The Care Quality Commission
  • Doctor
  • GP practice

Glyndon PMS

Overall: Good read more about inspection ratings

Glyndon Medical Centre, 188 Ann Street, Plumstead, London, SE18 7LU (020) 8854 6444

Provided and run by:
Glyndon PMS

All Inspections

25 August 2021 and 26 August 2021

During a routine inspection

Following our previous inspection on 12 July 2019. The practice was rated Requires Improvement overall and for the effective and well-led key questions. The caring key questions was rated good. The ratings for the safe and responsive key questions was good and was amalgamated from the previous inspection.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Glyndon PMS on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 25 August 2021 and 26 August 2021. Overall, the practice is rated as Requires improvement. The inspection looked at the following key questions:

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Good

The population groups, people with long-term conditions, families, children and young people and working age people were rated Requires Improvement.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

Part of the inspection was carried out remotely with the intention of us spending a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice’s Quality and Outcomes Framework (QOF) showed an improvement in several indicators compared to the data from 2017/18; however, there were areas where practice performance was still below the local and national average.
  • Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 90% in four areas where childhood immunisations are measured.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • We found instances when the provider had not carried out appropriate monitoring of patients on high risk drugs.
  • The practice had identified 1% of patients as carers.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.

There were areas where the provider should:

  • Continue to implement a programme to improve uptake for cervical screening and explore the reason why childhood immunisations uptake is higher for children aged one, compared to other age groups.
  • Review the threshold for safety incident reporting to ensure potential misses are captured and learning opportunities identified.
  • Ensure all staff are up-to-date with their booster vaccinations, in line with Public Health England guidance.
  • Take action to review patients listed on the practice’s safeguarding list.
  • Consider introducing a hearing loop, information in different languages and in an easy read format in the practice’s reception area.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

12 July 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Glyndon PMS on November 2016. The rating for the safe and effective key questions was requires improvement and for the caring, responsive and well-led key questions the rating was good. The overall rating for the practice was therefore requires improvement. The full comprehensive report can be found by selecting the ‘all reports’ link for Glyndon PMS on our website at www.cqc.org.uk.

An announced follow-up inspection was carried out on 20 June 2017. Overall the practice was rated as good. The rating for the effective key question was requires improvement.

An announced follow-up inspection was carried out on 11 July 2018. Overall the practice was rated as good. The rating for the effective key question was requires improvement.

Following our annual regulatory review of the service we decided to carry out an announced focused inspection on 12 July 2019 to answer questions which arose during the review.

This inspection was an announced focused inspection carried out on 12 July 2019, looking at effective, caring and well-led 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 11 July 2018.

At this inspection we found that

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The Quality and Outcomes Framework (QOF) data from 2017/18, showed that the practice performance was still below the local and national average for several clinical indicators. Unverified results for 2018/19 provided by the practice showed an improvement in some of the areas identified as requiring improvement at the last inspection. for example mental health, asthma and COPD; however some indicators showed a decline, for example diabetes.
  • The practice had increased the number of carers identified since the July 2018 inspection to 77 patients (1% of the practice list).
  • The provider had undertaken two full cycle clinical audits which demonstrated quality improvement for patients.
  • Not all staff were up to date with training and not all staff had appraisals undertaken.

We have rated this practice as requires improvement overall.

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

  • There was evidence that the care of patients in two population groups (people with long term conditions, families, children and young people) did not meet targets or was noticeably below average. The practice had actions underway to improve care, but these had not yet led to evidence of sufficient and sustained improvement.

We rated the practice as good for providing caring and services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had identified more than 1% of carers from the practice list.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services because:

  • Not all staff had an appraisal or were up to date with training.
  • This was the fourth inspection looking at the effective key question, whilst there was a slight improvement in some areas, evidence of sufficient and sustained improvement in clinical outcomes was not present.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way. (Please see the specific details on action required at the end of this report).

The areas where the provider should make improvement are:

  • Monitor and act on patient satisfaction with the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care.

11 July 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Glyndon PMS on November 2016. The rating for the safe and effective key questions was requires improvement and for the caring, responsive and well-led key questions the rating was good. The overall rating for the practice was therefore requires improvement. The full comprehensive report can be found by selecting the ‘all reports’ link for Glyndon PMS on our website at www.cqc.org.uk.

An announced follow-up inspection was carried out on 20 June 2017. Overall the practice was rated as good. The rating for the effective key question was requires improvement.

This inspection was an announced focused inspection carried out on 11 July 2018 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 20 June 2017. At this inspection we found that some improvements had been made.

Our key findings across the areas inspected is as follows:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The Quality and Outcomes Framework (QOF) data from 2016/17, showed that the practice performance was below the local and national average for several clinical indicators. Unverified results for 2017/18 provided by the practice showed an improvement in some of the areas identified as requiring improvement at the last inspection.
  • The practice had increased the number of carers identified since the June 2017 inspection from 41 patients (0.6% of the practice list) to 75 patients (1% of the practice list).
  • Since the last inspection, the provider added an additional four urgent appointments to their appointment system per day.
  • The practice had conducted two patient participation meetings since the last inspection.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

  • Continue to encourage patients to join the patient participation group (PPG) and establish regular communication with group members.
  • Review the use of read codes to enable clinical management based on collated patient data.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

20 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Glyndon PMS was previously inspected as part of the new comprehensive inspection programme. We carried out an announced comprehensive inspection on 22 November 2016. The rating for the safe and effective key questions was requires improvement and for the caring, responsive and well-led key questions the rating was good. The overall rating for the practice was therefore requires improvement. The full comprehensive report, published on 22 February 2017, can be found by selecting the ‘all reports’ link for Glyndon PMS on the CQC website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 June 2017 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 November 2016. This report covers our findings in relation to those requirements and any improvements made by the provider since our last inspection.

