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The Independent Pharmacy Good

Inspection Summary


Overall summary & rating

Good

Updated 8 August 2019

Letter from the Chief Inspector of General Practice

We rated this service as Good overall. (Previous inspection January 2018 – the service was not rated but was found to be providing care in accordance with the relevant regulations).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at The Independent Pharmacy on 20 June 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether The Independent Pharmacy was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to provide a rating for the service.

The Independent Pharmacy is an online service providing patients with prescriptions for medicines that they can obtain from the provider’s registered pharmacy (which we do not regulate). The service issues prescriptions for an average of 3500 items per month.

At this inspection we found:

  • The service had 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.

The areas where the provider should make improvements are:

  • Improve risks assessments so patients are referred to their own registered NHS GP following regular dermatological treatment.
  • Review the Clinical leadership so staff in this role are clear on their areas of responsibility and have up to date information.
  • Review information given to patients when prescribing medicines off label so they understand who is liable should anything go wrong. Medicines are given licences after trials which show they are safe and effective for treating a particular condition. Use for a different medical condition is called off label use and is a higher risk because less information is available about the benefits and potential risks
  • Identify ways to improve attendance at clinical meetings.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 8 August 2019

We rated safe as

Good

.

Keeping people safe and safeguarded from abuse

Staff employed at the headquarters had received training in safeguarding and whistleblowing and knew of signs of abuse. All staff had access to the safeguarding policies and where to report a safeguarding concern. For example, the service had a spreadsheet which included hyperlinks to the local authorities’ websites, named safeguarding individuals for the relevant local authorities and phone numbers dependant on where the patient resided. All clinicians and the directors of the service had completed safeguarding adult level three and level three child safeguarding training. All other staff had received level two safeguarding vulnerable adults and children training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification. The service also held annual refresher training for all staff where they reviewed their safeguarding policies and reference guides.

The service did not treat children. Where parents contacted the service for treatment for their child, the service informed them they could not prescribe for people under the age of 18 and advised them of other avenues of support including directing them to the NHS Choices website.

Monitoring health & safety and responding to risks

The supporting team carried out a variety of checks either daily or weekly. This included prescriptions that needed to be authorised, updates on guidelines and responding to patient queries. Any necessary actions were taken at the time and these were recorded and formed part of a clinical team weekly report, which was discussed at monthly clinical meetings.

The provider headquarters was located within an industrial estate and where administration staff worked from. Patients were not treated on the premises as clinicians 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.

The provider expected that all prescribers 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. Prescribers were required to complete a home working risk assessment to ensure their working environment was safe.

The service was not intended for use by patients with either long term conditions, other than those diagnosed with asthma, nor as an emergency service. The providers website detailed that the service was not to be used in emergencies and informed patients of what they should do in an

emergency situation.

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, improvements to the consent policy, learning from significant events and incidents and improvements to clinical pathways to align with national guidance.

Staffing and Recruitment

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

The provider had a selection and recruitment process 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/Doctor employees had to be currently working in the NHS and be registered with the General Medical Council (GMC). They had to provide evidence of having professional indemnity cover, an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act.

Newly recruited clinicians were supported during their induction period and an induction plan was in place to ensure all processes had been covered. We were told that clinicians did not start consulting with patients until they had read all the service’s policies and clinical guidelines.

We reviewed three recruitment files which showed the necessary documentation was available. The clinicians could not be registered to start any consultations until these checks and induction training had been completed. At the time of the inspection, they had recently recruited a prescribing pharmacist and we saw they were going through their induction period as set out by the provider’s policy. The provider kept records for all staff including the clinicians and there was an electronic system that flagged up when any documentation was due for renewal. For example, their professional registration and professional indemnity insurance.

We saw that the provider had had additional professional indemnity insurance which covered one of the pharmacist prescribers they employed. Other Medical and non-medical prescribers working for the service had their own professional indemnity cover.

