Island Health

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This is the first inspection for this service since its registration with CQC. We rated Safe as Good. We assessed a total of 8 quality statements for this key question – learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control and medicines optimisation. The service had a risk register, but it did not always show clearly what steps the service had taken to rectify the areas that safety assessors determined as high risk. Progress therefore could not be monitored effectively. The service learned from significant events and safety alerts and made improvements. There was a commitment to taking immediate action to keep people safe from abuse and neglect. The service’s systems for the appropriate and safe use of medicines, including medicines optimisation, were effective. Following our inspection, the provider told us they would improve monitoring of progress with remedial works and leaders supplied a copy of an updated risk register, to ensure appropriate action was taken on identified safety risks. People’s feedback in the national GP patient survey and friends and family test was mixed about their experience of the service. All patients that had a pre-bookable appointment received a Friend and Family survey request. The service shared analysis of patient feedback from quarter 3 Friends and family tests (July to Sept 2024); In response to the question ’would you recommend our service to your family and friends?’ The service received 317 responses, 261 said yes and 56 people said no.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Data from the National GP survey, NHS website and feedback provided to CQC via our website, identified some areas of concern. Patient dissatisfaction about difficulties in getting through to the practice by phone and in obtaining an appointment was evident in the national patient survey results and in patient reviews on the NHS website. We reviewed these areas during our site visit and staff shared examples where the service team used patient feedback to learn and make changes to the service. The service learned and made improvements when things went wrong. We asked the provider to place a link on their website to the Give Feedback on Care process so we could hear of patients’ experiences of care. We received 10 pieces of feedback. Feedback we received from people was positive with people feeling supported to raise concerns and feeling staff treated them with compassion and understanding. We spoke with a member of the Patient Participation Group, and they raised no concerns relevant to this quality statement and reported the service always listened to their feedback. The national GP patient survey carried out from January to March 2024 had 127 responses. This found 75% of patients stated the healthcare professional was good at listening to them, and 87% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 86% of patients had confidence and trust in the health care professional they saw or spoke to. CQC did not speak to patients on the days of the assessment. Local Healthwatch shared feedback, gathered between January 2024 and October 2024. Healthwatch staff interviewed patients in person at the practice and completed a questionnaire. There were 28 responses. The positive feedback included the quality of online consultations, of treatment and care received and the attitude of staff at the service. The negative comments were regarding delays in getting through on the phone and availability of appointments.

The provider had processes for staff to report incidents, near misses and safety events both internally and externally. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Staff told us that complaints were responded to promptly, discussed at management meetings and lessons learnt. Learning from incidents and complaints resulted in changes that improved care for others. Staff we spoke with felt able to raise concerns and said they were encouraged to do so.

The service management team encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from both clinical and non-clinical issues. Staff felt there was an open culture, and that safety was a priority. Lessons were learnt to continually identify and embed good practice. We found the management team were open and transparent and wanted to drive improvement at the service.

Island Health GP practice is one tenant (of three) in a multi-occupancy healthcare premises. There were risk assessments in relation to safety issues, however, the provider’s own risk management processes were not always clearly documented and gave an inconsistent overview of safety concerns. We found insufficient updating of the status of any action plans following risk assessments carried out by the building managers. The service had a system in place to manage safety alerts, which was supported by a Central Alerting System policy, last reviewed in October 2024. As part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the service. We reviewed five patient records who may have been affected by a Medicines and Healthcare products Regulatory Agency alert and found all had been informed of the side effects of the medicines. A review of the significant events and incidents process found that the service had a system in place to report, investigate and learn from significant events and complaints. The service had a significant events lead for clinical events. We reviewed two significant events which demonstrated the systems for managing safety events and incidents at the time of the assessment, were effective. The service had a complaints policy, last reviewed in July 2024. There was a system to record and investigate complaints. The complaints we reviewed showed they were recorded, investigated and people were informed of outcomes. People received an apology, and actions were taken to improve processes. Lessons learnt were discussed with staff directly involved with complaints and with clinical members of the team. The provider encouraged audit as an outcome of learning from an event. We saw that duty of candour was considered as part of the complaints and significant events processes.

