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Plumstead Health Centre PMS Good

Inspection Summary


Overall summary & rating

Good

Updated 23 October 2019

We carried out an announced focussed inspection at Plumstead Health Centre on 22 August 2018 under Section 60 of the Health and Social Care Act 2008 due to breaches found in the effective domain at the previous inspection in June 2017.

An announced follow up focused inspection was carried on 14 August 2019 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 22 August 2018.

This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice is rated as good but continues to be rated as requires improvement for providing effective services as the practice did not make sufficient improvements to patient outcomes. The practice had made significant improvements in some areas and is no longer in breach of regulation.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Plumstead Health Centre on our website at www.cqc.org.uk.

We rated the practice as requires improvement for providing effective services because:

  • At the last inspection we rated the practice requires improvement for providing effective care because we found that the practice’s Quality and Outcomes Framework (QOF) performance rates continued to be below the local and national average for several indicators; and the practice had not effectively monitor quality improvement. We rated the practice as requires improvement for five of our six population groups. We rated it as Good for providing effective services to Working Age people.
  • At this inspection we found that the practice has implemented two-cycle audits as part of their quality improvement activity, and additional quality improvement activity had demonstrated improvement for patients. However, the practice remains rated requires improvement for providing an effective service due to poor QOF performance in childhood immunisations and cervical screening. This means that the Family, Children and Young People population group remains as requiring improvement and Working Age people population group becomes requires improvement, but the other four population groups have improved to be rated good.

There were areas where the practice should make improvements:

  • Continue to take steps to improve the uptake of childhood immunisation.
  • Continue to take steps to improve the uptake of cervical cancer screening.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 11 January 2017

The practice is rated as good for providing safe services.

  • There was an effective system for reporting and recording significant events.
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful information and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Most risks to patients were assessed and well managed. However, a failsafe procedure was not in place to monitor and ensure that results were received for all specimens sent for cervical screening.
  • The practice were unsure if legionella checks had been carried out on the premises and did not monitor cleaning schedules.

Effective

Requires improvement

Caring

Good

Updated 11 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice as comparable to others for most aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect and staff maintained confidentiality of patient information.

Responsive

Good

Updated 11 January 2017

The practice is rated as good for providing responsive services.

  • Practice reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Despite the pressures imposed on the provider by the recent merger they had agreed to continue their arrangement to temporarily care for the patients from a neighbouring practice whilst the NHS England area team confirmed future arrangements for the patients.
  • Patients said they found it relatively easy to make an appointment with a named GP and there was continuity of care. Urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 11 January 2017

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.
  • The practice had systems in place for the reporting and investigation of incidents and shared this information with staff to ensure appropriate action was taken.
  • The practice proactively sought feedback from staff and patients which it acted on.
  • The patient participation group was active and contributed to the development of the practice improvement programme.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Families, children and young people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good