Prescribing safety

All medicines prescribed to patients from online forms and following a consultation were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation, the clinician could issue a private prescription to patients which was checked again by a clinical pharmacist to ensure the prescription was appropriate and met the provider’s clinical guidelines. If approved, medicines were dispensed, packed and delivered by a third party, tracked and secure, courier service. The service had a system to assure themselves of the quality of the dispensing process and to ensure that the correct person received the correct medicine. The clinician could only prescribe from a set list of medicines which the provider had risk-assessed. There were no controlled drugs on this list. The service’s website advertised which medicines were available and there were systems to prevent the misuse of medicines. For example, measures to prevent over-ordering and duplicate accounts. All newly registered accounts were scrutinised and if similarities were identified, the accounts were amalgamated, and the patient notified. Where risks to patients were identified, the details were placed on a list to prevent the patient from re-ordering from the provider. Medicines supplied had to be signed for on delivery.

When emergency supplies of medicines were prescribed, there was a clear record of the rationale and decisions made and the service contacted the patient’s own registered GP to advise them of the prescription. Some predefined medicines were only available for prescribing if the patient had provided the details of their NHS GP. For example, patients had to provide the details of their own registered GP if they requested asthma inhalers. Additionally, the patient was asked to upload a photo of their current inhaler so that clinicians could confirm if the patient had been prescribed these before and to ensure the correct one was prescribed.

We saw evidence from a sample of records that letters were sent to the patient’s own registered GP, informing them of what had been prescribed and that the patient had confirmed that they had received regular reviews. Where the GP responded that a patient had not been reviewed, the service ensured the patient received no further prescriptions from their service. However, we noted that the service’s risk assessment did not highlight the circumstances or triggers where patients would need to be referred to their own GP when prescribing higher strength steroid topical creams if patients requested these on multiple occasions. Following our inspection, the service told us that this would be on their agenda for the next clinical meeting in July to discuss with all clinicians and make the necessary changes.

We were told by the provider’s clinical lead that some conditions were treated symptomatically as opposed to obtaining test results confirming a diagnosis. For example, treatment for urinary tract infections (UTIs) were treated without a urine sample test. We discussed this with the provider who told us that they had reviewed best practice guidelines in January 2019 and had amended their consultation forms to take account of those guidelines, which included adding four symptoms to the consultation and clinical guidelines. If patients indicated they had two or more of those symptoms, then it was highly likely to be a correct diagnosis of UTI. Additionally, an audit was undertaken to ensure prescribing was in line with current evidence-based guidelines. The initial audit which was conducted before the actions were implemented in line with best practice guidelines, identified that 42 out of 51 consultations were approved for treatment of UTIs. Ten of those 42 patients had indicated that they had two or less of those symptoms. A re-audit indicated that 45 out 59 consultation were approved for treatment of UTIs. Two out of those 45 patients indicated they had two or less of those symptoms.

Once the clinician 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 prescribed some unlicensed medicines, and medicines for unlicensed indications. For example, for the treatment of jet lag, altitude sickness and hair loss. (Medicines are given licences after trials have shown they are safe and effective for treating a condition. Use of a medicine for a different medical condition than is listed on their licence is called unlicensed use and is a higher risk because less information is available about the benefits and potential risks). There was clear information on the consultation form to explain that the medicines were being used outside of their licence, and the patient had to acknowledge that they understood this information. Additional written information to guide the patient when and how to use these medicines safely, was supplied with the medicine. However, this did not include all the necessary information and the provider told us they will be reviewing and updating all the information relating to unlicensed medicines to ensure it included all the necessary information.

Information to deliver safe care and treatment

There were protocols for identifying and verifying the patient and General Medical Council guidance, or similar, was followed. The system included a credit card check followed by a two-factor verification. Without these verification steps, patients could not access the service. If this failed, patients wishing to use the service were required to upload photographic proof of identification.

The prescribers had access to the patient’s previous records held by the service.

Management and learning from safety incidents and alerts

There were systems for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We reviewed seven 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, following reports from two patients on separate occasions that the medicines they had been prescribed and supplied had no effect, the service gathered additional information from the patients and these were reported to the manufacturer and the Medicines and Healthcare Regulatory Agency. The service risk assessed whether there was the need to quarantine those medicines and were able to provide rationale for their reason not to quarantine them following risk assessment. This was also communicated to all staff through monthly meetings so that they were aware, and should patients report similar cases, appropriate actions could be taken.

We saw evidence which demonstrated the provider 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.

We were shown records of appropriate actions taken in response to recent patient alerts.

