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Inspection Summary


Overall summary & rating

Good

Updated 10 July 2019

This service is rated as Good overall. The service had been inspected previously on 17 July 2018 but had not been rated at that time.

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 of Exeter Medical on 14 May 2019 to ask the service provider the following key questions; Are services safe, effective, caring, responsive and well-led?

During the CQC inspection on 17 July 2018 and recommended the provider should make improvements regarding systems for retention of recruitment records and embedding the nationally recognised Health and Safety Executive environmental assessments. We checked these areas as part of this comprehensive inspection and found both of these issues had been resolved.

Exeter Medical is an independent health organisation providing medical services, minor surgery, advice and treatment and aesthetic cosmetic treatments, to privately funded patients and patients referred by local NHS clinical commissioning groups (CCG). The service is offered on a private, fee paying basis and is accessible to people who chose to use it. Some services are provided on behalf of NHS services. For example, vasectomy and carpal tunnel surgery. The service is part of Ramsay Health Care UK Operations group (Ramsay Health).

This service is registered with CQC under the Health and Social Care Act 2008 in respect of the provision of treatment, advice or surgery by a medical practitioner under the regulated activities of Diagnostic and screening procedures, Surgical procedures and Treatment of disease, disorder or injury. The aesthetic cosmetic treatments that are also provided are not covered under CQC regulations. Therefore, we were only able to inspect and report on the provision of minor surgery, advice and treatment

During our inspection we spoke with three patients and received six CQC comment cards. Feedback about the service was entirely positive. Patients told us they had their procedures fully explained beforehand and felt involved in decision making. Staff were described as patient, kind and considerate. Patients had confidence in the clinicians who provided their treatment.

Our key findings were:

  • There was an effective system for reporting and recording significant events. The service had systems in place to identify, investigate and learn from incidents relating to the safety of patients and staff members.

  • Staff had received appropriate training according to their role.
  • The provider had acted upon CQC recommendations arising from the previous inspection. For example, the system for retention of staff recruitment records had been reviewed and was in line with the regulations.
  • The provider had continued to embed nationally recognised Health and Safety Executive environmental assessments at the service.
  • Patient feedback about reception staff and clinical staff was positive. The service encouraged and valued feedback from service users via in-house surveys and their website.
  • Complaints had been dealt with in line with the regulations.
  • Staff told us that their morale was good, that they felt supported by the leadership and involved in decision making at the service.
  • Care and treatment was provided in a modern, clean and well organised environment.
  • Regular team meetings were held and there was an online training system for staff.
  • Procedures were safely managed and there were effective levels of patient support and aftercare advice.

  • There were systems, processes and practices in place to safeguard patients from abuse.
  • Information for service users was comprehensive and accessible. Staff had the relevant skills, knowledge and experience to deliver the care and treatment offered by the service.
  • The service had processes in place to securely share relevant information with others such as the patient’s GP, NHS organisations, safeguarding bodies and private healthcare facilities.

We saw the following outstanding practice:

  • The organisation engaged with the local community by providing an annual charity ‘mole check’ event at the service. The event included full mole checks for members of the local community in exchange for a minimum £10 cancer charity donation. The Saturday morning event in June 2018 had seen 130 patients being checked and £2340 being raised. Any abnormal results were processed using the urgent two week wait pathways. This year’s event is planned for 1 June 2019.

The areas where the provider should make improvements are:

  • Increase the number and range of clinical audits undertaken to enhance quality improvement systems in place.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 10 July 2019

We rated the practice as Good for providing safe services.

Safety systems and processes

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

  • The safeguarding policy had been updated April 2019 and up to date contact details for the local authority safeguarding team were on display in a staff area.

  • All clinical staff had been trained to safeguarding level three and administrative staff to safeguarding level two in line with national guidance.

  • Arrangements for safeguarding reflected relevant legislation and local requirements. The service had a safeguarding lead. Policies and protocols had been developed which covered safeguarding, whistleblowing, management of disclosure and referral. The policies clearly outlined processes to be adhered to.

  • We saw evidence that staff were up to date with all professional training requirements. We saw that records of training the provider considered was necessary were kept and all staff were up to date with training requirements. We were told that clinicians also undertook self-directed learning to support their own professional development. The provider was in the process of transferring training records to an online provider.

  • We found that the service had reviewed their recruitment system since our previous inspection, including their retention of recruitment records.

