Plympton Health Centre

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. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment in July 2015, we rated this key question as Good. At this assessment, the rating remains unchanged.

We evidenced a breach of the legal regulation in relation to safe care and treatment. People’s needs were not always appropriately assessed, in relation to monitoring of medicines and long-term conditions.

We evidenced the provider had an action plan in effect to make improvements and the action they were intending to take in response to our findings. The action plan detailed the review of the clinical records of people identified and to take further clinical action (where required) within a 6-week timescale.

We will review these improvements at our next assessment.

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 service made sure people’s care and treatment were effective. They appropriately checked and discussed people’s health and care needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Staff were aware of the needs of the local community, particularly those people in the rural locality of Wotter Surgery.

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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber (Social prescribing is an all-age, whole population approach that works particularly well for people who: have one or more long term conditions; who need support with low level mental health issues; who are lonely or isolated; who have complex social needs which affect their wellbeing). We saw evidence of social prescribing audits, which showed positive outcomes for people. Feedback from people using the social prescribing services was positive.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time.

We evidenced during the clinical searches that there were effective reviews and monitoring of people with asthma and diabetes. However, improvements were required for those prescribed disease modifying anti-rheumatic drugs (DMARDs -used to treat autoimmune diseases, particularly rheumatoid arthritis).

We evidenced that 3 out of 3 patients on the DMARD leflunomide did not have their required monitoring on weight or blood pressure.

We reviewed the records of people prescribed a nonsteroidal anti-inflammatory drug (medicines used to reduce pain, fever, and inflammation) in people aged over 65 years or anti-platelet (medicines that prevent blood clots) in people aged over 75 years. Both medicines increased the risk of digestive tract bleeding. We evidenced that 5 out of 5 records reviewed had not been prescribed a proton pump inhibitor (medicines that protect the digestive tract from bleeding).

People prescribed an Angiotensin-Converting Enzyme (ACE) inhibitors and/or Angiotensin II receptor blockers (used to treat high blood pressure), did not always have the required blood test monitoring recorded routinely in their records. We evidenced 3 out of 5 peoples records viewed had not had these recorded.

We reviewed the records of people with hypothyroidism (also called underactive thyroid; when the thyroid gland doesn't make enough thyroid hormones to meet the body's needs) who had not had a thyroid function blood test monitoring with the last 18 months. We evidenced 5 out of 5 records reviewed had the required blood tests, been completed in secondary care settings. However, this was not coded into their records, for staff to access when prescribing these medicines.

We reviewed the records of people with Chronic Kidney Disease Stages 4 or 5 who had not had the required blood test monitoring in the last 9 months. We evidenced 3 out of 5 people’s records reviewed had the required blood tests, had been completed in secondary care settings. However, this was not coded into their records and 1 out of 4 people did not have their blood pressure recorded.

Following our clinical searches, we obtained evidence of an action plan the service had implemented in response to our findings. This included a realistic 6-week date for completion and showed that several clinical records had already been reviewed as part of this, as well as people having attended appointments for reviews and required testing.

The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

Clinical staff had access to relevant national and formulary guidance, as well as local policies/guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

As part of our assessment, a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time.

We identified during the clinical searches that there were effective reviews and monitoring of patients following receipt of Medicines and Healthcare products Regulatory Agency (MHRA) alerts. For example, those relating to diabetes. However, some improvements were required to ensure a consistent approach to these. We reviewed the records of people prescribed mirabegron (medicines for treating an overactive bladder but with risk of severe hypertension). We found 5 out of 5 clinical records viewed did not always have blood pressure recorded routinely in their records.

Between 1 and 6 October, we obtained evidence of an action plan the service had implemented in response to our findings. This included a realistic 6-week date for completion and showed that several clinical records had already been reviewed as part of this, as well as people having attended or been invited to attend appointments for blood pressure recording.

The service held operations meetings which were utilised to highlight any new guidance. For example, the updated National Institute of Clinical Excellence (NICE) Diabetes type 2 guidance (July 2025) was used to assist with correct prescribing of medication and to monitor and follow up people with this diagnosis.

Staff were aware of the need to complete accurate and full records, such that information did not need to be repeated by people.People received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for people in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure people’s needs were met.

The service had a dedicated care home service to provide continuity of care for vulnerable people living in care homes and the community. There was a dedicated frailty lead who helped with this service, leading to reduced hospital admissions and ensured these people received the care they needed either in the community or in one of the 14 care homes supported by the GP service.

The service had an urgent care team (UTC) which was a workforce of GPs, physiotherapists, paramedics and nurses. The UTC team provided care and treatment for all people that present on the day for acute or exacerbations of chronic conditions of all ages; either by phone triage, e-consultations, face to face consultations or home visits.

There were clear and effective arrangements for booking appointments and transfers to other services.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and 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, people at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had not always met national targets for cervical screening of 80%. The provider was aware of the population of its service and had undertaken an innovation project from April to September 2025, to promote cervical screening for those people who did not engage with requests to attend. The service provided evidence of verified data, which showed rates for 2025/26 which showed a 2% increase (from 76% to 78% for the eligible population aged 25 to 49 years old and 77% to 79% for the eligible population aged 50 to 64 years old). The project had identified that people either did not respond to requests to book an appointment or were not attending booked appointments, meaning this influenced achieving the national target. The service was reviewing this data and was targeting these people to promote their engagement and find out why they were not engaging and had an action plan to address the outcome of the project.

The practice had achieved the average national targets for all childhood immunisations.

The provider submitted evidence of 11 clinical audits which they had carried out to improve outcomes for people. These covered medicines (including Direct Oral Anticoagulant (blood thinning medicines), asthma inhaler usage, health conditions (women’s health hub (menopause), cervical screening) and mental health/well-being monitoring. For example, introducing dermatoscopes (a handheld medical device used by healthcare professionals to examine skin lesions and conditions by providing a magnified view of skin structures) to provide skin screening images to secondary care settings when sending two week wait referrals. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes/changes to practice or policies/procedures were cascaded to staff.

People did not raise any concerns regarding the practice seeking their consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Consent documentation in relation to minor procedures was appropriately recorded and documented.

Relevant staff had been provided with training in the Mental Capacity Act. The service monitored the process for seeking consent appropriately and patient record searches demonstrated that consent was recorded appropriately. We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 3 people and found they were maintained in line with relevant legislation.