The national GP patient survey carried out from January to March 2024 had 127 responses. This found 75% of patients stated the healthcare professional was good at treating the patient with care and concern, and 87% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 91% stated their needs were met. When asked about overall experience of contacting the service, 49% stated this was fairly or very good. However, only 22% of patients found it fairly easy to very easy to contact the service by phone. This was lower than the National average of 50% and local average of 48%. Local Healthwatch shared feedback which they had gathered between January 2024 and October 2024. Healthwatch staff interviewed patients in person at the practice and completed a questionnaire. There were 28 responses. The positive feedback included the quality of online consultations, treatment and care received and people were positive about the attitude of staff at the service. There was negative feedback about people’s experience of getting an appointment and the ease of getting through to the GP practice by phone. CQC did not speak to patients on the days of the assessment. The provider had installed a new cloud-based telephone system in December 2023 and had taken steps to address feedback about access in the 2024 GP patient survey. During our assessment, we found there was active monitoring of patient feedback in place. For example, the practice audited live call monitoring reports, and the service had established a system of analysis to measure the impact on patient satisfaction.Evidence reviewed showed that care and support was planned and organised with people, together with partners and communities in ways that ensured continuity and that the views of people who used the service, partners and staff were listened to and taken into account.

Leaders and staff told us there was a designated team responsible for managing referrals through the NHS e-Referral Service (eRS). Staff monitored the system to ensure referrals to specialist services were documented, contained the correct information and that there were no delays. There was safety netting of referrals in place to ensure all patients were followed up. Routine referrals were monitored either to ensure patients continued to require the specialist support or check if their condition had worsened. Leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly.

Policies and processes about safety were aligned with other key partners who were involved in people’s care journey; to enable shared learning and drive improvement. The leaders explained they had a multidisciplinary team (MDT) meeting monthly to discuss and improve outcomes for people with complex needs and a monthly MDT meeting to discuss child and adult safeguarding. The local Integrated Care Board told us they did not have any concerns about the service.

There was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent referrals and any delays. The service had a clinical lead for patient referrals, this enabled staff to monitor and follow up urgent referrals and identify any delays. This was supported by a referrals policy, last reviewed in September 2024. The service had a safety netting protocol for 2-week wait (2WW) cancer referrals. The protocol was monitored weekly to ensure that no cases were missed. Staff told us that if patients did not attend appointments (DNA) or there were issues with getting an appointment it was raised with the service’s cancer lead.The provider had a system in place to ensure all patient test results and correspondence was followed up promptly. Our review of patients’ records and the clinical system indicated that letters, referrals and blood tests results were managed and responded to safely. The practice had processes in place to monitor that a result had been received for every cervical screening sample sent off for analysis. However, during our inspection, staff were not able to show us an audit trail that showed a result was received back by the practice for every cervical smear sample taken. We saw that there was a safety netting process in place for auditing inadequate smear results received. Following our inspection, leaders told us they had an EMIS safety netting audit template in place for monitoring the receipt of cervical smear test results and that the audit would be run on a regular basis. Leaders submitted evidence following our inspection, that the safety netting audit confirmed that all cervical smear results had been received for the last 3 years. There was a system in place to summarise patient records.

We could not collect the evidence to score this evidence category.

There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. The service had a safeguarding GP lead and administration lead who told us they were allocated time to review patients where there were safeguarding concerns. Internally the staff met monthly to review patients where a safeguarding risk had been identified. Staff told us that clinical coding was reviewed regularly to keep safeguarding codes such as "Child in Need" up to date in patient records. The service also monitored children who were not brought to appointments. Non-clinical staff told us they were aware of who to report any safeguarding concern to.

The children’s safeguarding leads met monthly with the health visiting team and reviewed any children at risk. In addition, vulnerable adults were included in the monthly meeting with the integrated care team.

The service had systems, services, and processes to keep, people safe and safeguarded from abuse. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. The service had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately. A review of patient records found the service had a system to highlight vulnerable adults and children to staff. The leaders submitted safeguarding children and adults policies last reviewed in July 2024, which provided information for staff to follow to enable the safe response to a safeguarding concern. We found one member of non-clinical staff who was not up to date with adult safeguarding training. Immediately following our inspection, the service provided evidence of the completed safeguarding adult training for this member of staff.

The national GP patient survey carried out from January to March 2024 had 127 responses. This found 86% of patients had confidence and trust in the health care professional they saw or spoke to. 49% of patients stated the overall experience of contacting the service was fairly or very good and 76% of patients knew what the next step would be after contacting this GP service. However, only 22% of patients found it fairly easy to very easy to contact the service by phone. This was lower than the National average of 50% and local average of 48%.

