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Inspection Summary


Overall summary & rating

Outstanding

Updated 16 June 2021

Letter from the Chief Inspector of General Practice

We rated this service as

Outstanding

overall. We have not previously inspected this service.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? – Outstanding

We carried out an announced comprehensive inspection at Livi UK on 5 May 2021 as part of our inspection programme.

Digital Medical Supply UK Limited (The Provider) (trading as “Livi UK”) was a wholly owned subsidiary of Digital Medical Supply Sweden AB, which itself was a wholly owned subsidiary of Kry International AB, a healthcare company, which provided healthcare services across a range of European countries. Livi UK (the service)provided access for patients within England (and other UK Home Nations) to healthcare for patients within three separate categories:

  • Patients of NHS GP practices with whom Livi UK had entered into contracts;
  • Self-funded patients (Pay as you go appointments),
  • Clients of an international life and health Insurance company.

Patients signed up to access the service via an app or through Livi Connect. They could book appointments either on the same day or up to seven days ahead. GPs were able to advise on a range of medical issues, so long as no physical examination was required, and provide prescriptions or referrals to specialist services. Prescriptions were, for most patients, sent to a pharmacy of their choice; for other patient’s prescriptions were sent according to the rules set by their NHS GP. The service was free to use for most patients, however self-funded patients paid one inclusive fee which included any necessary prescription and/or sick note.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw the following areas of outstanding practice:

  • On 7 March 2020, at the outset of the Covid-19 pandemic, NHS England asked the service to develop a system for home monitoring of early cases of patients with Covid-19. Within 30 hours of being asked, the service developed and adapted their systems, including expansion of its operational hours to 24 hours a day seven days a week to establish the NHS National Covid Home Monitoring Service (CHMS). CHMS enabled patients to receive access to care without risking potential exposure of others to the virus. In total the service supported 791 patients during the first month of the pandemic. All surviving patients were discharged back to their NHS GP’s on 31 March 2020.
  • In March 2020 the service launched Livi Connect (“Connect”), a free web-based platform enabling healthcare professionals (including those with no connection to the service) to conduct secure remote video consultations with their patients. Connect was launched in response to the spread of Covid-19 to make it easy for healthcare professionals to continue with their work remotely, and as a best way of replicating face-to-face contact. Connect was free to use for all doctors and other healthcare professionals and was available in 10 languages: English; French; German; Italian; Spanish; Swedish; Norwegian; Danish; Dutch; and Polish. The provider had launched Connect in other European countries. Since launching Connect, it had enabled 26,473 patients in the UK, and 190,000 across Europe to benefit from video consultations with their healthcare professional.
  • The service had implemented a comprehensive range of wellness benefits for staff it employed to ensure their physical and mental wellbeing. The impact of the benefits was demonstrated by the findings of the 2021 staff survey, including: 86% of GPs said the service took positive action on health and wellbeing.

The areas where the provider should make improvements are:

  • Review the system for recording GPs NHS appraisals and ensure GP records of these are kept up to date.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 16 June 2021

We rated safe as Good because:

  • A range of clinical and non-clinical meetings were held with staff, where standing agenda items covered topics such as significant events, complaints and service issues.
  • There were enough staff, including GPs, to meet the demands for the service.
  • All medicines prescribed to patients during a consultation were monitored by the provider to ensure prescribing was evidence based.
  • On registering with the service, and at each consultation patient identity was verified.

Keeping people safe and safeguarded from abuse

Staff employed at the headquarters had received training in safeguarding and whistleblowing and knew the signs of abuse. All staff had access to the safeguarding policies and where to report a safeguarding concern. The adult and child safeguarding policies included downloadable links to apps and the NHS Safeguarding website to facilitate access to contact details for adult and children safeguarding teams throughout the UK. All the GPs had received adult and level three child safeguarding training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification.

