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Inspection Summary


Overall summary & rating

Good

Updated 21 October 2019

This service is rated as Good overall.

The service was previously inspected in September 2011 and January 2013 and found to be meeting the standards in place at the time. At an inspection in April 2018, inspectors found the provider had breached Regulation 12 (1) Safe Care and treatment because arrangements for premises hard wiring safety and fire safety were either not in place or not sufficiently effective, medicines and vaccines were not well managed and a number of blood sample bottles were out of date. A requirement notice was served in respect of this breach of regulation. The service was re-inspected in October 2018 to confirm the provider had taken actions to address the breach of regulations and had met the legal requirements.

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 Doctor Today on 14 August 2019 as part of our ratings inspection programme for independent health services.

Doctor Today is an independent health service based in the Finchley Road and Frognal area of North West London that provides patient consultations, treatment and referrals for adults and children. Dr Marissa Vassilliou is the registered manager and a partner doctor in the business. 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.

The provider supplies private general practitioner services predominantly to private fee-paying patients. The provider also provides services to staff employed by corporate clients.

We received 6 CQC comments cards. All comment cards were positive with patients referring to the high standard of care provided by knowledgeable and supportive staff.

Our key findings were:

  • The provider had systems in place to keep people safe and to review, act and learn from significant events. We reviewed examples where the provider had made contact with the patient’s NHS GP to pass on information that was clinically necessary with the patient’s consent. We were told that, when necessary to ensure patient safety, the service would contact the patients NHS GP without consent.
  • There were processes in place to effectively handle emergencies and risks were managed appropriately. Recruitment checks had been completed for the staff whose files we reviewed.
  • Systems were in place for the safe management of medicines and we saw the provider had processes in place to review prescribing.
  • Staff at the service assessed patients in accordance with best practice and current guidelines and had systems in place to monitor and improve the quality of care provided to patients.
  • There was evidence of effective joint working and sufficient staffing to meet the needs of their patient population.
  • Feedback indicated patients were treated with dignity and care and the service had systems to support patients to be involved with decisions about their care and treatment.

  • The service met the needs of their targeted patient demographic and there were systems in place for acting on feedback and complaints.
  • The service had adequate leadership and governance in place.
  • There was clear strategy and vision which was tailored to patient need and staff and patients were able to engage and feedback to the service provider.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 21 October 2019

We rated the service as good for providing safe services because:

  • The provider had clearly defined and embedded systems, processes and practices to minimise risks to patient safety.
  • Staff demonstrated they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
  • The provider had adequate arrangements to respond to emergencies and major incidents.

Safety systems and processes

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

  • The provider conducted safety risk assessments to ensure the premises was safe for patients and staff. In addition to annual formal written risk assessments, the lead doctor carried out dynamic risk assessments on an ongoing basis and would document these whenever actions arose. It had safety policies, including Control of Substances Hazardous to Health and Health & Safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the provider and safety information was also part of the induction programme for new employees although the provider had not hired any new staff since the previous inspection. The provider had systems to safeguard children and vulnerable adults from abuse. Policies were accessible to all staff. They outlined clearly who to go to for further guidance. We found all policies had been reviewed within the previous twelve months.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • 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.
  • 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 and had received a DBS check.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • There was an effective system to manage infection prevention and control, including a protocol to assess and mitigate the risks associated with legionella. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • 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 was an effective induction system for temporary 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. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need. Systems were in place to manage people who experienced long waits.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse. We found staff were able to describe how to access emergency care locally and were able to give accurate instructions about how to find these providers.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.

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.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.
  • The clinic 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.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including medical gases, emergency medicines and equipment and vaccines, minimised risks. Arrangements were also in place to ensure medicines and medical gas cylinders carried in vehicles were stored appropriately. The service did not use pre-printed prescription stationary.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing. We noted the service’s Medicines Policy included a protocol for three-monthly monitoring of a randomised selection of consultation notes where medicines had been prescribed. This was carried out by the clinical director.
  • Staff prescribed, administered or dispensed medicines to patients, including anti-malarial treatment and antibiotics for treatment of infections. Patients were given appropriate information verbally and through patient information leaflets, in line with legal requirements and current national guidance. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • The service dispensed medicines to patients, including anti-malarial treatment and antibiotics for treatment of infections and provided patients with appropriate information verbally and through patient information leaflets.