Effective

Good

Updated 8 August 2019

Assessment and treatment

We reviewed 11 examples of medical records that demonstrated that each clinician 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 that there was no time limit on the online consultation and that clinicians time was variable depending on the consultation. If the clinician had not reached a satisfactory conclusion there was a system whereby they could contact the patient again.

Patients completed an online form which included their past medical history and for some conditions or medicines such as those for asthma, the details of the patient’s own registered GP had to be provided; including consent to share information with their own registered GP. There was a set template to complete for the consultation that included the reasons for the consultation and the outcome to be manually recorded, along with any notes about past medical history and diagnosis. We reviewed 11 medical records which were complete records. We saw that adequate notes had been recorded, and the clinicians had access to all previous notes.

The clinicians 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. Clinical guidelines which had been developed by the provider and included current evidence-based guidelines were accessible to all clinicians during the review of consultation forms. 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, each consultation and prescription that had been approved was routinely verified by the clinical pharmacist on duty to ensure that prescribing was in line with the provider’s clinical guidelines.

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 using audits, reviews of consultations and prescribing trends. For example, the provider had identified through an audit, that they needed to improve prescribing and the supply of asthma inhalers to ensure patient safety. Subsequently they introduced a photo upload facility where patients could upload a photo of their current inhaler, so the service could verify that the patient had ordered the correct one. The service undertook an audit before this intervention and identified that out of 26 patients who requested a prescription for an asthma inhaler, one patient was referred to their own registered GP due to either the wrong inhaler had been requested or they were not currently prescribed an inhaler. A re-audit following the introduction of the photo upload facility, identified that out of 31 asthma inhalers ordered, 25 patients provided a photo of their current inhaler and three patients were referred back to their own registered GP due to either the wrong inhaler being requested, or the patient not currently being prescribed this medicine. The audit demonstrated that the photo upload facility did not prevent patients from accessing the service and added another layer of verification to ensure patients were prescribed the correct inhaler.

Staff training

All staff completed induction training which consisted of health and safety, fire safety, safeguarding training and Mental Capacity Act training. Staff also completed other training on a regular basis including annual safeguarding updates. The service manager had a training matrix which identified when training was due.

The clinicians 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. Supporting material was also available. For example, a staff handbook, how the IT system worked and aims of the consultation process. Additionally, there was an e-mail update sent out to all staff when any organisational changes were made. The clinicians told us they received excellent support if there were any technical issues or clinical queries and that they could access policies easily. When updates were made to the IT systems, the clinicians received further online training.

Administration staff received regular performance reviews. All the clinicians had to have received their own appraisals before being considered eligible at the recruitment stage. The provider kept records of clinician’s external appraisals. Clinicians we spoke with confirmed they discussed the online work they undertake as part of their appraisal.

Coordinating patient care and information sharing

Before providing treatment, clinicians 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. For example, patients were directed to the NHS Choices website, so they could access the service most appropriate to their needs and nearer to their home address.

All patients were asked for consent to share details of their consultation and any medicines prescribed with their own 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 own registered GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their own registered GP in line with GMC guidance.

The service monitored the appropriateness of referrals/follow ups from test results to improve patient outcomes. For example, patients requesting testosterone supplements were sent a test kit for a blood sample. Once treatment had commenced, the provider followed up the patients and requested a further blood test within three weeks, six months, then annually to monitor the patient’s blood levels before making any further supplies. This ensured testosterone supplements were prescribed only when required.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support and had a range of information available on the website. For example, the provider had a section on their website for a range of health advice on topics such as smoking cessation, asthma and contraception. The provider told us that this page on their website had been improved so that patients could easily access it. We noted that some of this information was out of date. The provider was able to show evidence that the information had been reviewed, however an IT issue meant that the date had not been updated. They told us they would look into this and update the review date as soon as possible.

Where the provider could not assist a patient, they directed them to their own registered GP or the NHS Choices website for services that may be more appropriate for the patient.

Caring

Good

Updated 8 August 2019

Compassion, dignity and respect

We were told that the clinicians undertook online consultations in a private room and were not to be disturbed at any time during their working time. The provider carried out random spot checks to ensure the clinicians were complying with the expected service standards and communicating appropriately with patients. Feedback arising from these spot checks was relayed to the clinician. Any areas for concern were followed up and the clinician was again reviewed to monitor improvement.