Monitoring health & safety and responding to risks

The supporting team carried out a variety of checks on a daily, weekly and monthly basis. These were recorded and formed part of a clinical team weekly report which was discussed at clinical meetings. More urgent matters, such as inappropriate prescribing was monitored for and investigated on a daily basis.

The provider headquarters was located within modern offices which housed the IT system and a range of administration staff, though most IT and administration staff were, as a result of the Covid-19 pandemic working from home. Patients were not treated on the premises as GPs carried out the online consultations remotely; usually from their home. All staff based in the premises had received training in health and safety including fire safety. During the pandemic, staff were regularly updated regarding their roles and responsibilities via the internal messaging system and at weekly virtual meetings, updates included any issued government guidance and how this affected the service and its staff.

The provider expected that all GPs would conduct consultations in private and maintain patient confidentiality. Each GP used an encrypted, password secure laptop to log into the operating system, which was a secure programme. GPs were required to complete a home working risk assessment to ensure their working environment was safe. GPs received an annual equipment and training budget plus an annual wellness payment to fund a range of wellness activities, such as gym membership.

There were processes in place to manage any emerging medical issues during a consultation and for managing test results and referrals. The service was not intended for use by patients with either long term conditions or as an emergency service. In the event an emergency did occur, the provider had systems in place to ensure the location of the patient at the beginning of the consultation was known, so emergency services could be called.

GPs were required to raise an incident form for any consultations where there were concerns regarding serious mental or physical health issues which required further attention. Those rated as either higher risk or immediate risk were reviewed with the help of the support or medical team. All incidents were regularly discussed at monthly risk meetings and within the weekly clinical meeting. There were protocols in place to notify Public Health England of any patients who had notifiable infectious diseases.

A range of clinical and non-clinical meetings were held with staff, where standing agenda items covered topics such as significant events, complaints and service issues. Clinical meetings also included case reviews and clinical updates. We saw evidence of meeting minutes to show where some of these topics had been discussed, for example updates to the Safeguarding policies and an MHRA alert distributed to all GPs.

At the beginning of every consultation the GP established the identity, location and contact details for the patient. Whilst only a relatively small number of consultations were via phone calls, the service monitored calls waiting and identified any withheld phone numbers. If a patient had withheld their phone number when calling the service, the GP would not proceed with the call until satisfied that they had correctly identified the patient and had contact details in case an emergency arose, or there was an interruption.

Staffing and Recruitment

There were enough staff, including GPs, to meet the demands for the service and there was a rota for the GPs. There was a support team available to the GPs during consultations and a separate IT team. The prescribing doctors were paid on an hourly basis.

The provider had a selection and recruitment process in place for all staff. There were a number of checks that were required to be undertaken prior to commencing employment, such as references and Disclosure and Barring service (DBS) checks. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

Potential GP employees had to be currently working in the NHS (as a GP), be registered with the General Medical Council (GMC), on the GP register with a license to practice and on the National Performers List. Work carried out on behalf of Livi UK was covered by a group medical indemnity policy. The service held copies of up to date evidence relating to their qualification and training in safeguarding and the Mental Capacity Act.

During our inspection we found some of the GPs last NHS appraisal, recorded on the system, was greater than 12 months old. We noted NHS GP appraisals were suspended for the period 20 March 2020 – 30 September 2020 during the Covid-19 pandemic. However, some NHS appraisal records were overdue even allowing for that interlude. The service confirmed it was in the process of bringing all of these records up to date. The service also conducted its own appraisals of all clinical and non-clinical staff, these appraisal records were all up to date.

Newly recruited GPs were supported during their induction period and an induction plan was in place to ensure all processes had been covered. We saw evidence of a review process the service carried out to ensure newly appointed GPs consultations met the standards set by the service. We were told until new GPs had completed the induction programme, 100% of their consultations were reviewed to ensure they met the required standards.

We reviewed four recruitment files which showed the necessary documentation was available. The GPs could not be registered to start any consultations until these checks and induction training had been completed. The provider kept records for all staff including the GPs and there was a system in place that flagged up when any documentation was due for renewal such as their professional registration.