  • We spoke with staff regarding their recruitment process. These staff told us they had been interviewed, asked for proof of identification, an employment history, medical information and had given the names of two references to provide information on their conduct in previous employment. Clinical staff told us they had been interviewed by clinical staff and asked for information about their previous employment and experience. Records we checked contained evidence of these documents. Records were compliant with GDPR (General Data Protection Regulation) requirements.

  • The provider had a policy of completing a Disclosure and Barring Service (DBS) check for all staff. (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 persons who may be vulnerable).

  • All staff had received training on safeguarding children and vulnerable people relevant to their role. For example, doctors had been trained to child protection or child safeguarding level three.

  • Posters were displayed offering chaperones. All staff had received a DBS check and all staff had received chaperone training. Every member of staff was available to act as chaperone, although staff told us it was normally carried out by a nurse or health care assistant.

  • The provider told us clinicians had confirmed the identity of parents and the legal authority of accompanying adults before performing a procedure on a minor (child or infant). However, the provider verified they no longer provider services to minors under 18 years of age.

  • The provider maintained appropriate standards of cleanliness and hygiene. Patients commented that the practice appeared hygienic and clean. Cleaning schedules and records were in place in all clinical areas. Systems were in place to return surgical equipment to central sterilising services and tracking was in place to trace this equipment. Single use equipment was also used. Protective personal equipment and cleaning equipment was readily available and used.

  • There were infection control procedures in place to reduce the risk and spread of infection. An external infection control consultant was employed to complete an annual audit. The last audit had resulted in small repairs to areas of flooring. Hand hygiene audits were completed each month and a walk round was performed each month to highlight any issues. For example, the last walk through had highlighted additional cleaning which had been completed. We inspected the consultation rooms, theatre areas and waiting areas which were all visibly clean and were in good overall condition.

  • Appropriate systems were in place for clinical waste disposal. Records were seen of contracts held for clinical waste and clinical sharps that had been safely disposed of. Clinical waste was stored securely.

  • We reviewed the legionella risk assessment for the premises and confirmed that the clinic kept records of and were aware of the control measures in place (Legionella is a bacterium which can contaminate water systems in buildings).

  • Systems were in place for the prevention and detection of fire. Risk assessments and equipment was readily available.

  • General environmental risk assessments were completed on an annual basis. We examined the August 2018 report which had been carried out as a result of recommendations made at our previous inspection in July 2018. The service had embedded nationally recognised Health and Safety Executive environmental assessments. Reviews were carried out on a monthly basis and records were maintained and up to date. The NHS Co-ordinator was about to complete an Institute of Occupational Health and Safety course to further ensure safety at the location was managed more effectively.

Risks to patients

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

  • All staff had received basic life support training in line with the provider policy.

  • The service had a defibrillator, oxygen and emergency equipment on the premises which were checked appropriately, and staff knew how to use. Emergency alarms and panic buttons were situated throughout the premises. A first aid kit and accident book were also available on-site.

  • Emergency medicines were safely stored, checked and were accessible to staff in a secure area of the theatre area. We saw that the emergency medicine stock included medicines used for the emergency treatment of allergic reactions or surgery.

  • All electrical equipment was checked to ensure it was safe to use. Portable appliance testing had been carried out in June 2018.

  • Clinical equipment was checked regularly to ensure it was working properly and had been calibrated.

  • Clinical rooms storing medical gases had appropriate signage. This included liquid nitrogen which was stored appropriately

  • Managers had been made aware of any issues which could adversely impact on health and safety. Staff were aware of evacuation procedures and routes.

The provider had employer’s liability insurance cover and clinicians had medical indemnity insurance in place. All doctors were registered with the GMC and were on the performers list, nurses were all on the NMC register.

Information to deliver safe care and treatment

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

The providers and staff worked with other services when this was necessary and appropriate. For example, the provider liaised and communicated with patients, the patients GPs, the clinical commissioning group and insurance companies.

If a procedure was unsuitable for a patient, we saw records to demonstrate that the provider had referred the patient back to their own GP.

The clinic had processes in place to share information with safeguarding bodies when required.

Safe and appropriate use of medicines

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

The arrangements for managing medicines, including emergency medicines in the service minimised risks to patient safety (including obtaining, prescribing, recording, handling, storing, security and disposal).

Medicines were checked on a regular basis and expiry dates of all medicines clearly labelled. Expiry dates of medicines and equipment were recorded on a document to show these checks had taken place.

Prescription stationary was stored securely, and logs were in place to monitor the distribution of prescription pads.