We were provided with patient feedback from local Healthwatch which they had gathered between January 2024 and October 2024. Healthwatch staff interviewed patients in person at the practice and completed a questionnaire. There were 28 responses. The positive feedback included the quality of online consultations (filling out an online form about your symptoms) and the quality of treatment and care received. People were also positive about the attitude of staff at the service. There was negative feedback about people’s experience of getting an appointment and the ease of getting through to the GP practice by phone. The negative comments were regarding delays in getting through on the phone and availability of appointments. CQC did not speak to patients on the days of the assessment.

Staff told us there was an effective approach to managing staff absences and busy periods, this was reviewed weekly and at the GP partner meetings. Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient. Leaders told us there were enough staff to provide appointments and prevent staff from working excessively. They explained staff had induction tailored to staff roles and a probationary period. The leaders told us that in October 2024, the service offered an average of 83 appointments per 1,000 patients per week, which was within the NHS contract limits.

The service was equipped to respond to medical emergencies, and staff were suitably trained in emergency procedures. Staff had completed basic life support and anaphylaxis training where appropriate. The provider had delivered in house training on identifying sepsis to ensure all staff were able recognise and respond to acutely unwell or deteriorating patients who may have sepsis. During our inspection, the senior GP shared evidence of the presentation he had made to staff about recognition of sepsis in general practice. Practices must be aware of sepsis and be able to demonstrate how to identify and manage an acutely unwell or deteriorating patient before and during an appointment. The service operated an online consultation service, where patients could contact the service using a digital platform or by phone. The service had a team of patient navigators who triaged and signposted all requests for support at the first point of contact. A duty doctor hub supported patient navigators who had access to a clinical and non-clinical triage protocol. All contacts were responded to within 3 hours. Reception staff had the support of a duty doctor to enable them to respond to patient needs.

The provider told us that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. Leaders told us that there had been steady growth of the service list size, with a 5.4% average annual growth rate. The leaders told us the service had been working closely with the GP federation and also Island Health Trust who are the landlords of the building, to review the current premises and look at ways to improve the building and increase clinical space to meet the needs of the growing population. However, although the provider was aware of the additional risks posed by delivering care from premises managed by other organisations, at the time of our inspection, the provider had not set out information on what was expected of the building management to manage safety risks in areas used by Island Health patients. Following our inspection, the provider sent us a copy of a letter they had obtained from the building landlord, confirming the landlord’s responsibility to maintain the building. The letter confirmed the landlord had commissioned a full building survey in October 2024. The service also shared email correspondence from the landlord, which showed that the practice were in communication with the building management team regarding the building issues.Staff told us about improvements made in April 2024, when the reception area was repainted with hardwearing and cleanable paint and in July 2024, following the NHSE infection control audit, the ceiling tiles were replaced in areas where there had been damage, following a leak. There were systems for safely managing healthcare waste. Staff explained any maintenance concerns were promptly responded to by the leaders and improvements had been made. The leaders explained that the service had 3 fire wardens who were suitably trained, and all staff had completed their fire safety training.

We observed that recommendations from external assessments, arranged by the building managers, were recorded on the service’s risk register. However, there was insufficient recording of dates to review progress with the building managers. For example, the fire risk assessment dated 19 October 2023 determined several areas as medium and high risk. The assessor identified that not all fire-resisting doors were fitted with appropriate self-closing devices. The service risk register had documented the risk identified and recorded the status as ongoing. We saw a review date of May 2024 and a note to say the risk was discussed with building managers who were obtaining quotes for push bar mechanisms to be installed but no details of how this safety risk was being managed in the interim. The provider told us that progress of remedial work was reviewed regularly with the building managers. Following our inspection, the provider sent us a copy of a letter they had obtained from the building landlord, confirming the landlord’s responsibility to maintain the building. The letter confirmed the landlord had commissioned a full building survey in October 2024. We saw copies of meeting minutes which showed that building safety was reviewed at board meetings with the GP Federation.

