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Archived: Online Clinic (UK) Limited - Taybridge Road

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Reports


Inspection carried out on 12 March 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

Our first inspection of Online Clinic (UK) Limited took place on 21 March 2017 and identified the service was not providing safe, effective or well-led services in accordance with the relevant regulations. We carried out a follow up inspection on 6 June 2017 and found the provider had made substantial improvements.

The full comprehensive report on the 21 March 2017 inspection and the report for the focused inspection of 6 June 2017 can be found by selecting the ‘all reports’ link for Online Clinic (UK) Limited on our website at www.cqc.org.uk.

We carried out this announced comprehensive inspection at Online Clinic (UK) Limited on 12 March 2018 to ensure the necessary improvements had been embedded.

Online Clinic (UK) Limited was registered with the Care Quality Commission on 1 October 2010. The service offers online consultations to patients, through online forms and a messaging system conducted within the patients online record, for a condition selected by the patient themselves. A doctor will then review the request, may ask for further information and then, if appropriate, provide a private prescription to be dispensed by a third party pharmacy, which we do not regulate. The services are delivered by the provider via two websites; www.theonlineclinic.co.uk and www.privatedoctordirect.com.

Findings from our inspection on 12 March 2018 in relation to the key questions were as follows:

Are services safe? – we found the service was providing a safe service in accordance with the relevant regulations. Specifically:

  • The provider had ensured all staff had an understanding of safeguarding relevant to their role and arrangements were in place to safeguard people, including arrangements to check patient identity.
  • Prescribing was externally monitored by a locum pharmacist and audited regularly to ensure it was in line with national guidance, and people were told about the risks associated with any medicines used outside of their licence.
  • The provider had set a low threshold in recording and investigating significant events to ensure all possible improvements would be identified and these were implemented with a structured, team approach and outcomes monitored.

Are services effective? - we found the service was providing an effective service in accordance with the relevant regulations. Specifically:

  • The provider recognised that GP contact was the cornerstone of safety when patients choose to opt out of the NHS system for care and had taken several steps to improve the number of patients who consented to information sharing with their registered GP.
  • An audit showed an increase from 1% to 28% of patients completing their registered GP section on the form over the same period the previous year.
  • Additional resources, including allocating a lead member of staff, had been invested in auditing the quality of the service. There was a schedule of regular audits planned throughout the year and the service was working with an external pharmacist to ensure the outcomes were impartial and followed best practice guidelines.
  • There was comprehensive oversight of staff training and quarterly GP meetings had external speakers scheduled to allow for topical updates to the online environment.

Are services caring? – we found the service was providing a caring service in accordance with the relevant regulations. Specifically:

  • Although consultations occurred remotely through a messaging system, the GPs were encouraged to interact with the patients to ensure their involvement and understanding of the treatment options.
  • Follow up of patients after a prescription was issued, on different timeframes depending on patients presenting condition, was given to allow for ongoing support from the provider.
  • Patient feedback reflected they found the service treated them with dignity and respect.
  • There was a GP profile for each GP so patients had access to information about GPs working at the service.

Are services responsive? - we found the service was providing a responsive service in accordance with the relevant regulations. Specifically:

  • Information about how to access the service was clear and the service was available seven days a week.
  • The provider did not discriminate against any client group and would provide assistance to access the service if safe to do so.
  • Guidance for patients to complain about the service was clear, and the provider supported patients through the process. Complaints were handled appropriately with an open and honest approach.

Are services well-led? - we found the service was providing a well-led service in accordance with the relevant regulations. Specifically:

  • There was a clear leadership and governance structure. The registered manager and clinical lead worked closely with the IT lead and practice manager to ensure staff were supported, and patients received appropriate care.
  • There was a range of information which was used to monitor and improve the quality and performance of the service.
  • Systems were in place to ensure that all patient information was stored safely and kept confidential.

We saw an area of notable practice:

  • GPs we spoke to praised the development of a prescribing matrix which listed the limited formulary the provider used, the maximum allowed doses, against the presenting conditions to allow easy reference and a consistent and safe approach to all patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 6 June 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection undertaken on 6 June 2017. Previous inspections included an announced comprehensive inspection at Online Clinic (UK) Limited on 21 March 2017, and a further inspection on 21 April 2017.

