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 Inadequate. At this assessment, the rating has changed to Requires Improvement.

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

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There was evidence that significant events and complaints were discussed in meetings with clinical and non-clinical staff. Areas for improvement were identified, and learning was shared with the team.

People felt supported to raise concerns and understood the processes involved. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Staff shared examples of where safeguarding concerns had been identified and action had been taken to keep people safe.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. There were clear processes for the checking of emergency equipment and records showed this was followed by staff. Staff could recognise a deteriorating patient and knew of action to take. Care navigators were employed by the practice and were trained to recognise clinical emergencies. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Action plans had been created as a result of the risk assessments and there was evidence that action had been taken to mitigate risk. There was a business continuity plan in place which was monitored and reviewed.

The service made sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The provider was in the process of recruiting to fill additional clinical and non-clinical roles. Staff reported some pressures relating to staff numbers but were supported by the leadership team to ensure patients could access timely, appropriate care.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Staff knew how to raise any concerns relating to infection prevention and control. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

Clinical waste and cleaning products were stored appropriately. There was evidence of communication between the practice and cleaning staff to ensure cleaning standards were maintained.

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

Patients who were prescribed repeat medicines did not always receive regular medicine reviews. There was not an effective recall process to monitor which patients were due medication reviews.

We reviewed the records of patients prescribed a medicine that required regular monitoring. These patients did not always receive appropriate and timely reviews to ensure the medicine remained safe and effective for the patient.

The provider had not taken action to ensure compliance with Medicines and Healthcare products Regulatory Agency (MHRA) alerts. We reviewed the records of patients who were prescribed a teratogenic medicine. A teratogenic medicine is a medicine that may cause developmental disorders or birth defects in an embryo or foetus. There was no documented evidence that patients had been informed of the risks associated with this medicine nor was there always a documented discussion relating to contraception, as per the MHRA alert. By failing to take these measures, there was an increased risk of birth defects or developmental disorders should these patients become pregnant. In addition, there was no evidence the patients were aware of these risks to allow them to make informed decisions prior to commencing and continuing their treatment.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.