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Japan Green Medical Centre Limited Good

Inspection Summary


Overall summary & rating

Good

Updated 14 May 2020

This service is rated as Good overall. (Previous inspection June 2019 – Good).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

We carried out an announced focussed inspection of Japan Green Medical Centre Limited (the provider) on 27 February 2020 in response to concerns raised about the quality of care being provided to paediatric patients. We had previously inspected the service in June 2019 when we found that the service was providing safe, effective, caring, responsive and well-led care in accordance with the relevant regulations. At that time the service was rated as ‘Good’ for all key questions and rated as ‘Good’ overall. The provider also operates another separately registered clinic in West London, which we inspected in November 2017.

You can read our findings from our last inspections by selecting the ‘all reports’ link for Japan Green Medical Centre on our website at https://www.cqc.org.uk/location/1-113093813/reports.

Our key findings were:

There were adequate systems for reviewing and investigating when things went wrong.

Leaders were knowledgeable about issues and priorities relating to the quality of the service.

The areas where the provider should make improvements are:

• Take action to ensure that all clinicians undertake Mental Capacity Act training in accordance with the provider’s Mandatory Training Policy and are aware of Gillick competence principles of consent for children.

• Take action to ensure non-clinical staff receive documented sepsis training. 

• Take action to ensure effective systems are in place for sharing learning from clinical audit with all relevant staff.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 14 May 2020

Safety systems and processes

We looked at systems to keep people safe and safeguarded from abuse.

The service had systems to safeguard children and vulnerable adults from abuse. Leaders told us that the nature of the patient group meant it was unusual for Japanese nationals who used the service to also register with an NHS GP.

• The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. 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.

• Staff had received up-to-date safeguarding and safety training appropriate to their role. Staff who acted as chaperones were trained for the role and had received a DBS check. 

• There was an effective system to manage infection prevention and control (including taking action to manage risks associated with a bacteria called Legionella which can proliferate in water systems).

• The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

Risks to patients

We looked at systems to assess, monitor and manage risks to patient safety.

Clinicians understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. However, on the day of the inspection, we were told that reception staff had not received sepsis awareness training. Following the inspection, the provider advised us that reception staff used a 'symptom prompt sheet' to direct their response to patient enquiries. The prompt sheet did not refer to sepsis and no documentary evidence confirming sepsis training for all relevant staff has been provided.

• There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.

• There were appropriate indemnity arrangements in place.

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We looked at how the provider monitored staffing changes and their impact on safety. We noted the service’s paediatric lead doctor had left the service in January 2020 and that the four doctors subsequently designated by Japan Green Medical Centre as specialists in treating ‘child chronic’ and ‘child acute’ patients had clinical backgrounds in cardiology, general surgery, allergy and dermatology.

Following our inspection, we were sent additional documents which confirmed that all four doctors had received paediatric training. We were further advised that the provider had begun the process of recruiting a new paediatric lead doctor.

Information to deliver safe care and treatment

We looked at whether staff had the information they needed to deliver safe care and treatment to patients.

• 

A written protocol for sharing information with patients’ doctors was in place.

• The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.

Safe and appropriate use of medicines

We looked at systems for the appropriate and safe handling of medicines.

• The systems and arrangements for managing medicines (including vaccines and emergency medicines) minimised risks. The service kept prescription stationery securely and monitored its use.

• Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

We looked at the service’s track record on safety.

• We saw that building risk assessments took place in relation to safety issues. 

• The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

• There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.

• There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety in the service. For example, a syringe leak during a vaccination had been logged as a safety incident and had resulted in the service reminding doctors of the correct pre vaccination syringe check procedure.

• The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.

When there were unexpected or unintended safety incidents:

• The service gave affected people reasonable support, truthful information and a verbal and written apology.

• They kept written records of verbal interactions as well as written correspondence.

• The service acted on and learned from external safety events as well as patient and medicine safety alerts. We saw evidence of an effective mechanism in place to disseminate alerts to all members of the team.

Effective

Good

Updated 14 May 2020

Effective needs assessment, care and treatment

We saw evidence that protocols were based on NICE guidance and current evidence based practice.

Monitoring care and treatment

The service was involved in quality improvement activity.

The service used clinical audit to drive positive outcomes for patients. For example, an August 2019 diabetic care audit highlighted that the service had achieved NICE targets for recording blood pressure, cholesterol and glucose for all eleven audited patients. The audit further highlighted that performance against NICE treatment targets for blood pressure (below 140/80), cholesterol (less than 193mg/dl) and blood glucose levels (less than 42mmol/mol) were respectively 5/11 patients (45%), 6/11 (55%) and 10/11 (91%). We saw that there was a process of clinical audit and governance structures to share the learning with relevant members of the clinical team. During the inspection a member of the clinical team was unclear on how learning from clinical audit was shared and embedded across the service and we have asked the provider to review their approach.

