You are here

Inspection Summary


Overall summary & rating

Updated 13 December 2018

We carried out an announced comprehensive inspection on 4 October 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was not providing safe care in accordance with the relevant regulations

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations

We carried out this inspection 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 service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Medical Express Clinic provides an independent doctors consultation service from a single clinic in the Harley Street area of West London. Patients can book appointments or attend on a walk-in basis. The service provides onward referral to diagnostic and specialist services as appropriate. The service treats both children and adults. It typically treats between 200 and 500 patients per month.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Medical Express Clinic, some services are provided to patients under arrangements made by their employer. These types of arrangements are exempt by law from CQC regulation and we did not include these within the scope of our inspection.

One of the GPs at the clinic is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received 31 completed comment cards completed by patients in the days leading up to the inspection. These were wholly positive and described the service as accessible, the quality of care as excellent, and the staff as kind, patient and professional.

The service is registered to provide the regulated activities of: diagnostic and screening services; treatment for disease, disorder or injury and, surgical procedures.

Our key findings were:

  • There was a vision to provide a competitive, personalised service with a strong focus on preventive care. However quality improvement activity was more limited.

  • The clinicians were aware of current evidence-based guidance and had the skills and knowledge to deliver effective care and treatment.

  • Patients were able to access the service in a timely way. Staff were caring.

  • The provider had some systems in place to protect people from avoidable harm and abuse. It had not appropriately assessed all risks however.

  • The provider had systems in place to record, monitor, analyse and share learning from significant events. Systems to act and learn from safety alerts were under-developed.

  • The service had arrangements in place to respond to medical emergencies.

We identified regulations that were not being met and the provider must:

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

You can see full details of the regulation not being met at the end of this report.

There were areas where the provider could make improvements and

should

:

  • Review its quality improvement activity, in particular the scope to increase its use of clinical audit to drive improvement.
  • Review the systems in place for supporting patients whose first language is not English.
  • Review the systems in place to obtain useful feedback from patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Updated 13 December 2018

We found that this service was not providing safe care in accordance with the relevant regulations.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted various safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the service as part of their induction and refresher training.
  • The service had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff, locums. They outlined clearly who to go to for further guidance.
  • The service had not experienced any incidents or concerns about abuse but staff were familiar with the local safeguarding arrangements and agencies. Staff knew how to escalate any concerns to protect patients from neglect and abuse.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. These processes also covered the sessional doctors who were contracted to the service rather than directly employed. The provider’s policy was to obtain Disclosure and Barring Service (DBS) checks for all staff members. (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).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role. It was the clinic’s policy to have a chaperone present for every physical examination. Information about the use of chaperones was displayed in reception and the consultation rooms, including the room used by the gynaecologist.
  • We were told that staff asked adults attending the service with children about the nature of their relationship with the child, that is, whether they had parental authority. The clinic did not formally record this information or ask for documentary evidence.
  • There was an effective system to manage infection prevention and control.

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

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for agency and sessional staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities including arrangements covering the health care assistants.
  • However, we identified some gaps in the clinic’s risk assessments. Access to the clinic and some unrelated services (for example a dental surgery located in the basement of the building) was via a shared entrance. While there was a CCTV system in the reception area, the clinic had not carried out a comprehensive risk assessment to ensure the environment was sufficiently secure.
  • The clinic had recently introduced a new option allowing patients to sign up to email communication including diagnostic test results. These email communications were not encrypted. This process had not been risk assessed in relation to the security of patient information.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with DHSC guidance
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines. However, we were concerned that the clinic was occasionally prescribing for substance misuse when its doctors did not have specialist training in this area.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular audits of its controlled drugs prescribing.
  • 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.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.
  • The clinic did not initiate substance misuse services. However, the clinic was on occasion prescribing an opioid replacement to at least one patient on an ongoing basis with regular reviews. The doctors did not have additional training on substance misuse.
  • The doctors occasionally prescribed higher risk medicines that required regular blood testing. We saw evidence that the clinic was checking that this monitoring was taking place and had recorded the results.
  • The clinic was no longer carrying out any remote or telephone prescribing. Two of the doctors had related restrictions on their current GMC registration.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to most safety issues although we identified some gaps.
  • 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.
  • 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.
  • The service did not have a clear system to act on and learn from patient and medicine safety alerts. The service had a mechanism in place to disseminate alerts to all members of the team including sessional doctors but did not have a system for recording and checking that appropriate action had been taken.

Effective

Updated 13 December 2018

We found that this service was providing effective care in accordance with the relevant regulations. However, the arrangements for recording written consent from patients required improvement. The clinic had carried out limited clinical audit to monitor the quality of care and patient outcomes.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.

  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. For example, patients were able to book to see the same clinician over time and the service kept comprehensive records of each consultation which were updated at each visit.
  • A small group of patients attended the clinic for treatment for long-term conditions such as diabetes. We saw that these patients had regular reviews documented in their records in line with current guidelines.
  • The clinic encouraged patients to share important information about their health with their NHS GP, if they had one, for example, following positive screening results.

Monitoring care and treatment

The service carried out some quality improvement activity.

