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Inspection Summary


Overall summary & rating

Good

Updated 11 June 2019

We carried out an announced comprehensive inspection at Doctorcall Manchester as part of our inspection programme.

Doctorcall Manchester is registered with the Care Quality Commission as an independent provider of medical services for adults and children. Doctorcall Manchester is located in Manchester City Centre and is provided by Doctorcall Limited.

There are no geographical boundaries to using the service which is mainly accessed through pre-booked appointments. Consultations however, can also be at short notice depending on the availability of doctors.

The service is registered with the CQC to provide the following regulated activities:

  • Diagnostic and screening procedures;
  • Treatment of disease disorder and injury.

The service employs medical doctors who provide, private GP appointments; health screening; travel clinic services; visa medicals; flu and other immunisation vaccinations and genitourinary care and treatment. 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 exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in and of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Doctorcall Manchester services are provided to patients under arrangements made by their employer or insurance company with whom the service user holds a policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Doctorcall Manchester we were only able to inspect the services which are not arranged for patients by their employers or an insurance company with whom the patient holds a policy (other than a standard health insurance policy).Doctorcall Manchester provides a range of interventions, for example occupational health and physiotherapy which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. The provider is represented by 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 found that patients were positive about the care and treatment provided by the service. Feedback was provided by 26 patients and their comments indicated that the service was efficient, the clinicians were knowledgeable and provided clear explanations about care and treatment; staff treated patients with respect and consideration; patients felt the staff went above expectations and felt the consulting rooms and waiting areas were clean and pleasant to use.

Our key findings were:

  • Processes were in place to protect people from abuse however, these needed to be strengthened. Processes for reporting and dealing with incidents were well developed, lessons learnt were shared with all staff and processes were changed as a result of learning. There were reliable systems and processes in place to ensure the premises were safe, clean and fit for purpose. Medicines were well managed.
  • The service provided care and treatment in line with best practice guidance and had introduced an audit programme to monitor the outcomes for patients. However, the provider did not review all audit information available to them for example the quality of cervical smear reports were not checked.
  • All records were stored electronically to a secure server however, information about how records would be stored if the service closed was unclear.
  • The provider ensured staff had the skills, qualifications and competencies to carry out their duties to the required standards. There were effective arrangements in place for working with other agencies.
  • Consent to care and treatment was gained but the appropriateness was not monitored.
  • The provider did not routinely seek permission to inform the patients NHS GP about visits to the practice.
  • The identity of children was not routinely verified and systems were not in place to confirm the status of adults accompanying children or adults accompanying other adults. Feedback from patients and the attitudes demonstrated by staff confirmed patients were treated with dignity, compassion, respect and understanding. The equipment and facilities in the consulting rooms indicated that the patient’s privacy was also respected.
  • The service was flexible and able to adapt to the needs of the patients in relation to communication needs and access. There was access to a translation service however, this service was not always used and at times an accompanying adult was allowed to translate.
  • There were a wide range of appointment times. The complaints system was easy to use and complaints fully investigated. 
  • There was a clear leadership team and staff were aware of their roles and responsibilities; leadership was visible and approachable. A quality improvement plan was in place and quality assurance systems included clear and detailed policies, procedures and guidelines relating to all aspects of service delivery for staff to follow. Monitoring processes were in place.

The areas where the provider

must

make improvements as they are in breach of regulations are:

Ensure patients are protected from abuse and improper treatment.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the consent process for sharing information with the patient’s NHS GP to ensure this is in keeping with best practice.
  • Review the translation policy and consider always providing an independent translator when a translator is required.
  • Consider including consent when the audit programme is developed.
  • Clarify the information available about retaining medical records if the service ceased trading.
  • Review how the outcomes of audits are used to influence changes and improvements to the service.
  • Consider ensuring the quality of cytology smears are formally reviewed when the results are returned.
  • Review the contents of the business development plan.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Requires improvement

Updated 11 June 2019

There were insufficient processes in place to:

  • Confirm the identity of children and the adults who accompanied them.
  • Identify and protect vulnerable adults who may use the service.

Safety systems and processes

The service had some systems to keep people safe and safeguarded from abuse however, these needed to be strengthened.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. 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. However, formal policies and procedures were not in place to confirm the identity of children or confirm their relationship with accompany adults. In addition, there were no processes in place to provide assurance about the relationships between adults who accompanied other adults to appointments.
  • The service had an informal system in place to check that an adult accompanying a child had parental authority which relied on the GP or doctor to complete checks during the consultation. We saw evidence that a GP had asked pertinent questions and recorded the relationship of accompanying adults during a consultation. However, a policy with supporting guidelines was not in place to ensure compliance and consistency.
  • 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 practice gave examples of supporting people in vulnerable situations to achieve their independence.
  • 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.
  • There was an effective system to manage infection prevention and control. The management of the building was provided by an independent company provided by the landlord of the building. Legionella reports for the entire building was in place and corresponding certificate in place. The landlord had responsibility for ensuring all recommendations were actioned. We most recent water safety tests (October 2018) came back clear of legionella colonisation.
  • 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.
  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them.

