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Inspection Summary


Overall summary & rating

Updated 23 December 2019

This service is rated as Good (Previous inspection in January 2017 was not rated)

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 Briarswood Clinic as part of our inspection programme.

Briarswood clinic provides weight loss services for adults, including the provision of medicines for the purposes of weight loss under a doctor’s supervision.

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 Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A separate organisation provides a range of non-surgical cosmetic interventions from the same premises.  These services are not within CQC scope of registration and we did not inspect or report on these services.

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

24 people provided feedback about the service and their comments were all positive. They told us that it was a professional service provided in an appropriate environment and the staff were friendly, supportive and non-judgemental.

Our key findings were:

  • Patients gave positive feedback about the service they received at the clinic.
  • The premises were suitable for the service provided.
  • Patients were given a welcome pack including information about diet and weight loss, and were given support and encouragement at each visit.
  • The prescribing audit had not been repeated to ensure that prescribing remained in line with the clinic’s policy and we saw one record where this was not the case.

The areas where the provider should make improvements are:

  • Review prescribing to ensure that medicines are only supplied to patients with a BMI of less than 30 when they meet the criteria in the policy, and the rationale is documented.
  • Review the audit programme to include clinical audits such as prescribing.
  • Consider including a question on the quality of clinical care provided when asking patients for feedback.
  • Only supply unlicensed medicines against valid special clinical needs of an individual patient where there is no suitable licensed medicine available.

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

Inspection areas

Safe

Good

Updated 23 December 2019

We rated safe as

Good

Safety systems and processes

The service

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, aligned with local authority guidelines, 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 vulnerable adults from abuse.
  • 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 had not been required to act as chaperones but were trained to do so and information was available for patients.
  • There was an effective system to manage infection prevention and control including an annual legionella risk assessment.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions.
  • The provider carried out appropriate environmental risk assessments, which took into account 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.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
  • The provider had assessed that the risk of a medical emergency was very low and therefore they did not hold any emergency medicines other than oxygen, which was suitable for use. The doctor was trained in basic life support.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place

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 such as patient’s height, weight and body mass index were recorded as well as an initial target weight for each patient.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

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 controlled drugs, emergency medicines and equipment minimised risks.
  • The service used data from a previous prescribing audit to assess potential weight loss for new patients. However they had not repeated the audit to update the data and ensure that prescribing was in line with their prescribing policy and best practice guidelines for safe prescribing.
  • Staff 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. The service prescribed weight loss medicines to patients with a BMI of 30 and over in line with national guidance, but also to patients with a BMI of 27 and over with one or more co-morbidities. They had a policy in place to ensure consistency and we saw that patients with a BMI of less than 27 were not treated. One of the ten records we reviewed showed that medicines were prescribed for a patient with a starting weight BMI of 27.3 with no record of any co-morbidity.
  • The medicines this service prescribes for weight loss are unlicensed. Treating patients with unlicensed medicines is higher risk than treating patients with licensed medicines, because unlicensed medicines may not have been assessed for safety, quality and efficacy. These medicines are no longer recommended by the National Institute for Health and Care Excellence (NICE) or the Royal College of Physicians for the treatment of obesity. The British National Formulary states that ‘Drug treatment should never be used as the sole element of treatment (for obesity) and should be used as part of an overall weight management plan’.

Track record on safety and incidents

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.

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 although the definition of what was considered significant did not include incidents which did not affect patient safety. 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. Discrepancies in the records of medicines received, used and in stock had been identified and shared with the local Controlled Drugs Accountable Officer. The service had stopped packing tablets on the premises and purchased pre-packed tablets to reduce the risk of error. The discrepancies had not been documented in line with the incident policy since the service only applied that to patient safety incidents, but appropriate action was taken.
  • 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
  • No safety incidents had occurred in the last 12 months so there were no examples of written records of verbal interactions or written correspondence.
  • 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

Effective

Good

Updated 23 December 2019

We rated effective as

Good

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’ immediate and ongoing needs were fully assessed.
  • Clinicians had enough information to make or confirm a diagnosis. Patients completed a health questionnaire before seeing the doctor.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients, including a treatment break after 12 weeks.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits, for example they audited the process for ensuring that new patients were given a letter for their GP. They reviewed the process and repeated the audit which showed that only patients who did not make a repeat visit did not collect a letter. The doctor and manager reviewed the records at the end of each clinic to resolve concerns and improve quality.

Effective staffing

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

  • All staff were appropriately qualified.
  • The doctor was registered with the General Medical Council and was 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.

Coordinating patient care and information sharing

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

  • Patients received coordinated and person-centred care. Staff gave all new patients a letter for their GP, outlining the treatment provided by the clinic. The service monitored the collection of these letters but had no information on whether patients gave them to their GP.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health and their medicines history. We saw examples of patients being declined treatment, for example where their body mass index was below the eligibility criteria set by the service. .
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP.
  • Most patients did not provide GP contact details or consent to information sharing so since the last inspection the service had introduced a letter which all new patients were asked to give to their GP.

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. The service provided an information pack for new patients, including information on weight loss and healthy eating and we saw that patients were supported with advice and encouragement when they were weighed.
  • 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

.

  • 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.

Caring

Good

Updated 23 December 2019

We rated caring as

Good

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received through an annual survey.
  • Feedback from patients was positive about the way staff treat people
  • We received comment cards from 23 patients and they were all positive about the kind and respectful care given by all the staff.
  • 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 not available for patients who did not have English as a first language. The service had considered the need for this and had not identified a requirement as their local area is predominantly English speaking.
  • Patients told us in person and through comment cards that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Consultations with the doctor were held in a private room and other staff knew that if patients wanted to discuss sensitive issues they could offer them a private room to discuss their needs.

Responsive

Good

Updated 23 December 2019

We rated responsive as

Good

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. They added an extra clinic session each week to meet demand.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. The service provided guidance to staff on assisting people with a disability and staff described how they supported a patient with visual impairement.

Timely access to the service

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

  • Patients had timely access to initial assessment, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • When contacting the service for the first time, patients were given information about the service and the costs involved. This saved people making an unnecessary journey if they were ineligible for treatment.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. There had been no complaints in the last 12 months. The manager spoke to patients on each visit and would resolve any concerns as they arose.

Well-led

Good

Updated 23 December 2019

We rated well-led as

Good.

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 realistic strategy and supporting business plans to achieve priorities.
  • 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 monitored progress against delivery of 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.
  • Openness, honesty and transparency were demonstrated when responding to incidents. 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. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff.
  • There were positive relationships between 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
  • 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 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 audit had a positive impact on quality of care and outcomes for patients but was not included in a regular audit schedule.
  • 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.
  • 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 involved patients and staff to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from patients, staff and external partners and acted on them to shape services and culture.
  • The service carried out an annual patient survey and used the results to improve services for example increasing the number of sessions each week. Staff were involved when appropriate.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There were systems in place for learning and improvement.
  • Staff told us they were able to make suggestions for improvements.