Prescribing safety

All medicines prescribed to patients during a consultation were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation, the GPs could issue a prescription to patients:

  • For NHS GP patient consultations GPs could only prescribe from a set list of medicines (these differed according to with which GP Practice the patient was registered).
  • When prescribing for patients whose care was commissioned by the insurance company, and self-funding patients, there were no specified prescribing limitations imposed. However, the service had risk-assessed its prescribing and did not prescribe from a list of medicines it had prohibited. Prohibited medicines included controlled drugs. Nor did it prescribe medicines where prescribing was subject to very specific safety concerns or any medicines requiring the patient to be subject to complex ongoing monitoring.

The service had risk-assessed all prescribing, and when a GP considered prescribing outside of the permitted lists of medicines a prominent warning message was automatically displayed. In addition, for self-funding patients and clients of the insurance company a clinical code was inserted into the medical record enabling the service to audit this activity, and potentially support the GP with further training and/or advice.

GPs were not permitted to prescribe controlled drugs, with the exception of two schedule 5 medicines used for pain-relief (Schedule 5 includes certain Controlled medicines which due to their low strength, are exempt from virtually all Controlled Drug requirements other than retention of invoices for two years). The service regularly reviewed controlled drug prescribing.

When emergency prescriptions were provided, GPs were required to ensure the prescribing was in line with its prescribing guidance. There was a clear record of the decisions made and, where possible, patients were referred to their normal NHS GP.

The service was not a repeat prescribing service. When prescribing antibiotics, GPs did so with reference to appropriate antibiotic guidelines. It encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics which was based on national guidance.

Once a GP prescribed the medicine and dosage of choice, relevant instructions were given to the patient regarding when and how to take the medicine, the purpose of the medicine and any likely side effects and what they should do if they became unwell.

The service did not prescribe any medicines that did not hold a UK medicines licence but did occasionally prescribe medicines for conditions outside of their licensed use. Medicines are given licences after trials have shown they are safe and effective for treating a particular condition. Use of a medicine for a different medical condition than is listed on their licence is not uncommon but is a higher risk because less information is available about the benefits and potential risks. In addition, the patient information leaflet may not provide details about the condition being treated. There was clear information within the documented consultation regarding the prescribing of medicines outside of their licence and why, and confirming this had been discussed and agreed with the patient. Additional written information to guide the patient when and how to use these medicines safely was supplied with the medicine.

The administrative team monitored all prescribing to ensure it was within the range of medicines the service prescribed. If a GP prescribed a prohibited medicine, such as a controlled medicine (controlled medicines are tightly controlled by the government because they may be abused or cause addiction) it was recorded as a formal clinical incident and individual feedback was given to the GP concerned. Incidents were logged centrally, and repeated breaches resulted in performance management steps being taken. This was ultimately regarded by the company as a disciplinary matter.

There were protocols in place for identifying and verifying the patient and General Medical Council guidance, or similar, was followed.

Most patients could choose the pharmacy where they would like their prescription dispensed. The prescription could be dispensed by their preferred local pharmacy for collection by the patient. Other patients received their prescriptions according to instructions given by their NHS GP.

Information to deliver safe care and treatment

On registering with the service, and at each consultation patient identity was verified. The GPs had access to the patient’s previous records held by the service.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We reviewed four incidents and found that these had been fully investigated, discussed and as a result action taken in the form of a change in processes. For example, monitoring disclosed that duplicate, and sometimes multiple, EMIS records were being created for some individuals. The service investigated and found a range of reasons for these duplicated records, including: unreliable data from patients and partners, and transcription errors when passing patients from one part of the service to another. Any duplicate, or suspected duplicate, records were reviewed by the senior clinical team. Where duplicates were identified these were incorporated into the master record. The service had subsequently developed and implemented workflows to minimise the risk of repetition.