The service liaised with the local hospital to ensure they used a similar medicine formulary to provide consistency across the area. The service was planning to strengthen this area in order to improve antibiotic stewardship to reduce risks to patients of resistant infections.

Track record on safety

The service had a good safety record.

Management staff received safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA). A system was in place to reviewed and document these. Any relevant information was cascaded to the staff team through team meetings using the secure in house email system. We saw evidence of a recent alert from the 7 May 2019 regarding safety of medical devices. This had been received and recorded. There were no actions arising from this alert. The service had reported this back to Ramsay Health head office.

There was a system in place for reporting and recording significant events. The provider had systems and processes in place to identify, record, analyse and learn from incidents and complaints.

There had been no significant events recorded by the service since the acquisition by Ramsay Health Care in December 2018.

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 systems in place to record, report and take action on significant events and complaints received by the clinic, so that these were reviewed and investigated promptly.

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. An annual duty of candour report was produced to monitor any themes.

The service had an effective mechanism in place to disseminate alerts to all members of the team. There was wider sharing of all significant events across the global Ramsay Health group, for discussion at staff meetings.

Effective

Good

Updated 10 July 2019

We rated the service as

Good

for providing effective services.

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)

Patients who used the service had an initial consultation where a detailed medical history was taken from the patient. If the initial assessment showed the patient was suitable for the procedure this would be documented, and the patient was then assessed and treated.

Patients and others who used the service were able to access detailed information regarding the procedures and different procedures which were delivered by the provider. This included advice on the procedures and post-operative care. Some treatments required a ‘cooling off’ period enabling the patient time to decide on the treatment and opportunity to return at a later date for the treatment. Some treatments were offered on a ‘see and treat’ arrangement.

After the procedure the staff discussed after care treatment with patients and informed them of what to expect during the recovery period. This was both to reduce concerns and anxiety of patients; and to minimise the risk of further treatment being needed. Patients were requested to contact the service during their opening hours if they had any concerns and were signposted to out of hours services when the service was closed.

The provider was aware of evidence based guidance and had access to written guidance should this be required. For example, NICE (National Institute for Health and Care) guidance. The provider told us the patients they treated were mostly fit and healthy but was also aware of identifying the symptoms of the acutely unwell patient. For example, anaphylaxis and sepsis.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

The provider kept a record of each procedure conducted in theatre and had processes in place to capture histology (samples taken during surgery) results. Patients were given comprehensive details of what complications may arise and what to look for. Details of out of hours providers were given and instructions to contact the service should any complications arise. The service provided data to show complications from infection or the surgery were recorded at less than 2% which was lower than the national averages of 5%.

We found evidence of complete cycle clinical audits, for example on skin lesions and patient notes. The provider told us they planned to expand the number of clinical audits completed in order to monitor care and treatment.

Effective staffing

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

The majority of doctors were also employed as NHS consultants in their area of speciality and kept up to date in their specialist fields. One of the doctors practised purely privately and kept up to date through training, attendance at conferences, seminars and five yearly revalidation. All doctors were scrutinised by the GMC to ensure they remained competent to carry out their work. All clinical staff had medical indemnity cover and were registered on their professional registers, when needed. For example, the Nursing and Midwifery Council and the General Medical Council. All staff had training records and had completed training the provider considered mandatory, such as basic life support, safeguarding and fire safety.

Each staff member had an annual appraisal where training needs were identified, although staff said training needs could be identified informally throughout the year or more formally at staff meetings.

The practice had a staff risk assessment overview document which listed how the organisation would reduce risks associated with staffing. This document included adhering to training and appraisal programmes, facilitating targeted specialist training programmes, monitoring consultant practising privileges and implementing health and safety assessments.

Coordinating patient care and information sharing

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

We were given many examples of working with other services and saw that the provider did so when necessary and appropriate. For example, the provider liaised with patients GPs, insurance companies, Clinical Commissioning Groups, NHS departments and appointment booking departments.

The medical staff asked for consent to contact the patients’ GP at the initial consultation and did so when consent had been obtained. We saw records to show that consent was given or declined.

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.

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 following treatments. Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.

Where patients needs 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

.

We found that staff sought patients’ consent to care and treatment in line with legislation and guidance.

The provider had developed protocols and procedures to ensure that consent for procedures and treatment were obtained and documented. Consent forms were bespoke to each treatment and contained benefits and risks associated with the procedure.

