performance by the Integrated Care Board. The practice was aware that the number of patients with a learning disability had increased due to the merger and in response had planned dedicated clinics to increase their capacity to offer health checks to ensure this level and quality of care continued.

The practice provided examples of the different types of support they provided to multiple patient groups to help those patients live healthier lives. Examples included the following: Homeless patients were supported by the practice with not only their care needs but also assessment of other needs such as housing. A register of homeless patients was maintained by a care coordinator and some of the support offered included allocation of a named GP, giving a bypass number and priority access to the practice. The practice had 2 first contact physiotherapists available to patients that offered advice about self-care as well as onward referrals. We saw evidence that the practice offered tiered levels of care and support for patients with mental health concerns. This included same day triage and contact when requests for care were made and signposting to support services such as talking therapies. The practice also hosted a Mental Health Integrated Community Service which was designed to bridge the gap where primary care could not meet the patients’ needs but secondary care was not appropriate either. The practice had achieved an accreditation as an Armed Forces Veteran Friendly Practice and had a dedicated clinical lead for veterans. The practice shared evidence they had been commended by the Integrated Care Board for their achievement in delivering health checks for patients with a learning disability. We found the practice was aware that patients with a learning disability were susceptible to health inequalities and placed emphasis during health checks on several aspects of health promotion which included opportunistic immunisation including COVID-19, influenza and pneumococcal, identification of health needs and required actions, mental health and wellbeing support, discussion about screening for cancer and cardiovascular disease, and review of medications and their side effects.

We asked the provider to share details of our Give Feedback on Care process on their website and although we received 35 pieces of feedback, none were specific to this area.

We spoke with the practice about the findings of our remote clinical searches, and it was explained that clinical governance processes included running searches of the clinical system to maintain oversight of clinical risks. The practice explained that when they merged with another practice in July 2023, they found the two practices operated different processes in some areas. The leadership told us both practices’ processes had strengths and weaknesses, but they were in the processes of aligning them all. In response to our findings regarding missed diagnosis of diabetes, the practice explained their policy was to ensure the diagnosis was confirmed and consult with the patient before coding this in the patients’ record. However, the practice accepted the feedback that this posed the risk of patients being lost to follow-up and not knowing their diagnosis, as found by our searches. In response to our feedback regarding our findings for the documentation of medicines reviews, the practice explained that pre-merger, they had designed a template to be used and this was followed. However, the patient list had grown significantly because of the merger and several staff had left the practice since merging, therefore the practice had used a lot of locum staff during this period. This was provided as a possible cause for the lack of documentation within the reviews but the findings were accepted and the practice told us they would review the process and make improvements.

We found evidence the practice audited the prescribing of clinicians within the practice. For example, the practice shared an audit completed in December 2023 of a sample of 138 prescriptions completed by non-medical prescribers (NMPs) in a 3 month period. The audit reviewed whether the prescription was accurate to the indication and was the correct dose and quantity. The audit found 10 examples where prescribing could improve but found no errors that led to patient harm. Feedback about improvements was provided to the NMPs and the practice intended to repeat the audit in 3 month cycles. We were also provided an example of an audit of prescribing of paracetamol that was completed following an incident in another healthcare setting where a patient died following paracetamol overdose. The audit was focused on patients that weighed less that 50 kilogrammes or had no weight documented. Prescribing for a 1 month period was reviewed and 18 patients were identified. The audit found 72% of the sample did not have an up to date weight recorded and 22% had no weight recorded. When updated weights were obtained, 44% of patients weighed more than 50 kilograms and did not need prescription changes. The practice intended to provide education and improve recording of weight for patients and intended to repeat the audit in 6 months. Our remote clinical searches found 3523 patients had a medication review coded in their record in the last 3 months. Our GP specialist advisor reviewed a sample of 5 patients’ records and found 3 of the reviews were a coded entry and did not contain details of what had been reviewed. They also found in 2 of the reviews sampled that the patient was not involved in the review. Overall we were not assured there were effective processes in place that ensured medicine reviews covered all the appropriate considerations and supported patients to optimise their health.

Our remote clinical searches also reviewed the care for patients with long-term conditions including hypothyroidism, chronic kidney disease stages 4 or 5 and patients with asthma that had received 2 or more courses of rescue steroids. Overall we found no significant concerns with the monitoring for these groups of patients and records were well documented. Our GP specialist advisor also reviewed a sample of 5 patients with diabetic retinopathy with a latest HbA1c greater than 74mmol at their last monitoring test (HbA1c is the average blood glucose (sugar) levels for the last 2-3 months and is used to give an indication of how well controlled a patient’s diabetes is). Of these, we found no concerns with the care for 1 patient and another had complex care needs, but the practice had made multiple attempts to engage with the patient. For the 3 other patients we found they all required follow up appointments or repeat testing but did not find evidence this had happened. Our remote clinical searches found 34 patients had been issued 12 or more short-acting bronchodilator (SABA) inhalers. Over prescribing of SABA inhalers gives an indication that a patients’ asthma is poorly controlled. Our GP specialist advisor reviewed a sample of 5 patients and found no concerns with the care for 1 patient. Another was overdue an asthma review but was being actively recalled. Two patients had received reviews in the last year which had not identified the high prescribing of SABA inhalers. The final patient reviewed was overdue an asthma review, but their poor asthma control had been noted and they had recently been invited for review. For the findings above, opportunities to improve the quality and consistency of monitoring patients' care existed. After the searches the practice confirmed they had reviewed and acted on the findings of the searches.

We asked the provider to share details of our Give Feedback on Care process on their website and although we received 35 pieces of feedback, none were specific to this area.

Staff told us how they would assess a patients’ capacity to consent to a procedure. We were assured that staff understood the importance of ensuring that people fully understood what they were consenting to. Where staff had concerns about a person’s capacity to consent to treatment, they explained the action they would take. We spoke with a clinician and heard they explained the risks and benefits of a minor surgical procedure to inform the patients decision of whether to go ahead with the procedure. This member of staff explained they often found patients decided not to go ahead once this had been explained. We also heard examples of how staff obtained and recorded consent during cervical screening appointments. Staff also described circumstances where they would ask the consent of the patient for other members of staff to be present during the consultation, for example, a supervising GP or chaperone.

We were told templates were used by staff to document to patients’ consent to care and treatment and these were recorded in the clinical system.