Following our March 2017 inspection, we found the service was not providing safe, effective or well-led services in accordance with the relevant regulations. However, we found they were providing caring and responsive services in accordance with the relevant regulations. As a result, we took urgent action and suspended the provider’s registration, which took effect from 22 March 2017.

This suspension remained in force following a focused inspection on 21 April, when we found there had not been adequate improvements.

The full comprehensive report on the March 2017 inspection and the report for the focused inspection of 21 April can be found by selecting the ‘all reports’ link for Online Clinic (UK) Limited on our website at www.cqc.org.uk.

Our key findings across the areas we inspected were as follows:

  • The provider had developed guidance for all conditions they treated and these referenced relevant national guidance
  • The registered manager and clinical lead had reviewed policies and systems in place, updated them to ensure they were relevant, and reflected what happened in practice
  • We saw evidence to show there was effective oversight of staff recruitment and training, with all staff having completed the provider’s mandatory training.
  • There were systems in place to reduce the likelihood of unsafe treatment. The provider had ceased to offer treatment for some conditions, as the provider now deemed them unsafe for the online environment.
  • There was a new clinical lead in post. They worked six sessions per week for the provider in this role. We saw evidence of a close working relationship between the registered manager and clinical lead and numerous positive changes had been made to the service since our last inspection, due to clinical leadership.
  • The computer system had been reviewed and changes made to the dashboard view the clinicians and clinical lead had, to improve the way information was displayed, and aid decision making and audits.
  • The use of contemporaneous notes in the patient record was being encouraged and audited by the clinical lead.
  • An availability schedule had been implemented for GPs to ensure cover was provided seven days a week.

The areas where the provider should make improvements are:

  • As identified by the provider during the inspection, prescribing guidance should reflect the manner in which the provider operates.

At this inspection on 6 June 2017 found the provider had made substantial changes in a systematic way, with clinical leadership at the heart of improvements. The suspension ended on 7 June 2017.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 21 April 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection undertaken on 21 April 2017, which followed an announced comprehensive inspection at Online Clinic (UK) Limited on 21 March 2017. In March, we found the service was not providing safe, effective or well-led services in accordance with the relevant regulations. However, we found they were providing caring and responsive services in accordance with the relevant regulations.

Following the 21 March 2017 inspection, we took urgent action to safeguard patients and suspended the provider’s registration, which took effect from 22 March 2017. This suspension will remain in force until it expires or is removed by the Care Quality Commission. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Online Clinic (UK) Limited on our website at www.cqc.org.uk.

Our key findings across the areas we inspected were as follows:

  • The provider showed us evidence of clinical input in to decision making in the form of minuted meetings and emails. However, there were still recommendations made by the clinical lead that had not yet been implemented.
  • Some protocols for prescribing for specific areas, such as asthma and emergency contraception, had been completed. However, their creation was not based on risk, was limited in number and did not reference best practice guidelines.
  • Limitations to the number of prescriptions that could be issued to one patient had been implemented if a patient did not consent to their GP being informed. However, it would still be possible to receive a single prescription for opioid medicines or asthma medicines on a one off basis without the person’s GP being informed.
  • The provider had not reviewed the systems in place for medicines prescribed ‘off-label’. Information on how to take these medicines was only given online and not included with the medicine, which may have led to inappropriate use.
  • We were assured there was a system in place, to aid identification of patients, ready to be implemented once the suspension was lifted on the provider’s registration.
  • We saw examples of medicines’ alerts, which had been actioned correctly by the registered manager; however, there was no system or process in place to set out roles and responsibilities for disseminating and acting on clinical or prescribing alerts.
  • Staff had undergone training the provider deemed mandatory and all files had been updated to reflect the level of training that had completed.
  • The provider had ceased treating patients with conditions we highlighted as being potentially unsafe to provide care for in an online environment following our initial inspection, of 21 March 2017.

This inspection of 21 April 2017 found the provider had not yet made adequate improvements and the suspension remains in place.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 21 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Online Clinic (UK) Limited – Taybridge Road on 21 March 2017.

This service operates two websites that offer online medical services; www.theonlineclinic.co.uk and www.privatedoctordirect.com. On the day of our inspection, the provider’s statement of purpose was not up to date; only one website was mentioned within the statement of purpose and this did not detail all addresses involved in the provision of services. The service only provides services to patients aged over 18 years old and to patients within the UK.