Consent was obtained for the use and retention of medical photographs. The provider understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.

Caring

Good

Updated 10 July 2019

We rated the service as

Good

for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

Comment cards and internal and external surveys contained comments which demonstrated that the patients were happy with the care, treatment and service received. Patient comments included feedback that the staff were courteous, caring and helpful to patients and treated them with dignity and respect.

Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.

Involvement in decisions about care and treatment

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

Feedback from comment cards showed that patients had been involved in the decision making process. The medical staff actively discussed the procedure with patients and recorded discussions in the patient record. We saw evidence of this on the day of inspection.

The provider made use of patient feedback as a measure to monitor and improve services and did this by monitoring compliments, complaints and results from NHS Choices, Google reviews and patient surveys. The provider maintained a social media page.

Interpretation services were available for patients who did not have English as a first language. Patients were told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.

Privacy and Dignity

The service respected patients’ privacy and dignity.

Doors were closed during consultations and conversations taking place in these rooms could not be overheard. Equipment was available in theatre areas to protect the privacy and dignity of patients when surgery was taking place. Staff communicating with patients over the telephone about intimate surgery moved to a quiet room to provide patients with a more confidential environment to discuss their procedure as required.

The provider told us that time was spent with patients both pre- and post-procedure carefully explaining the after care, recovery process and options to reduce any anxieties they may have.

The provider had access to written information and advice resources for patients that they could take away with them to refer to at a later time.

Responsive

Good

Updated 10 July 2019

We rated the service as

Good

for providing responsive services.

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 had a range of information and support resources which were available to patients.

  • The website for the service was very clear and easily understood. In addition, it contained valuable information regarding treatment and procedures available, fees payable, procedures and aftercare.

  • The provider maintained a social media page which provided information about the services available.

Exeter Medical offered both self-funded and privately insured local anaesthetic operations. The service also worked for Devon Clinical Commissioning Group and other NHS organisations to provide outpatient services including medical consultations and minor operations.

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 operated between Monday and Friday depending on patient demand. Appointments were available from 9am to 5pm on Mondays, Thursdays and Fridays and from 9am to 7pm on a Tuesday and 9am to 8.30pm Wednesday.

Enquiries could be made by telephone, using the website and appointments were made via a dedicated telephone booking line. Since the acquisition by Ramsay Health, a national enquiry centre supported the service and reduced telephone traffic directly into the service. This enabled a faster response to be made to patients and enabled clinical staff to spend more time with their patients.

The clinic offered appointments to anyone who requested one and did not discriminate against any client group.

Exeter Medical was in a good condition and repair and were easily accessible for patients with mobility needs and wheelchair users. Treatment was provided on the ground floor and first floor which could be accessed by passenger lift. There were two disabled parking bays in the car park and two disabled toilets, one on each of the two floors.

The provider told us the majority of patients used the English language but added that telephone interpreting services were available if required. The practice also had a hearing aid induction loop available for patients with hearing impairment.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded respond to them appropriately to improve the quality of care.

The provider had a complaints policy and process in place.

Detailed records showed that complaints had been managed in an open, transparent and reflective way.

Patients had been given explanations and external organisations contacted where appropriate to check procedures had been correctly followed and to show evidence that duty of candour had been followed.

There had been two complaints since Dec 2018 (the date the new provider had acquired the service). These had included a complaint from a patient as they were upset in the way they were questioned by a member of staff. This had been investigated by the manager. Staff had been spoken with. The manager met with the patient and they were satisfied with the outcome.

Well-led

Good

Updated 10 July 2019

We rated the service as Good for providing a well led service.

Leadership capacity and capability

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

The service had been acquired by a new provider Ramsay Health Care UK Operations UK (Ramsay Health) in December 2018. Ramsay Health is a global healthcare provider which in England focuses on adult outpatient services, diagnostics, screening and elective surgical procedures. Exeter Medical is led by a Hospital Director supported by a Head of Clinical Services, Theatre Manager/ Clinical Lead, an Operations Manager, an NHS co-ordinator and a team of administration and nursing staff.

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.

Following Ramsay Health’s acquisition of Exeter Medical in December 2018 they had carried out a consultation process with staff and patients. Notices had been displayed in reception areas and information made available to patients about the new provider.

Staff forums had been held to inform staff about any changes and repeat forums held to ensure any absent staff were also able to attend a forum. The new provider had also invited all staff to request a one to one meeting with a manager to discuss the changes should they wish to do so. Staff had chosen to remain working at the clinic and none had left. All of the staff we spoke with during the inspection told us they felt supported by the new provider. Staff told us the new provider offered a wide range of benefits.

