Plumstead Health Centre PMS

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last inspection, we rated this key question as good. At this inspection, the rating has changed to requires improvement.

The service was in breach of legal regulation in relation to good governance.

This service scored 43 (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 have a clear shared vision, strategy and culture. Staff were unable to tell us what the vision of the practice was and had not been involved in the development of a strategy or culture.

Staff told us they felt leaders were capable, approachable and supportive. Staff described a positive working environment, driven by practice leaders.

We found a number of areas of concern that had not been identified or addressed by practice leaders. These included medicines management, management of long-term conditions, health and safety, supervision of clinical staff, fire safety, infection prevention and control, recruitment, and training.

There were no established Freedom to Speak up arrangements within the practice. Whilst staff told us they felt comfortable raising concerns with practice leaders, there was not a policy detailing how staff could raise concerns outside of the practice’s leadership structure. The practice did not have a designated Freedom to Speak up Guardian.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued.

The provider’s governance processes had failed to identify improvements were required in a number of areas including medicines management, management of long-term conditions, health and safety, supervision of clinical staff, fire safety, infection prevention and control, recruitment, and training.

Whilst policies included details of responsibilities, roles and systems of accountability, all staff were not aware of the roles and responsibilities of others within the practice. Some staff did not know who the safeguarding and infection prevention and control leads were.

Managers held regular meetings with staff. We found that concerns and emerging risks were discussed in clinical meetings, however this was not always the case in non-clinical meetings.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The practice had a quality improvement plan in place to help drive improvements in services This focussed on the appointment system.

We saw evidence of improvement through the use of clinical audits.

However, the practice did not always use information from patients in the form of feedback, complaints and significant events to drive improvement. Learning from such events was not always shared with all staff so that improvements could be made to the service.