  • The service used information about care and treatment to make improvements, for example the doctors carried out periodic peer review of clinical notes and reviewed the results. The notes we reviewed were clear and comprehensive. The service did not have a programme of clinical audit or completed audit cycles.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff and an induction checklist when sessional doctors started at the practice.
  • Relevant professionals were registered with the General Medical Council (GMC) and were either up to date with or pending revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Doctors whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together and with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care.
  • 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.
  • Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services insofar as possible. For example, the clinic had occasionally seen overseas patients with learning disabilities. The clinic did not have access to these patients’ records or other paperwork but could contact their usual doctors directly.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. The practice relied on paper records but had systems in place to retrieve, update and file these securely following a consultation. There were clear arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

The was a strong focus on preventive health and screening at the practice. Staff were consistent and proactive supporting patients to understand their own health and respond to raised risks.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. The clinic provided pre-screening counselling for certain tests, for example HIV+.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent. 

Caring

Updated 13 December 2018

We found that this service was providing caring services in accordance with the relevant regulations. However, the clinic staff were unclear about whether and how they could organise interpreter services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treated people. Patients described the service as excellent and the staff as professional and caring. Patients consistently described the doctors as attentive and non-judgemental. Some patients mentioned this was particularly important in relation to sexual health services.
  • The clinic was attended by both UK and international patients, for example, visiting London on holiday. Staff told us they considered patients’ personal, cultural, social and religious needs.
  • The service provided patients with timely information.

Involvement in decisions about care and treatment

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

  • We were told that most patients were able to communicate well in English but where this was not the case, they tended to prefer to bring a family member or friend who could translate. The staff were unclear about how to arrange an interpreter for patients if this was requested.
  • 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.

  • 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

Updated 13 December 2018

We found that this service was providing responsive care in accordance with the relevant regulations

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, for example engaging with a range of specialist sessional clinicians including a psychiatrist.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, the clinicians could see patients with mobility difficulties on the ground floor and could switch offices to facilitate this.

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. The walk-in facility and long opening hours were popular with working adults.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that the appointment and walk-in systems were easy to use.
  • Referrals and transfers to other services were undertaken in a timely way, for example, same day diagnostic testing was an integral part of health screening packages.

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.
  • 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 and complaints. It acted as a result to improve the quality of care. For example, patients referred to the clinic for blood tests were not always aware that there would be an additional charge. The manager was liaising with referrers to provide clearer information to patients so they knew what to expect.

Well-led

Updated 13 December 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

Leadership capacity and capability

The clinic had a stable leadership and staff team. Leaders were visible and approachable.

  • Leaders were clear about issues and priorities relating to the quality and future of services. They understood the challenges to the business.
  • The provider had processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a vision and a strategy to deliver high quality care.

  • There was a clear vision. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against its business and service goals and objectives.

Culture

The service had a positive working culture with an ethos to provide accessible, high quality care, advice and information that met patients’ needs.

  • The staff described a positive, open working culture at the service. Staff said they were supported and valued. They told us they were able to raise any concerns and were encouraged to do so.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • There were processes for providing staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year.
  • The service promoted equality and diversity. Staff had received equality and diversity training.

Governance arrangements

There were clear organisational structures to support good governance. 

  • The leadership and clinical teams met regularly. 
  • Service policies and procedures were documented and accessible.
  • The clinic provided staff training to underpin its policies and processes.
  • The clinic held regular staff meetings.

Managing risks, issues and performance

The clinic had a range of policies and processes to manage risks, however we identified a number of gaps.

  • There was an effective, process to identify, understand, monitor and address most current and future risks including risks to patient safety. However we identified a number of gaps, for example, in consideration of security arrangements at the shared entrance to the service.
  • The service had some processes to manage current and future performance. Performance of clinical staff was assessed through periodic peer reviews of their consultations, prescribing and referral decisions. There was no internal appraisal process for the doctors.
  • Leaders reviewed incidents, and complaints and had taken action to improve as a result.
  • There was limited use of clinical audit to drive improvement. However, there was evidence of some action to review and improve quality, for example through clinical team meetings and peer review.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Information was used to review performance.
  • Quality and sustainability were discussed in relevant meetings.
  • The service used limited information to assess patient outcomes. Where issues were identified, there were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • The service used paper records to manage clinical information. There were effective arrangements to protect the security of these records and to reduce the risk of breaches of confidentiality.
  • The clinic had systems in place to facilitate patient requests to see their own medical records.
  • The reliance on paper records however created challenges in facilitating clinical audit and other types of record searches (for example, in response to patient safety alerts).

Engagement with patients, the public, staff and external partners

The clinic used feedback from patients, staff members and external partners to improve the range and quality of services.

  • The clinic had limited mechanisms to obtain feedback about its services. It put out feedback forms for patients to complete and reviewed online feedback provided about the service. Few patients completed these forms however and the clinic had not carried out more systematic patient surveys or feedback exercises.
  • Staff were able to describe to us the systems in place to give feedback, for example informal discussion and staff meetings. The clinic had made improvements, for example to the waiting room area, following suggestions from staff members.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement in order to offer patients a competitive and personalised service.
  • The service made use of internal reviews of incidents and complaints, for example it had reviewed its moving and handling procedures following a fall by a staff member. Learning was shared and used to make improvements.
  • The practice carried out clinical peer review but there was scope to develop a more comprehensive programme of clinical quality improvement including clinical audit.
  • The clinic had introduced an email service for communicating test results which was proving population with patients. However, the clinic had not fully assessed the risks of this innovation to ensure that patient information was appropriately secure.