The providers had a clear vision to provide care and treatment options in response to patient demand and within their clinical competencies within a clinically-clean and safe environment.

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.

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.

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. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work.

There was a strong emphasis on the safety and well-being of all staff. The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. 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 clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.

  • Staff were clear on their roles and accountabilities

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. For example, checks on medicines, WHO (World Health Organisation) safe surgical check lists, cleaning schedules and minor surgery procedures.

Managing risks, issues and performance

There was clarity around processes for managing risks, issues and performance.

Arrangements were in place for identifying, recording and managing risks and issues. The service had produced a summary document of how the organisation reduced risks. This included methods of minimising risk in infection control, medicines management, clinical governance, staffing, reputational risk and security and information technology. We saw evidence of these processes and systems in place. The service had processes in place to record and act on significant events or incidents.

The providers rented the premises but had full responsibility of managing and mitigating any risks associated with the premises. These included systems, processes and contracts for annual portable electrical equipment testing, equipment calibration, fire safety procedures, waste management and laser equipment and legionella risk assessments for the premises. (Legionella is a bacterium which can contaminate water systems in buildings). 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 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.

There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. Staff had been trained in General Data Protection Regulations (GDPR).

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 provider encouraged and valued feedback from patients and staff. It proactively sought feedback from:

  • Online feedback and compliments and complaints.

  • Verbal feedback post procedure and at reviews.

  • External independent surveys

During the period of July 2018 and May 2019 the service had received 20 letters of thanks and numerous verbal thanks. Since December 2018 the service had received two letters of complaint.

Online feedback about the service had been positive. Feedback on NHS Choices included five out of five stars overall from the one reviewer. Exeter Medical Limited Facebook page showed that the practice had received 22 reviews, with an overall rating of five stars.

The service had conducted an annual patient experience survey in March 2018. A total of 135 patients were asked to complete a survey and 67 responses had been received. Of the 67 respondents:

  • 61 people said they rated the building and facilities as good (6 average)

  • 64 people rated staff as good (3 average) and

  • 66 people were satisfied with the service (one neither satisfied or dissatisfied)

The practice encouraged staff to give feedback and offer suggestions for improvement. Staff we spoke with said they felt able to share new ideas and offer suggestions which were usually implemented. For example, the service had consulted with the staff on the relocation and refurbishment of the new staff room. This had been listened to and acted upon.

The organisation engaged with the local community by providing an annual charity ‘mole check’ event at the service. The event included full mole checks for members of the local community in exchange for a minimum £10 cancer charity donation. This Saturday morning event in 2018 had seen 130 patients being checked and £2340 being raised for charity. Any abnormal results were processed using the urgent two week wait pathways. The next such event was planned for June 2019.

Continuous improvement and innovation

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

We saw some evidence of clinical audits. For example,

Diagnostic accuracy of skin lesions amongst plastic surgeons and a dermatologist. This looked at the accuracy of examination of benign and cancerous lesions. For the period April 2015 to March 2016 the clinical diagnosis of all patients at Exeter Medical was collected. This totalled 721 patients. Results showed that the overall diagnostic accuracy was 73%. There were 15 pre-malignant lesions identified during the study. The four clinicians shared their learning in order to improve accuracy of diagnosis. Shared learning included using a dermascope (a specific piece of equipment which enlarges the area of skin looked at to improve the accuracy of diagnosis, rather than relying solely upon a clinical inspection.

A clinical notes audit was completed monthly and a random selection of clinical notes were reviewed, to ensure the patient had consented appropriately; patient information was accurate, and a medical history had been taken, which include prescribed medicines. In addition, the audit covered whether the medical records had been fully completed with the patient’s name on each page, a safety assessment and a GP letter sent when consent had been given. The January 2019 audit had looked at eight patients, as had the February audit. This helped the service to improve the quality and accuracy of the notes. Any areas of improvement were shared and addressed.

The new provider maintained an ongoing project implementation plan to support the service through the transition to Ramsay Health as the new provider. The plan identified areas for improvement, with required actions needed, timescales for completion and persons responsible for implementation. For example, a risk assessment of the whole site was completed in January 2019. The assessment had identified that improvement was needed in staff training, and safeguarding arrangements to check they met required standards. We saw there was a plan in place with timescales for completion.