  • The service had audited antimicrobial prescribing and there was evidence of actions taken to support good antimicrobial stewardship. For instance, as a result of a recently investigated significant event, the provider had ensured information about antibiotic resistance was prominently displayed in the waiting area. The significant event had been recorded when a patient who had been diagnosed with a viral condition, complained about not being prescribed antibiotics.
  • Processes were in place for checking medicines and staff kept accurate records of medicines. We saw records showing staff recorded details of medicine deliveries, batch numbers, medicine usage and had a process in place to reconcile calculated stock levels against physical stock counts.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • Arrangements for dispensing medicines kept patients safe.
  • Palliative care patients were able to receive prompt access to pain relief and other medication required to control their symptoms.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments 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.
  • The service had a Safety Alert Protocol in place to govern how safety alerts were received and actioned, including steps to create an action plan if the service or its patients were affected by an alert.

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 and incidents. 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, when the service had encountered a computer virus it had undertaken a full review of IT security. Although no records had been accessed or compromised during the incident, the service had involved all staff in the review and had identified learning points to mitigate against the risk of further incidents.
  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional staff.

Effective

Good

Updated 21 October 2019

We rated the service as good for providing effective services because:

  • The provider had systems to keep clinicians up to date with current evidence-based practice.
  • The service had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

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 supported by clear clinical pathways and protocols.

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • Arrangements were in place to deal with repeat patients. For instance, there was a system in place to identify frequent callers and patients with particular needs, including palliative care patients. We saw no evidence of discrimination when making care and treatment decisions.
  • When staff were not able to make a direct appointment on behalf of the patient clear referral processes were in place and a clear explanation was given to the patient or person calling on their behalf.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had a programme of quality improvement activity and routinely received the effectiveness and appropriateness of the care provided.

  • The service took part in quality improvement activity. For example, it had carried out a two-cycle audit of prescribing for urinary tract infections and a single-cycle audit of clinical note-taking. It had also carried out a review of consultations with patients presenting with self-limiting conditions to identify whether advice had been given about self-care and the risks of overusing antibiotics. During this review, the provider had looked at 28 sets of consultation notes and found that although in 96% of notes there was evidence clinicians had given advice about self-care, only in 7% of notes was there evidence the risks associated with overuse of antibiotics had been discussed with patients. The provider had identified this as an area where improvement could be made. We were told clinicians had been reminded to discuss this during consultations and to ensure this past of the consultation was documented in the notes. We also noted the provider had placed information posters about antibiotic usage in reception and the waiting area. The provider told us it had a plan to carry out a second cycle of this audit in January 2020.

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. This covered such topics as safeguarding, confidentiality and infection prevention and control.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • 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.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation.

Coordinating care and treatment

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

  • Patients received coordinated and person-centred care. Patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP. Staff communicated promptly with patient's registered GP’s so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • There were clear and effective arrangements for booking appointments and for referring people to other services. The provider had a process in place to follow-up on referrals made to ensure the patient engaged with the referral.

Helping 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.

  • The service supported patients to live healthier lives by providing same day doctor access for patients including those unable to take time off to attend their local GP or obtain a same day appointment.
  • The service was also available for patients who worked in London but did not have an NHS GP, preferred to access a private doctor or who were visiting from abroad, particularly tourists. These patients were able to access a doctor, receive a diagnosis and medication where required in a single appointment with results being sent to the patient by their preferred method.
  • If the provider was unable to provide a service to a patient, they would refer them to other services either within the private sector or NHS. We also found a selection of health promotion information in the reception area.

Consent to care and treatment

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

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

Caring

Good

Updated 21 October 2019

We rated the service as good for caring because:

  • Feedback from people who used the service was positive about the way staff treated people.
  • People’s privacy and confidentiality was respected at all times.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • GPs undertook consultation assessments in private rooms and were not to be disturbed at any time during their working time. Induction training covered the service’s confidentiality agreement and for example the need to ensure that computer screens were not in view.
  • All of the six patient Care Quality Commission comment cards we received were positive about the service experienced.

Involvement in decisions about care and treatment

Patient’s feedback indicated that staff listened to patients concerns and involved them in decisions made about their care and treatment. However, the service did not have a hearing loop for deaf or hard of hearing patients; staff told us they would communicate with these patients in writing.