The Medical Director presented all incidents at monthly Incident and Patient Experience meetings. There were also monthly incident review meetings attended by Medical Operations staff, the Clinical Team, the Practice engagement Team, the Product Team and any involved GP. Trend analysis was conducted quarterly and reviewed at the Clinical Governance Committee and the Senior Management Team meetings. A monthly summary/Newsletter of incidents was shared with the relevant stakeholders and all service staff. At all incident reporting meetings there was an opportunity to discuss any need to add themes of incidents or a high-risk incident to the risk register.

We saw evidence from one incident which demonstrated the service was aware of, and complied with, the requirements of the duty of candour by explaining to the patient what went wrong, offering an apology and advising them of any action taken.

There were systems in place to ensure that the correct person received the correct medicine.

Effective

Good

Updated 16 June 2021

We rated effective as Good because:

  • The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes.
  • All new clinical and non-clinical staff undertook induction training which varied according to their role.
  • GPs followed an induction programme, and to complete the programme they had to be reviewed and signed off by an Associate Medical Director.
  • The service identified patients who may be in need of extra support and had a wide range of information available on the website.

Assessment and treatment

We reviewed a total of 32 examples of medical records (across the three patient groups) these demonstrated each GP assessed patients’ needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence based practice.

We were told most GP consultations were completed within 10 minutes, but other GPs took up to 30 minutes to complete consultations. If the consultation ended, and a GP had not reached a satisfactory conclusion, there was a system in place where they could contact the patient again.

The GPs providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely from patients. They worked carefully to maximise the benefits and minimise the risks for patients. If a patient needed further examination, they were directed to an appropriate agency.

The service used a range of decision-making tools for clinical assessment. For patient consultations provided for NHS GP contracts the service used the same tools as the patients’ own GP practice. For other patients, it used a propriety clinical information gathering tool. If the service could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes. For example, the service carried out a monthly rolling consultation audit of at least 1.5% of every GP’s consultations. These audits gathered a range of information, including on every GPs performance. Any GP whose work was found to be below the required standard was referred to an internal clinician quality review process and provided with guidance and support as appropriate.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes.

  • The service used information about patients’ outcomes to make improvements.
  • The service took part in quality improvement activity, for example audits, reviews of consultations and prescribing trends. For example, the service undertook an audit of prescriptions issued for broad-spectrum antibiotics. From a total of 12,406 consultations audited the service found 1,749 prescriptions for antimicrobials of which only 33 prescriptions were for broad-spectrum antibiotics. It reviewed all of the prescriptions for broad-spectrum antibiotics and found 12 of those prescriptions were unjustified. This equated to 0.7% of all antimicrobial prescribing. Where necessary, further support was given to GPs regarding their prescribing.

Staff training

All new staff completed induction training which varied according to their role. GPs, for example, were required to undertake, or show satisfactory (up to date) evidence of the following training: vulnerable adult and child Safeguarding both to level 3; anaphylaxis; basic life support or advanced life support; equality and diversity; female genital mutilation awareness; infection prevention and control; Mental Capacity Act; NHS data security awareness level 1; and Prevent training level 3 (WRAP).

Staff also completed other training, which varied according to their role, on a regular basis. This included regular updates when there were changes to the service. The service manager had a training matrix which identified when training was due.

The GPs registered with the service received specific induction training prior to treating patients. An induction log was held in each staff file and signed off when completed. For example GPs followed an induction programme, and to complete the programme they had to be reviewed and signed off by an Associate Medical Director.

Supporting material was available: GPs had access to all medical guidelines and policies located within the IT system. In addition, they were able to access all training material and clinical induction material; this allowed them to be fully aware of pertinent clinical processes and guidance which was regularly updated.

An internal newsletter was regularly sent out, it included updates when organisational changes were made.

The GPs told us they received excellent support if there were any technical issues or clinical queries and could access policies. When updates were made to the IT systems, the GPs received further online training.

Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage.