During the inspection, we reviewed the provider’s premises safety processes. The service had completed fire drills and fire alarm testing. The building managers had completed emergency lighting checks, electrical installation condition inspection and legionella risk assessments. The service showed us their risk register which documented risk assessments relating to health and safety. However, the risk register did not always include action plans for managing all identified risks. For example, we obtained a copy of electrical installation condition report dated 6 June 2024. We saw the overall condition of the whole fixed wiring was deemed unsatisfactory. The condition report determined several areas as medium and high risk. It was found that the circuit board had failed numerous tests but at the time of our inspection, the service had not added this to the risk register. During our inspection, staff told us that building managers had scheduled remedial work to the electrical wiring and circuit board in the building, to start in April 2025. However, the service risk register lacked details on how this safety risk was being managed in the interim. Following our inspection, leaders obtained written assurance from the building managers that quotes to improve the fixed wiring were being obtained and the risks identified were being monitored. Leaders also told us they had contacted the landlord to request that the electrical repair work be prioritised. The service provided evidence of annual portable appliance testing, and calibration of equipment.The service had completed an infection prevention and control audit in July 2024 and achieved 100% compliance.

The national GP patient survey carried out from January to March 2024 had 127 responses. This found 86% of patients had confidence and trust in the health care professional they saw or spoke and 76% stated the health care professional was good at treating the patient with care and concern. In addition, 91% stated that their needs were met. CQC did not speak to patients on the days of the assessment. We were provided with patient feedback from local Healthwatch which they had gathered between January 2024 and October 2024. Healthwatch staff interviewed patients in person at the practice and completed a questionnaire. There were 28 responses. The positive feedback included the quality of online consultations (filling out an online form about your symptoms) and the quality of treatment and care received. People were also positive about the attitude of staff at the service. There was negative feedback about people’s experience of getting an appointment and the ease of getting through to the GP practice by phone. The negative comments were regarding delays in getting through on the phone and availability of appointments.

The provider was aware that GPPS results demonstrated that patients at the practice faced challenges in accessing an appointment and contacting the practice. The service had introduced a cloud-based telephone system in December 2023 with new functions, such as a callback option. In response to patient feedback, the service switched from using “econsult” to accurx online consultations (as patients felt this was easier to use). The service also redesigned the practice website to improve accessibility and information for patients.

Leaders told us they had a system in place to ensure safe recruitment of staff. However, at the time of our inspection we checked 6 staff files and there was no record of a check of the GP Performers List for two clinicians. Checking this information would confirm that the doctor holds a licence to service medicine as a GP in the UK and is up to date with revalidation and appraisal requirements. (The GP Performers List is the framework that assures GPs are qualified and competent to provide safe and effective primary medical care). Leaders explained it was standard practice for managers to verify the professional registration status of all clinical staff at the point of creating an EMIS account for any GP who joins the service, including locums. However, leaders acknowledged there was no system of recording that these professional registration checks had been done. Following our inspection, leaders told us they would implement a log to ensure these checks are consistently carried out.

There was a programme of learning and development in place, and they provided protected learning time and appraisals. Staff had undertaken updates and development activities to ensure their knowledge and skills were up to date. The provider made use of an online training tool for staff training. Staff kept a training matrix to record mandatory training which the service manager reviewed regularly, and this was reviewed at partner meetings. We checked staff files and found most staff had completed mandatory training. However, we found no record that managers had checked what mandatory training one locum clinician had completed, prior to their employment at the service. The service had enough staff. Leaders told us staff always worked within their job description and competency. Where people had specialist needs, such as, a learning disability, staff had received Oliver McGowan training to support these people safely. There was a structured system for clinical supervision.

The service had a recruitment policy, which included the necessary recruitment checks; but staff had not always followed it. For example, the service had not ensured that staff immunity was checked in line with the service’s own recruitment policy. Some recruitment information we asked for was unavailable. For example, during the assessment, we found that some relevant immunisation information had not been collected. We looked at six staff files. There was no record of immunisation status for tetanus, diptheria or polio for two clinical staff members. This did not meet the guidance of the current UK Health and Security Agency. However, we saw evidence of all other relevant immunisation information had been collected and recorded. There was no risk assessment of immunity in the files of two non-clinical staff members.Where staff had exercised their right to refuse immunisation, the practice did not have a documented risk assessment to assess the risks to staff and they had not fully considered the risks to patients. This meant staff vaccination was not maintained in line with national guidelines. It was not clear that managers had identified these gaps in staff recruitment checks. Following our inspection, managers took prompt action to review the gaps in recruitment records. The provider sent us evidence of an audit recording the staff members who have declined vaccination. The service had a staff immunisation policy, last reviewed June 2024 which included reference to vaccination/immunity to hepatitis B for all staff who might come into contact with body fluids, clinical waste and sharps in the course of their duties. Records we checked showed those staff had been screened and completed a hepatitis B immunisation course.