We did not speak to patients directly on the day of the inspection. However, we reviewed the latest survey information. We were told that patients had the opportunity to rate the service on an online system called “Trustpilot” which is an open system provided by a third-party supplier. The service also carried out annual surveys to gather feedback from patients.

The Independent Pharmacy had been awarded a five out of five-star excellent rating on the Trustpilot website based on 8,440 reviews.

Results provided from the service on the latest survey undertaken in April 2019 showed that out of 1,782 responses, 72% rated the service as very high quality and 77% were extremely satisfied with the communications they have had with the service. Approximately 2% of patients who responded rated the service as low quality and less than 1 % were dissatisfied with the communication they had received. The provider had analysed the results and identified that most of the lower results were due to delivery issues and they were working with the delivery company to address these.

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 had access to information about the clinicians working for the service.

The latest survey information available from 1,782 responses indicated that 84% of patients who responded, said they received enough information about their treatment, before and after a purchase.

Responsive

Good

Updated 8 August 2019

Responding to and meeting patients’ needs

The service can be accessed through the provider’s website, where patients can place orders for medicines seven days a week. The service was available for patients in the UK only. Patients can access the service by phone or e-mail from 9am to 5pm, Monday to Friday. 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 registered GP or NHS 111.

Patients selected the treatment or medicines they required, filled in a consultation form and paid for the cost of the medicines and the consultation. The consultation form was then reviewed by a clinician, and once approved, a prescription was issued. Where the clinicians required further information before approving the consultation form, they would send a request to the provider to contact the patient to gain additional information. We were told that the clinicians did not communicate with the patient directly and any communication between the clinicians and the patients were fulfilled by the provider’s support team who had access to the patient’s details.

The digital application allowed people to contact the service from abroad, but all clinicians were required to be based within the United Kingdom. Any prescriptions issued were delivered within the UK to the patient’s address.

Staff also told us they identified that older patients had on occasions struggled with completing the online consultation forms and therefore, they developed a duplicate form accessible to the administration staff, so they can support patients to complete this if they experienced any difficulties.

We received six feedback through the CQC share your experience page, all of which were positive about the service patients had experienced. Patients commented that they received a quick response from the service, they were involved in decisions about their care and that they were treated with dignity and respect.

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

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 access a brief description of the GPs available.

Managing complaints

Information about how to make a complaint was available on the service’s web site. The provider 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 has 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 three complaints out of 51 received since December 2018. We found the provider had responded to these complaints in a timely manner and offered an apology to patients. We observed the provider had analysed trends and implemented actions to make improvements. For example, they had identified that most complaints related to delivery issues. As a result of this, the service were incorporating parts of the external delivery service into their delivery policy and added information into their website. This supported a more coordinated and improved approach to the delivery service and also provided patients with clearer understanding of delivery timescales.

The provider 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. For example, 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 with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The website had a set of terms and conditions and details on how the patient could contact them with any enquiries. Information about the cost of the consultation was known in advance and paid for before the consultation appointment commenced. The costs of any resulting prescription were handled by the administration team at the headquarters following the consultation.

All staff 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. 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

Good

Updated 8 August 2019

We rated well-led as

Good

Business Strategy and Governance arrangements

The provider told us they had a clear vision to work together to provide a high-quality responsive service that put caring and patient safety at its heart. We reviewed business plans that covered the next year. This included plans to re-design the service’s website so there will be improved functionality and accessibility following patient feedback.

There was a clear organisational structure and staff were aware of their own roles and responsibilities except for staff in clinical lead roles who did not indicate that they had full knowledge and awareness of the provider’s policies and operations. There was a range of service specific policies which were available to all staff. These were reviewed annually and updated when necessary.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included random spot checks for consultations. The information from these checks was used to produce a clinical monthly team report that was discussed at weekly team meetings. This ensured a comprehensive understanding of the performance of the service was maintained.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. For example, the service had installed additional internet lines and a mobile dongle, so the service could continue operating should there be issues with access to the internet from one of the broadband internet providers.

Care and treatment records were complete, accurate, and securely kept.

Leadership, values and culture

The Directors had responsibility for any medical issues arising and attended the service daily. There were systems to address any absence of clinicians.