Overall the practice is now rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting significant events. The procedure had been improved since our last visit to ensure that a formalised and structured approach was now in place.
  • The practice had satisfactory facilities and was equipped to treat patients and meet their needs. The practice did not have an Automated External Defibrillator (AED) or all recommended emergency medicines available on the premises but risk assessments had been carried out with regards to this.
  • All staff had received an annual appraisal and there was a programme in place to carry out appraisals on an annual basis.
  • The Quality and Outcomes Framework (QOF) data from 2015/16, showed that the practice performance was below the local and national average for several clinical indicators. Unverified results for 2016/17 provided by the practice showed a small improvement in the asthma related indicators but no improvement in the other areas identified as requiring improvement at the previous inspection.
  • Information about how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. The procedure for the management of complaints had been improved since our last visit to ensure that a more structured and thorough procedure was now in place.
  • Results from the GP patient survey published in July 2017 showed that patient responses to most questions were comparable with local and national averages for most areas. However, although 65% of patients described their experience of making an appointment as good compared to the local average of 69% and national average of 73%, satisfaction rates for the other responses related to booking GP appointments remained below the local and national average. The practice was aware of this and continued to explore and implement ways to improve this.
  • The practice sought feedback from staff and patients. Following the previous inspection the practice had introduced a patient participation group to be contacted by email communication. Six patients had so far signed up to join the group.
  • The practice had identified only 41 patients as carers (0.6% of the practice list). Written information was available to direct carers to the various avenues of support available to them.

We identified regulations that were not being met and the provider must continue to make improvements:

Systems and processes were not established and operated effectively to ensure compliance. This was a breach of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17 (1) Good governance:

  • The provider did not do all that was reasonably practicable to assess, monitor and manage the health of patients. The provider must improve patient outcomes by implementing a clinical quality improvement programme and monitoring performance against clinical audit results and the Quality and Outcomes Framework.

There were areas of practice where the provider should continue to make improvements:

  • The provider should continue to encourage patients to join the patient participation group (PPG) and establish regular communication with group members.
  • The provider should continue to review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to all carers registered with the practice.
  • The provider should continue to monitor patient satisfaction rates regarding booking routine and urgent appointments and implement improvements as appropriate.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

22 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Glyndon PMS on 22 November 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting significant events. However, investigations and recording of actions were not always thorough and records not always kept. Lessons learned were not always communicated effectively to support improvement.
  • The practice had satisfactory facilities and was equipped to treat patients and meet their needs. However, the practice did not have a defibrillator or all recommended emergency medicines readily available on the premises.

  • Risks to patients were not always assessed and well managed. A risk assessment had not been undertaken with regards to the provider’s decision not to provide all recommended emergency medicines and equipment in their surgeries.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Staff did not receive an annual appraisal or formal assessment of learning needs.
  • Data from 2015/16 showed that the practice performance was below the local and national average for several QOF clinical indicators.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they often found it difficult to make a routine or urgent appointment with a GP.
  • There was a clear leadership structure and staff felt supported by the partners.
  • The practice sought feedback from staff and patients. However, the practice did not have a patient participation group (PPG).

The areas where the provider must make improvements are:

  • The provider must ensure that a more structured and thorough procedure for complaints and incident reporting is implemented.

  • The provider must carry out a thorough assessment of the risks to patients resulting from their decision not to provide all recommended emergency medicines and equipment in their surgeries.

  • The provider must improve patient outcomes by implementing a clinical quality improvement programme and continue to monitor performance against the Quality and Outcomes Framework and clinical audit.

  • The provider must ensure that a programme of annual appraisals for all staff is implemented.

The areas where the provider should make improvements are:

  • The provider should consider proactive strategies to encourage patients to join a patient participation group (PPG) and should establish regular communication with group members.

  • The provider should review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to all carers registered with the practice.

  • The provider should continue to monitor patient satisfaction rates regarding booking routine and urgent appointments and implement improvements as appropriate.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

24 April 2014

During an inspection looking at part of the service

During this inspection we spent time at both GP surgeries in Ann Street and Samuel Street. Most people we spoke with were happy with the treatment they received from the surgery. One person told us "I've accessed this service from childhood and it is a great service. I have no complaints' and another described the care they received as "generally good depending on the doctor you see and seeing my preferred GP can take weeks". We found the practice had systems in place to ensure the quality of the service was assessed and monitored on most occasions.

5 September 2013

During a routine inspection

We visited both the Ann Street surgery and the branch surgery in Samuel Street as part of this inspection and spoke to people at both locations. People we spoke with told us they were happy with the treatment they received from staff at the practice. One person told us "the reception staff ring me up to remind me that I have an appointment" and that they were "friendly and caring". Another person told us that the clinical staff were "brilliant" and they felt listened to when discussing their concerns.

We found that people were treated with dignity and that staff took time to explain things to them in a way they could understand. People received care and treatment which met their individual needs. Appropriate measures were in place to help protect people from the risk of abuse and the provider undertook checks on new staff to ensure their suitability for employment. However, we also found that effective systems were not always in place to ensure the risks to people's safety and welfare were appropriately monitored and managed.