We could not collect the evidence to score this evidence category.

The leaders explained the senior GP Partner was the lead for infection prevention and control, and they carried out regular infection prevention and controls checks of the premises. In addition, staff carried out daily checks of the clinical rooms they worked in. Staff told us that an individual from an external organisation was responsible for the day-to-day legionella control at the service. We saw evidence that this individual had completed legionella awareness training. However, the practice risk register had no record of the risks identified from the legionella risk assessment carried out in September 2023, or log dates of consultation or review with building managers, regarding the required corrective actions.

The service was clean. Clinical rooms were clean and well equipped. However, at the time of our inspection, there were no copies of the cleaning schedule available with evidence of tasks signed off and dates when cleaning tasks were completed. There were arrangements to protect staff and patients from the risks of legionella bacteria. Staff showed us evidence of monthly temperature checks made at the service location to control the risk from Legionella. The service had a legionella control policy. However, staff could not show us a copy of the written Scheme of Control identifying the measures required to control the risks from exposure to legionella bacteria.

The service had completed an infection prevention and control audit in July 2024 and achieved 100% compliance. The service had acted on any issues identified in infection prevention and control audits. During our on-site inspection, we asked staff to show us a copy of the cleaning schedule. Staff told us they were unaware of a cleaning schedule for the service premises, However, following our inspection, leaders spoke with the cleaning supervisor who told staff there were detailed cleaning schedules that were consistently followed by all cleaning contractors. These were stored on the first floor of the building. Following our inspection, leaders sent us copies of cleaning schedules which were signed and dated to show cleaning tasks in the service premises had been completed. The building managers completed legionella risk assessments of the service site dated 08 September 2023. The legionella assessment covered the whole of the building and determined 17 areas as medium and high risk. For example, the assessor identified that there were no documented records of regular testing for legionella in the building. We looked at the risk register but found there was no written action plan to monitor risks identified from the Legionella risk assessment arranged by building managers in September 2023. Following our inspection the practice sent us evidence of a technician report of some remedial work undertaken on site on 30 September 2024, as part of the required corrective actions from the 2023 legionella risk assessment. However, the completed actions had not been recorded on the practice risk register. There was no record of how the outstanding corrective action would be managed in the interim. We saw the service had a system of recorded bi-monthly checks of hot water outlets to ensure that all temperature readings are above 55°C.Following our inspection, the provider sent us evidence of ongoing water sample tests completed three monthly by a subcontractor, to control the risk of legionella.

We could not collect the evidence to score this evidence category.

The leaders explained there was a process for monitoring patients’ health in relation to the use of medicines including high-risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of patients’ repeat medicines. Staff explained the systems they used to manage vaccines, emergency equipment and medicines.

Staff received regular training on medicines management, and felt confident managing the storage, administration and recording of medicines. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). Staff managed medicines-related stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. Vaccines were appropriately stored and transported in line with UKHSA guidance to ensure they remained safe and effective.

The service had a system in place to monitor the storage of medicine. The service had put systems in place to monitor the safe administration of patients’ medicines, the prescribing of repeat medicines and the monitoring of emergency medicines. The service has systems in place to monitor the temperature of vaccine fridges. The service had purchased computer monitoring software to monitor the safe prescribing of medicines. Staff shared performance data which showed the service was ranked in second place out of the 30 practices in Tower Hamlets for performance on drug monitoring. The service had employed a full-time clinical pharmacist to support with medication reviews, medication reconciliation and regular medicine monitoring audits. The provider did not stock any controlled drugs.

As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, and to review if the service was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance. We found that medicines were being prescribed safely and monitoring was appropriate overall. Our clinical record searches found safe management and monitoring of high-risk medicines and people with long-term conditions. We found the service had completed 823 annual medicine reviews in the last three months.

The NHS Business Services Authority (NHSBSA) medicines data from July 2023 to June 2024 for the average daily quantity of hypnotics prescribed per specific therapeutic group was better than the national average for prescribing. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antibiotics issued by the provider was lower than local and national averages. There was a programme of regular clinical auditing of prescribing that focused on improving care and treatment.