However, the Clinical lead for the service indicated that they were not aware of some of the key information in relation to the organisation’s operations. For example, they were not aware of the provider’s policy on mandatory sharing of information to patients’ own registered GP. Pharmacist prescribers were employed by the service however, we were told by the clinical lead that there was not an effective system for the independent prescribers to liaise with the clinical lead. The clinical lead also told us that there were plans for a group messaging service to be set up so there was a more effective way to communicate.

The provider had plans to change the structures of meetings and enabling prescribers to work on site as opposed to remotely. We saw that one of the prescribers attended meetings with the directors and another prescriber was already working on site.

The values of the service were to provide a safe and effective online healthcare service which was readily accessible and efficient for patients and to exceed individual expectations.

The service had an open and transparent culture. We were told that if there were unexpected or unintended safety incidents, the service would give affected patients reasonable support, truthful information and a verbal and written apology. This was supported by an operational policy.

Safety and Security of Patient Information

There were systems to ensure that all patient information was stored and kept confidential.

There were policies and IT systems to protect the storage and use of all patient information. The service could provide a clear audit trail of who had access to records and from where and when. The service was registered with the Information Commissioner’s Office. There were business contingency plans to minimise the risk of losing patient data.

Seeking and acting on feedback from patients and staff

Patients could rate the service they received. This was constantly monitored and if it fell below the provider’s standards, this would trigger a review of the consultation to address any shortfalls. In addition, patients were emailed at the end of each consultation with a link to a survey they could complete or could also post any comments or suggestions online. Additionally, the service carried out annual surveys and analysed the results for feedback. Patients were asked a number of questions including if they were satisfied with the speed with which their medication request was dealt with and if the treatment they received was effective at treating their medical condition. The number of patients who responded was 1,782 of whom, 98% and 87% responded positively to those questions respectively.

There was evidence that clinicians could provide feedback about the quality of the operating system and any change requests were logged, discussed and decisions made for the improvements to be implemented.

Staff told us that the management team were approachable and responsive. They told us they were proud to work for the service.

The provider had a whistleblowing policy in place. (A whistle blower is someone who can raise concerns about practice or staff within the organisation.) The Directors were the named person for dealing with any issues raised under whistleblowing. Additionally, the service had arrangements for staff to raise concerns to another named person external to the organisation.

All staff had received an appraisal in the last 12 months. They told us that the appraisal process was supportive and that they could identify opportunities for training and learning.

Continuous Improvement

The service consistently sought ways to improve. All staff were involved in discussions about how to run and develop the service and were encouraged to identify opportunities to improve the service delivered. For example, staff told us they raised concerns about the volume of work they were undertaking as a result of an increase in service demand, that the provider had purchased an automatic labelling machine to assist with their work and had recruited additional staff.

One member of the staff had recently been promoted as team leader and told us they were put forward for an accredited dispensing course and once they had completed this, they would be completing a management course.

We saw from minutes of staff meetings where previous interactions and consultations were discussed. However, we noted that some members of the clinical team did not always attend those meetings. Minutes of meetings were shared with all staff via e-mail. The provider told us that they were aware that not all clinical staff attended the meetings and had started requesting regular face to face meetings with some clinicians, so they could be updated on discussions held. They were working on how they could develop their meetings to include video conferencing, which were due to be implemented from the 24 June 2019 and to monitor the feedback from the new style of meetings.

Staff told us that the team meetings were the place where they could raise concerns and discuss areas of improvement. However, as the management team and the rest of the team worked together at the headquarters there was ongoing discussions at all times about service provision.

There was a quality improvement strategy and plan to monitor quality and to make improvements. For example, through clinical audit. We saw that the service had undertaken an audit of dual prescribing of antibiotics for acne. This related to prescribing of oral antibiotics and topical treatment. There was evidence that the service had reviewed best practice guidelines and implemented actions to ensure prescribing was in line with these guidelines. The first audit in April 2019 identified that five out of 14 patients were prescribed dual antibiotic for the treatment of acne. Following updated clinical guidelines, a re-audit in May 2019 showed that out of eight patients who requested topical and oral antibiotics, none were prescribed both treatments. This demonstrated that the service reviewed best practice guidelines and aligned their prescribing with these guidelines accordingly.