  • The provider told us how they would arrange interpretation services if a patient specifically requested this although we were also told that people using the service were generally aware English was the spoken language at the service and chose to use the service on that basis.
  • 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.
  • Staff communicated with people in a way that they could understand, for example, the provider was able to show us online resources they would use to aid communication when necessary, including easy read materials and video clips.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff respected confidentiality at all times.
  • 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 appropriately.

Responsive

Good

Updated 21 October 2019

We rated the service as good for providing responsive services because:

  • The importance of flexibility and choice was reflected in the service.
  • It was easy for people to raise a concern and they were treated compassionately when they did so.
  • People could access the right care at the right time.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider’s website had a set of terms and conditions and details of how patients could contact them with any enquiries. Information about the cost of the consultation and treatment was available on the website and was prominently displayed in the reception area.
  • The provider made it clear to patients on their website what services were offered and the limitations of the service. For example childhood and travel immunisations were provided including Yellow Fever and the service was registered with the NaTHNaC (The National Health and Travel Network Centre).
  • The service was set up to provide GP services at convenient location for patients, it was close to London Finchley Road Underground and Finchley Road & Frognal Overground stations and served by multiple bus routes.
  • The service offered consultations to anyone who requested and paid the appropriate fee, and did not discriminate against any client group. The facilities and premises were appropriate for the services delivered.
  • The provider subscribed to a consumer review website and had received 258 reviews over the previous three years. Of these, 254 were positive reviews where the service was rated as Excellent. The service had an overall rating of 4.8 stars out of five.

Timely access to the service

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

  • The service was open Monday 9:30am to 7pm, Tuesday 9am to 7pm, Wednesday to Friday 9am to 6pm, and Saturday 9.30m to 1.30pm.
  • The appointment system was easy to use and patients could book appointments online, over the telephone or face to face.
  • The service accepts walk-in patients if appointments are available. Telephone consultations are available if requested by patients and where appropriate.
  • Waiting times, delays and cancellations were minimal and managed appropriately.

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 and it was easy to do. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The service had not received any complaints in the last year although we noted it had identified one of 258 reviews left on a consumer review website as negative and had investigated this as though it were a formal complaint. The provider had responded to the reviewer’s comments respectfully and had invited the person to make contact to discuss any concerns confidentially.

Well-led

Good

Updated 21 October 2019

We rated the service as good for leadership because:

  • The leadership, governance and culture promoted the delivery of high-quality person-centred care.
  • There was an effective governance framework, which focused on delivering good quality care.
  • Internal audit processes functioned well and had a positive impact in relation to quality governance, with clear evidence of action to resolve concerns

Leadership capacity and capability

The service was led by the two founding Doctors and overseen and supported by the medical director who was also a consultant in NHS Accident and Emergency services. Leaders had the capacity and skills to deliver high quality, sustainable care. They had identified clear priorities for maintaining the reputation, quality and future of the service. They understood the challenges facing the sector and had developed a strategy to address these. We were told by staff and patients that the service leads were visible and approachable

Vision and strategy

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 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 provider ensured that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values.

Culture

There was a positive and professional working culture at the service. Staff stated they felt respected, supported and valued. They told us they were able to raise any concerns and were encouraged to do so and had confidence that these would be addressed. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour with patients.

  • Staff told us they were proud to work for the service.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There was a strong emphasis on the safety and well-being of all staff.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.

The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.

The providers had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • 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 information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service used information technology systems to monitor and improve the quality of care.
  • 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 took on board the views of patients and staff and used feedback to improve the quality of services. For example, the service gathered feedback from patients via trust pilot, google and paper surveys and results showed patients said the location could be difficult to find using satellite navigation. As a result, the provider improved the clarity of location signposting on its website which we checked and found contained clear satellite, photographic and written location instructions on the front page of its website. The service had also tried to rectify this issue in conjunction with search engine and online navigation providers but had experienced a limited response. The most recent survey results continued to show patients had difficulty finding the service and staff told us they would be reviewing the website again to see how it could further improve.

Continuous improvement and innovation

There was a focus on continuous learning and improvement at all levels within the service, such as immediate response to our inspection feedback, through completed clinical audits, and in response to patient and staff feedback.