Plumstead Health Centre PMS

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to inadequate.

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

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. There were 5 significant events recorded in the previous 12 months. We saw evidence that significant events were discussed in clinical meetings with learning shared with clinical members of staff. However, we did not find the same processes for the discussion and sharing of learning with non-clinical staff. Staff told us they were aware of the processes to report incidents, near misses and safety events and felt comfortable raising concerns. However, some staff told us they were not always invited to meetings where significant events were discussed and that learning was not always shared with them to identify and embed good practice.

The service did not always work well with patients and healthcare partners to establish and maintain safe systems of care. We found the processes for managing incoming documents were not always clear. We found 524 documents in the practice’s clinical document workflow system held in a file named pharmacist. These documents were not recorded as having been actioned and dated back to 19 March 2025. Actions required from these documents included a hospital letter requesting changes be made to the patients repeat medicines. Incomplete patient records meant there was a risk that patients would not receive all appropriate monitoring tests associated with their medicines and clinical staff would be unaware of potential interactions between medicines. However, we saw referrals and test results were managed in a timely manner.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations. We found safeguarding policies were available and kept up to date. There were details of the safeguarding leads in clinical rooms. However, not all staff members were aware of who the safeguarding leads were or the processes for raising concerns. We were not assured that all potential safeguarding concerns were identified or acted upon.

The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was maintained. However, the processes for checking emergency equipment were unclear. There was a written process that said the defibrillator and oxygen should be checked weekly. However, the checklists showed these were checked monthly. An additional oxygen checklist showed this hadn’t been checked since May 2025. Therefore, it was unclear how often emergency equipment was checked and whether this was sufficient to ensure the equipment remained safe to use.

The practice did not hold all suggested equipment and medicines for use in an emergency. There was no documented risk assessment to show why these items were not held, and therefore there was a risk the practice was not sufficiently equipped to manage an emergency situation.

The service did not always detect and control potential risks in the care environment. We requested evidence of health and safety risk assessments for each site; practice leaders told us these had not been completed. A fire risk assessment had been completed at the Tewson Road site in July 2024. This had identified some actions the provider needed to take, including the addition of fire assembly point signage and a procedure and training for staff regarding the evacuation of vulnerable patients in the event of a fire. We found these actions had not been completed. This fire risk assessment had a review date of July 2025. We found a fire risk assessment had not been repeated but had been scheduled for November 2025. We requested evidence of a fire risk assessment for the Garland Road site; practice leaders told us this had not been completed. There was a policy stating that fire drills took place regularly, however there was no documented evidence of fire drills. Staff we spoke to were unable to tell us when the last fire drill took place.

There was legionella risk assessment for each site, the review date for the Tewson Road site was August 2025. However, we found a repeat risk assessment had not been scheduled.

There were a range of clinical and non-clinical roles within the practice. We found there were no formal processes for the supervision of non-medical prescribers and physician’s assistants. Staff told us GPs were available throughout the day to discuss any concerns with non-medical prescribers and physician’s assistants. We requested evidence of formally recorded reviews, discussions and audits of the consultations of these staff members; however, we were told this was not formally recorded. Therefore, we could not be assured that staff were working only within their agreed areas of competence.

We reviewed 5 staff training records and found no evidence that 4 staff members had completed training in support for patients with a learning disability and autistic patients. There was no evidence that 1 staff member had completed equality and diversity training or that another staff member had completed training in basic life support. Staff told us they were not always given time to complete mandatory training. Practice leaders told us staff were required to complete mandatory training during working hours; however, it was not always possible to remove staff from their regular duties to complete this training.

We reviewed 5 staff (2 clinical and 3 non-clinical) recruitment records and found the immunisation records for all staff members were incomplete. None of the records included a record of diphtheria, tetanus or polio immunisations. In addition, there was no record of measles, mumps, and rubella (MMR) immunisations for the 3 non-clinical staff members. We found there was no evidence of pre-employment references for 4 members of staff. There was no evidence of an appraisal for 1 staff member.

The service did not always assess or manage the risk of infection. The practice had a designated infection prevention and control (IPC) lead; however not all staff were aware of who this was. Staff told us an IPC risk assessment had not been completed for either site. We were provided with evidence of an IPC audit that had identified some areas for improvement, including the need for cleaning staff to complete IPC training. Staff told us this training had not been completed.

We were told hand hygiene and sharps audits took place, but we were unable to see evidence of these as they were not formally recorded.

We requested evidence of cleaning schedules but were told records of the areas cleaned and the dates of cleaning were not formally recorded. There was a cleaning checklist in the women’s toilet at the Tewson Road site dated as October, but this did not have a year recorded. A cleaning checklist in the men’s toilet at Garland Road was dated from 2021. We found no other records of cleaning checklists for the toilets at either practice. The cleaning cupboard at Tewson Road was unlocked and accessible to patients. This contained cleaning products, we also found mops left in buckets rather than hung up to dry. There were large clinical waste bins kept in a storage room within the Garland Road site. We found both the storage room and the bins were unlocked. We asked staff if the bins and room could be locked, however staff were unable to lock either the room or 3 out of the 4 bins. We were not assured that appropriate action had been taken to manage the spread of infection, therefore staff, patients and people accessing the buildings were at risk of harm.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capacities and preferences.

We carried out searches on the provider’s clinical records system. Patients prescribed medicines requiring monitoring did not always receive the necessary monitoring tests. Practice leaders told us the requirement for monitoring tests was triggered by patients’ requests for their repeat prescriptions. There were no processes in place for the oversight of patients who required monitoring tests, nor were there audits to check compliance.

Patients prescribed medicines subject to safety alerts did not always receive the necessary monitoring tests. There was a spreadsheet to log Medicines and Healthcare products Regulatory Agency (MHRA) alerts and to record whether action was required by the practice. However, practice leaders told us there were no processes in place to run historic alerts to ensure all patients prescribed medicines subject to a safety alerts received the associated monitoring tests and/or information.

We found prescription stationery stored in a printer in an unoccupied and unlocked room. We requested evidence of a log to record the receipt and distribution of prescription stationery; however, we were provided with a log with only one date (17 September 2025), showing serial numbers distributed to a consulting room. However, there were no records of the prescription stationery being received and checked on arrival, nor was access to prescription forms restricted to authorised individuals. There was a risk of theft of prescription forms and fraudulent misuse which may result in potentially serious harm to individuals.

We were not assured that staff had the appropriate authorisation to administer medicines. We reviewed Patient Group Directions (PGDs) and found these were completed incorrectly. In most cases either the authoriser had not dated their signature to provide authorisation or the unused lines on the PGD had not been scored through to prevent staff members adding their names after authorisation.