Both websites allow patients to request treatment for a range of specific conditions; this request is reviewed by a doctor (not all of the doctors working for Online Clinic (UK) Limited were GPs), who then prescribed a medicine to treat the condition. This medicine is dispensed by a third party pharmacy and delivered by an external courier service.

We found this service did not provide safe, effective, responsive or well led services in accordance with the relevant regulations. The service did provide caring services in accordance with the relevant regulations.

Our key findings were:

  • Systems were in place to protect personal information about patients. The company was registered with the Information Commissioner’s Office.
  • At the time of our inspection there was no system in place to verify a patient’s identity. We were informed the provider was arranging for a system to be put in place.
  • There were no systems in place to deal with the event of a medical emergency whilst a patient was in contact with the service provider. The service did not have a business contingency plan.
  • Patient consultations and prescribing decisions were monitored informally by a non-clinician at the time of our inspection; however, we have been told that some prescribing decisions were peer reviewed by a second clinician. We were also told a clinical lead had recently been appointed and this member of staff intended to conduct reviews in the future.
  • There was no overarching clinical governance system in place to ensure the delivery of safe and effective care. A clinical lead had recently been appointed and intended to improve clinical governance.
  • We were not assured that patient consultation records were always accurate or complete. We were not assured that patients were treated in line with best practice guidance. We spoke with two clinicians, one was not aware of the ‘Good practice in prescribing and managing medicines and devices’ Guidance produced by the General Medical Council.
  • There was no effective system in place to ensure safety or medicines alerts were received, understood or actioned by all relevant staff.
  • Clinical staff we spoke with had a limited insight into the way services were provided, of other staff within the organisation and of other staff member’s roles and responsibilities.
  • There were limited, informal systems in place to mitigate safety risks including analysing and learning from significant events and safeguarding. There was no significant event policy and limited information relating to previous incidents. There was no formal safeguarding lead in place at the time of our inspection and records of staff attendance at safeguarding training were incomplete.
  • There were appropriate recruitment checks in place for all staff; however training records were incomplete and did not assure the provider that staff had completed appropriate training.
  • Not all policies reflected current practice; for example, the provider’s consent policy did not align with the process for gaining consent in place at the time of our inspection.
  • Limited information about how to complain was available on the websites.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • The service encouraged and acted on feedback from patients via a third party review website, we saw evidence of actions taken in response to this feedback. Feedback via this website reported that patients felt they were treated with compassion, dignity and respect.
  • The provider had prepared a business plan for the purpose of our inspection outlining plans for additional services and recruitment. We saw no evidence of this having been shared or discussed with staff.

The areas where the provider must make improvements are:

  • Ensure the safety of patients by having appropriate systems to manage incidents, safety and medicines alerts, consultation forms, prescribing, patient consent and identity verification, safeguarding and business continuity.
  • Ensure the quality of the service by having appropriate clinical leadership and governance strategies including up to date policies and protocols available for all staff, training, quality assurance monitoring and learning from complaints.
  • Ensure all staff are aware of the ‘Good practice in prescribing and managing medicines and devices’ and evidence based guidance when deciding how to protect patients from the risk of unsafe prescribing of medicines.
  • Implement and embed a system of quality improvement, such as clinical and non-clinical audits.

We have taken urgent action in response to the concerns identified at Online Clinic (UK) Limited; we have suspended the provider’s registration until 22 June 2017.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 19 December 2012

During a routine inspection

As this was an online internet prescription service we took the opinions of people using the service from the survey information they provided to the service. They said they were satisfied with the service, the way it was provided and would recommend it to others. The procedure for consultation and treatment had been explained clearly to them including cost. They were also told about any risks that might arise from treatments. The system operated meant their confidentiality was maintained and observed.

They did not comment on the suitability of staff numbers to provide the service although indicated that the time taken to provide it was satisfactory. They were aware of the complaints procedure and how to access it.

We found the service to be efficient, safe and secure with appropriate policies, procedures and records kept. There were enough qualified staff to meet the needs of people using the service.

Inspection carried out on 14 March 2012

During a routine inspection

We were unable to discuss the outcomes with people who use the service, due to there being no face-to-face contact between the people and the agency.

Inspection carried out on 6, 7 April 2011

During a routine inspection

We did not discuss the outcomes with people who use the service, due to there being no face-to-face contact between the people and the agency.