Background to this inspection
Updated
6 October 2021
Glyndon PMS is located at:
Glyndon Medical Centre
188 Ann Street, Plumstead
London
SE18 7LU
The practice has a branch surgery at:
123 Samuel Street
Woolwich
London
SE18 5LG
Glyndon Medical Centre is registered with the CQC as a Partnership, providing the regulated activities of family planning; maternity and midwifery services; treatment of disease, disorder and injury, surgical procedures and diagnostic and screening procedures.
The practice has 6838 registered patients. The practice age distribution is similar to the national average with a slightly higher than average number of patients in the 0 to 20-year age group and a slightly lower than average number in the 60+ year age group. The surgery is based in an area with a deprivation score of 3 out of 10 (with 1 being the most deprived and 10 being the least deprived).
Clinical services are provided by two full time GP partners (male) and two part-time practice nurses (1.6 wte). Administrative services are provided by a Practice Manager (1 wte), a medical secretary (0.7 wte), two data/ scanning administrators (1.5 wte) and six reception staff
(3 wte). Reception is open between 8am and 6pm Monday, Tuesday, Thursday and Friday and from 8am to 3pm on Wednesday. On Wednesday afternoons when the surgery is closed, patients are instructed to contact the Samuel Street Surgery. Reception at the Samuel Street branch
surgery is open from 9am to 1.15pm and 4pm to 7.30pm on Monday and Tuesday; from 9am to 1.15pm and 4pm to 8pm on Wednesday and from 9am to 1.15pm and 4pm to 6.30pm on Thursday and Friday.
Pre-booked appointments are available with the practice nurse at the surgery from 8am to 1.30pm and 2pm to 5.30pm on Monday; from 8am to 1.30pm and 3pm to 5.30pm on Tuesday and Thursday and from 8am to 1pm on Wednesday. The practice is closed at weekends. When the surgery is closed urgent GP services are available via NHS 111.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 16.7% Asian, 48.6% White, 27.4% Black, 5.3% Mixed, and 1.9% Other.
Updated
6 October 2021
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