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 all 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.
  • Emergency equipment available was in line with the Resuscitation Council UK guidelines and emergency medicines available were in line with the British National Formulary (BNF).
  • 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. Medical staff had the appropriate medical indemnity and the public liability insurance certificate was in date and displayed in a public area.

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.
  • A clear protocol for retaining medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading was not in place.
  • 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.

  • 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 medicines audit to ensure prescribing was in line with best practice guidelines for safe 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.
  • There were protocols for verifying the identity adults paying for their own treatment however those for identifying children needed to be strengthened. This was discussed during the inspection visit.

Track record on safety and incidents

  • There were comprehensive risk assessments in relation to safety issues. For example, health and safety risk assessment.
  • 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 acted to improve safety in the service. For example, systems were changed following breaches in confidentiality. Changes included a review of how confidential data was protected when sent through email; changes were discussed with staff at the team meeting and on an individual level. Staff were aware of the events and the changes and improvements made.

  • 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 acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team. However, the system did not include monitoring the action taken by staff in response to notifications.

Effective

Good

Updated 11 June 2019

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 (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • 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.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity however this needed to be strengthened.

  • The service used information about care and treatment to make improvements. For example, the provider reviewed the quality of clinical records against best practice guidance and acted to improve access to the electronic system as a result. A re-audit had been conducted and some improvements found. Additional suggestions made by the auditor, however, there was no indication about the providers response to these suggestions.
  • An antibiotic prescribing audit had also been completed, however the response to the findings was unclear. There was not clear indication of the action taken to share the information or implement the suggestions from the findings.

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.
  • Relevant professionals (medical) were registered with the General Medical Council (GMC) and were up to date with 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.
  • Staff whose role included immunisation could demonstrate how they stayed up to date.
  • Although there was no evidence that these were of poor quality, doctors who completed cytology smears did not routinely review the quality of their samples.

Coordinating patient care and information sharing

Staff worked well with other organisations, to deliver effective care and treatment however, action is needed to ensure information is shared with the patients NHS GP in keep with best practice.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, contact was made with the patients GP when secondary NHS services were required; referrals were made to other independent services and patients were signposted to NHS acute services when necessary.
  • 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. The provider audited the clinical competence in relation to this.
  • Patients were not routinely asked for consent to share details of their consultation; however, they were usually asked about medicines prescribed by their registered GP.
  • The custom and practice of the service was to inform the NHS GP if the patient requested or if additional secondary investigations or treatment was need. The provider stated that very few patients used the service more than once.
  • 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 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 registered GP in line with GMC guidance.
  • When shared, 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.
  • There were clear arrangements for following up on people who had been referred to other services if required.

Supporting patients to live healthier lives

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

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. For example, letters in response to referrals to private specialists had been copied to the patients NHS GP.
  • Where patients need could not be met by the service, staff redirected them to the appropriate service for their needs.

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 did not monitor the process for seeking consent, however the records reviewed indicated consent was gained appropriately.

Caring

Good

Updated 11 June 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language.
  • 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, communication aids and easy read materials could be made available if required.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect. Staff had competed customer relations and communication training.

Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 11 June 2019

Well-led

Good

Updated 11 June 2019

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

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 strategy and supporting action plans to achieve priorities, for example redecorating the clinic rooms.
  • The service developed its vision, values and strategy jointly with staff.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service was developing a comprehensive monitoring program that would review the progress of delivering the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year as appropriate.
  • Clinical staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. Records indicated causes of any workforce inequality was discussed and action taken to minimise the effects. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

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, in the main, clearly set out, understood and effective. The governance and management of contract arrangements for example with the building’s management team, laboratory and clinical waste company worked efficiently.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety however, more action was needed to ensure the provider could assured themselves that all systems 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 service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audits were used to promote a positive impact on quality of care and outcomes for patients. There was some evidence of action to change services to improve quality.
  • 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.

  • 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 reviewed performance information which was reported and monitored however it was not always clear that clinical staff were held to account. For example, it was not clear what action was planned in relation to improving performance in response to findings of the reaudit of antibiotic prescribing.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. Plans however, to address any identified weaknesses were not evident.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, the service had reviewed and strengthened the general data protection regulations (GDPR) policy.
  • Staff could describe to us the systems in place to give feedback for example; informally during general conversations; at monthly supervisions; during meetings; during yearly appraisals and staff away-days.
  • We saw evidence of feedback opportunities for staff.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The provider had developed a business plan however, this did not provide clear details about the current performance of the or information about what the service aimed to achieve between 2019 and 2022.