Plumstead Health Centre PMS

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• 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 inspection, we rated this key question as requires improvement. At this inspection, the rating remains the same.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 58 (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 did not always make sure people’s care and treatment were effective. Patients with long term conditions, including hypothyroidism and diabetes, did not always receive the necessary monitoring tests for their condition.

We reviewed 5 patients with hypothyroidism and found 3 patients had not had the required monitoring tests in the previous 18 months.

We reviewed 5 patients with diabetes whose last HbA1c result was 75mmol/l or higher (HbA1c or haemoglobin A1c is a measure of average blood glucose levels over the past 2 to 3 months). This clinical search reviewed patients with a previously high HbA1c reading which placed patients at risk of diabetes-related complications such as cardiovascular disease, kidney damage and nerve damage. We found 2 patients had not had a review of their diabetes or diabetic medication since their most recent high reading. Another patient had not had a review since 2022 when their HbA1c was significantly raised.

We reviewed 5 patients with a potential missed diagnosis of diabetes. We found action was required for 3 patients that had not been identified by the provider. One patient was at risk of developing diabetes but had not been coded as such. Two patients had previously had blood results indicating type 2 diabetes but had not been coded as such. One of these patients had not had a repeat blood test since 2018. Therefore, we were not assured that all patients had an assessment of their needs with appropriate action taken by the provider.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. However, the clinical records we reviewed demonstrated care was not always provided in line with current guidance. Some patients did not receive monitoring tests prior to prescribing of certain medicines. Some patients with long term conditions did not receive reviews and monitoring tests within recommended timeframes.

The service 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 patients 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, including where clinical tasks were delegated to other services.

The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients 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, patients 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.

NHS England data from June 2024 showed the practice had not met national targets for the uptake of cervical cancer screening. Screening for eligible patients aged 25 to 49 years old was 65.1% and for eligible patients aged 50 to 64 years old was 73.6% (the national target for both groups is 80%). To address this the provider sent out 3 invitations using different methods of communication (telephone call, text message, and letter). If the patient did not respond to invites, a nurse contacted the patient to give the opportunity to discuss any concerns. There was a self-booking tool that patients could use to book appointments, including on Saturdays. Alerts were placed on patients’ records so that staff could opportunistically speak to patients about their screening appointments.

UK Health Security Agency (UKHSA) data for the period of April 2023 to March 2024 showed the practice had not met the World Health Organisation (WHO) minimum recommendations for uptake for all the 5 indicators relating to childhood immunisations. To address this the provider had introduced a dedicated administrative member of staff to support this work. Reminders were sent using 3 different methods of communication and parents were given the opportunity to speak to a nurse to discuss their concerns.

The service told patients 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.