Effective staffing

Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and records indicated doctors were up to date with revalidation.

We noted the service’s paediatric lead doctor had left the service in January 2020 and that the four doctors subsequently designated by Japan Green Medical Centre as specialists in treating ‘child chronic’ and ‘child acute’ patients had clinical backgrounds in cardiology, general surgery, allergy and dermatology.  We received documentary confirmation that that these doctors had undergone paediatric training consistent with their designated roles. We were further advised that the provider had begun the process of recruiting a new paediatric lead doctor.

Coordinating patient care and information sharing

We looked at how staff worked with other organisations, to deliver effective care and treatment.

We noted the service’s ‘Standard Operating Procedure for doctors’ document described how information would be shared with other relevant clinicians and organisations.  

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

Where appropriate, staff gave people advice so they could self-care.

Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

We looked at systems in place to ensure that consent to care and treatment was obtained in line with legislation and guidance.

A clinician was unaware of criteria for assessing patients’ capacity (such as a presumption of capacity and acting in the best interests of patients). They also lacked awareness that children under the age of 16 can consent to their own treatment if they are believed to have sufficient competence and understanding to fully appreciate what is involved in their treatment (this is known as being ‘Gillick competent’).

Records showed that only four of the eight doctors had received Mental Capacity Act (MCA) training. However, we noted the service’s Mandatory Training Policy required that doctors undertake MCA training every two years.

Caring

Good

Updated 26 July 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • We received 54 patient Care Quality Commission comment cards. Patients complimented the care and treatment provided by the clinical and non-clinical staff.
  • On the day of inspection, we spoke with three patients who were happy with the care they had received.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • The clear majority of patients (99%), were Japanese and spoke Japanese as their first language. All notices and information were displayed in Japanese. Information on the website was also in Japanese but was easily translated into English.
  • When recruiting new staff, one of the requirements was an ability to speak fluent Japanese, in order to be able to communicate effectively with patients.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • The provider had privacy and consent policies which were available to all staff.
  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 26 July 2019

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care, for example, patients complained that literature in the waiting area was mostly in English. As a result, the information is now in Japanese.

Well-led

Good

Updated 14 May 2020

Leadership capacity and capability

We looked at leaders’ capacity to deliver high-quality, sustainable care.

• Leaders were knowledgeable about issues and priorities relating to the quality of the service. 

• The practice manager was visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

• The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

We looked at whether the service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

• There was a clear vision and set of values.

• The service developed its vision jointly with staff.

• Staff were aware of and understood the vision, values and strategy and their role in achieving them.

Culture

We looked at whether the service had a culture of high-quality sustainable care.

• Staff felt respected, supported and valued. They were proud to work for the service.

• The service focused on the needs of patients.

• Openness, honesty and transparency were demonstrated when responding to incidents and complaints; and when promptly acting on concerns raised by CQC. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

• Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

• All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.

• There was a strong emphasis on the safety and well-being of all staff.

• The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. 

• There were positive relationships between staff and teams.

Governance arrangements

Governance arrangements regarding training and learning from clinical audits did not always operate effectively.

For example, on the day of the inspection, we were told that reception staff had not received sepsis awareness training. Following the inspection, the provider advised us that reception staff used a 'symptom prompt sheet' to direct their response to patient enquiries. The prompt sheet did not refer to sepsis and no documentary evidence confirming sepsis training for all relevant staff has been provided.

• Also, some doctors had not undertaken mandatory Mental Capacity Act training within the last two years (as was required by the service's Mandatory training Policy). We consequently identified a lack of understanding regarding consent issues.

Managing risks, issues and performance

We looked at systems for managing risk, issues and performance.

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Leaders had oversight of safety alerts, incidents, and complaints.

• In addition, clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.

• The provider had plans in place for major incidents.

Appropriate and accurate information

We looked at how the service acted on appropriate and accurate information.

• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

• The service used performance information which was reported and monitored and management and staff were held to account.

• The service submitted data or notifications to external organisations as required.

• There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients and staff to support high-quality sustainable services.

• The service encouraged and heard views and concerns from patients. For example, an on line survey had recently been introduced and the service continued to provide a ‘suggestion box’ in reception.

• Staff could describe to us the systems in place to give feedback. For example, team meetings, supervision meetings and annual appraisal meetings.

• The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

• The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

• Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

• There were some systems to support improvement and innovation work. For example, recent clinical audits included diabetes care and an audit of radiation doses used in barium meal examinations.