GPs working for the service were subject to a range of performance monitoring, including: a formative appraisal with a Lead GP following a review of their first 15 consultations; ongoing monthly review of their clinical work, structured according to the individual GP’s performance; six-monthly review meetings with a Lead GP; and an annual in-house appraisal with a Lead GP.

Coordinating patient care and information sharing

Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.

All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.

The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse. Where patients agreed to share their information, we saw evidence of letters sent to their NHS GP practice in line with GMC guidance.

Patients consulting the service via their NHS GP practices were referred for necessary tests, but the results and accompanying correspondence were sent directly to their NHS GP practice. The services’ GPs conducting consultations had full access to the NHS GP patients record and could review and record notes of consultations onto these as required.

The service did not make investigation referrals for patients who were clients of the insurance company it worked with, or for self-funding patients. Instead those patient groups were signposted back to their NHS GP practice or referred for a private secondary care review, where independent clinicians would arrange investigations at their discretion.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support and had a wide range of information available on the website. Information and links available included: diet advice; smoking cessation; sleep problems; and mental health.

In their consultation records we found patients were given advice on healthy living as appropriate.

Caring

Good

Updated 16 June 2021

We rated caring as Good because:

  • The provider regularly reviewed a random 1.5% of every GP’s consultations to ensure they were complying with the expected service standards and communicating appropriately with patients.
  • Patients could book a consultation with a GP of their choice.

Compassion, dignity and respect

We were told that the GPs undertook online/video/telephone consultations in a private room and were not to be disturbed at any time during their working time. The service regularly reviewed a minimum random 1.5% sample of every GPs consultations to ensure they were complying with the expected service standards and communicating appropriately with patients. Feedback arising from these spot checks was relayed to the GP. Any areas for concern were followed up and the GP was again reviewed to monitor improvement.

We did not speak to patients directly on the day of the inspection. In preparation for the inspection the service had contacted all patients seen within the preceding three months, asking them to give feedback direct to CQC. We received 160 comments, most expressed satisfaction with the service, though a small number raised issues about the need to provide identity documents when registering with the service, delays in arranging appointments and issues relating to receiving a prescription. We also reviewed the services’ latest survey.

At the end of every consultation, patients were sent an in-app message, or an email, asking for their feedback. Patients completing the feedback, within the preceding 12 months, for the iPhone app (18,200) said:

  • 95% (17,290) were helped by the service;
  • 85% (15,470) were seen within an hour.

Patients giving feedback via email (4,397) within the last 12 months (this included NHS GP patients and self-funding patients): 90% (3,957) said their overall experience of using the service was good or very good.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical issues were available. There was a dedicated team to respond to any enquiries.

Patients were able to access to information about the GPs working for the service and could book a consultation with a GP of their choice. For example, whether they wanted to see a male or female GP. The GPs available could speak a variety of languages.

Responsive

Outstanding

Updated 16 June 2021

We rated responsive as Outstanding because:

  • At the request of NHS England, the service had set up the NHS National Covid Home Monitoring Service (CHMS) to provide home monitoring for patients diagnosed with Covid-19. The service was developed and implemented within 30 hours of the request from NHS England. It supported 791 patients during the first month of the pandemic.
  • At the outset of the Covid-19 pandemic the service had developed and launched Livi Connect, a free web-based platform enabling healthcare professionals to conduct secure remote video consultations with their patients. Since launching Livi Connect had enabled 26,473 patients in the UK, and 190,000 across Europe, to benefit from video consultations with their own healthcare professional.

Responding to and meeting patients’ needs

Consultations were provided seven days a week, with the specific operating hours dependent upon the agreed contracts, within overall limits of:

Monday - Friday 7:00am - 10:00pm; and;

Weekends 8.00am – 6.30pm

The services’ website clearly set out when the different patient groups were able to access consultations. Patients could contact the service via the website to request a consultation all day every day.

This service was not an emergency service. Patients who had a medical emergency were advised to ask for immediate medical help via 999 or if appropriate to contact their own GP or NHS 111. If a GP became aware of a medical emergency during a consultation, they would contact the emergency services whilst staying on the phone with the patient.

The digital application allowed people to contact the service from abroad, but all medical practitioners were required to be based within the United Kingdom, and the service was unable to issue prescriptions (or refer to other medical services) to be dispensed outside of the UK. The administrative team liaised with most patients to deliver prescriptions to a pharmacy of the patient’s choice. Other patients received their prescriptions according to instructions given by their NHS GP.

Patients signed up to receiving this service via an app on their mobile phone or tablet (iPhone or android versions were available), or by logging on to their account via the services’ website. The service offered flexible appointments to meet the needs of their patients.

The provider made it clear to patients what the limitations of the service were.

Patients requested an online consultation with a GP and were contacted at the allotted time. Whilst GPs usually completed consultations within 10 minutes, others took up to 30 minutes. The service recognised some consultations would take longer to complete, so did not terminate consultations but allowed them to run to completion.

During our inspection we saw the following areas of outstanding practice:

  • On 7 March 2020 NHS England sought support from a number of online healthcare providers to devise a solution for management of the first few hundred patients who had tested positive for Covid-19, who could be, initially managed in the community rather than requiring admission to hospital. The service put forward proposals and on 11 March 2020 NHS England asked the service to establish the NHS National Covid Home Monitoring Service (CHMS). The service was able to set up the CHMS and received details of the first cohort of patients by 12 March 2020. In addition to rapidly developing and adapting their systems, the service expanded its appointment delivery hours to 24 hours a day, seven days a week, to enable CHMS patients to access care as needed. In total, the service supported 791 patients during the early phase of the pandemic.
  • In March 2020 the service launched Livi Connect (“Connect”), a free web-based platform enabling all healthcare professionals (including those with no connection to the service) to conduct secure remote video consultations with their patients. The service launched Connect in response to the spread of Covid-19 to make it easy for healthcare professionals to continue with their work remotely, and as a best way of replicating face-to-face contact. Connect was free to use for doctors and other healthcare professionals and is available in 10 languages: English; French; German; Italian; Spanish; Swedish; Norwegian; Danish; Dutch; and Polish. It has been launched in other European countries. Since launching Connect, it had enabled 26,473 patients in the UK, and 190,000 across Europe, to benefit from video consultations with their healthcare professional.

Tackling inequity and promoting equality

The provider offered consultations to anyone who requested and paid the appropriate fee and did not discriminate against any client group.

Patients could choose either a male or female GP or one that spoke a specific language, if available within the GP workforce, or had a specific qualification. The service had arrangements in place for translation into other languages patients spoke. For patients with hearing issues, the service was conducting a pilot study of using British Sign language (BSL) translators where needed.

Managing complaints

Information about how to make a complaint was available on the service’s web site. The service had developed a complaints policy and procedure. The policy contained appropriate timescales for dealing with the complaint. There was escalation guidance within the policy. A specific form for the recording of complaints had been developed and introduced for use. We reviewed the complaint system and noted that comments and complaints made to the service were recorded. We reviewed four complaints out of 36 received in the past 12 months.

The service was able to demonstrate that the complaints we reviewed were handled correctly and patients received a satisfactory response. There was evidence of learning as a result of complaints, changes to the service had been made following complaints, and had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website regarding how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The website contained details on how the patient could contact the service with any enquiries. For patients who were responsible for any fees incurred, information about the cost of the consultation was known in advance and paid for before the consultation appointment commenced. The consultation fee included the cost of any resulting prescription or sick note.

All GPs had received training about the Mental Capacity Act 2005. Staff understood and sought patients’ consent to care and treatment in line with legislation and guidance. When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance. Where a patient’s mental capacity to consent to care or treatment was unclear the GP assessed the patient’s capacity and, recorded the outcome of the assessment. The process for seeking consent was monitored through audits of patient records.

Well-led

Outstanding

Updated 16 June 2021