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Isokinetic Medical Group Good

Inspection Summary


Overall summary & rating

Good

Updated 16 March 2020

This service is rated as Good overall. (previously inspected, 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 Isokinetic Medical Group on 9 January 2020. Isokinetic Medical Group is an independent clinic based in central London which offers private sports and exercise medicine related healthcare. The service also provides treatments for musculoskeletal injuries.

We previously inspected the service on 19 February 2019 at which time we identified governance concerns and served a Requirement Notice under regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report on the 19 February 2019 inspection can be found by selecting the ‘all services’ link for Isokinetic Medical Group on our website at www.cqc.org.uk.

The service sent us a plan of action to ensure the service was compliant with the requirements of the regulations. We carried out this comprehensive inspection on 9 January 2020 to review the practice’s action plan, look at the identified breaches set out in the Requirement Notice and to rate the service.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

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 general exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We received 26 patient Care Quality Commission comment cards. All of the comment cards we received were positive about the service. Patients said they were satisfied with the standard of care received and said staff were approachable, committed and caring.

Our key findings were:

  • Action had been taken since our last inspection such that appropriate arrangements were now in place governing how the service monitored staff pre-employment checks, staff training and staff appraisals.
  • There were adequate systems for reviewing and investigating when things went wrong. For example, we saw evidence the service identified lessons, shared learning and took action as necessary to improve safety.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. For example, we saw evidence that audits were used to ensure care and treatment were being delivered according to evidence-based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • The leadership, governance and culture promoted the delivery of high-quality person-centred care.

We saw the following examples of outstanding practice:

  • The service produced its own bi monthly clinical journal which was circulated to clinicians working at its network of eight global treatment centres and which enabled prompt dissemination of sports medicine best practice.
  • The service had introduced its own sports medicine guidelines based upon a combination of a global audit of more than 1000 of its own patients and an extensive international scientific literature review.

The areas where the provider should make improvements are:

  • Continue to take action to ensure patient surveys capture feedback on the quality of clinical care, as well as capturing existing feedback on customer satisfaction.

  • Continue to take action to recruit female doctors to the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 16 March 2020

We rated safe as

Good:

  • Action had been taken since our last inspection such that appropriate arrangements were now in place governing how the service monitored staff pre-employment checks, staff training and staff appraisals.
  • The service had adequate systems in place for reviewing and investigating when things went wrong. For example, we saw evidence the service identified lessons, shared learning and took action as necessary to improve safety.

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, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • 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.
  • When we inspected in 2019, the service had not ensured all necessary recruitment checks were in place for non-clinical staff members. We asked the provider to take action and at this inspection we noted recruitment checks were in place (including references, health checks and proof of identity. Disclosure and Barring Service (DBS) checks had also taken place (identifying 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).

  • When we inspected in 2019, we could not be assured that all administrative staff had received adult safeguarding training in line with intercollegiate guidance for staff working in healthcare settings. At this inspection, we noted that all staff had received up-to-date safeguarding appropriate to their role. For example, we saw that receptionists had been trained to level 2 children and adult safeguarding. The service’s Managing Director (part located in Italy) spoke positively about how their recent safeguarding training had developed their knowledgebase of local safeguarding systems. Staff knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. For example, an IPC audit had recently taken place and in June 2019 the service commissioned a contractor to assess risks associated with the Legionella bacterium (which can exist in water systems).
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which 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. They knew how to identify and manage patients with severe infections, for example sepsis.

  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. If items recommended in national guidance were not kept, there was an appropriate risk assessment to inform this decision.
  • 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 needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including emergency medicines and equipment minimised risks. We were advised that the service's online prescribing system ensured security and allowed ease of auditing of prescribing practices.
  • The service carried out regular medicines audit (including antibiotic) to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • There were effective protocols for verifying the identity of patients including children.

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. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were appropriate 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. For example, a patient fainting had led to improvements in how such incidents were reported to doctors.
  • 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.
  • They kept written records of verbal interactions as well as 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 16 March 2020

We rated effective as

Good:

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • We saw evidence that quality improvement activity (such as clinical audit) supported the delivery of safe and patient centred care.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines; and Public Health England Physical Activity Guidelines.
  • The service had produced its own guidelines based upon a combination of a review of more than 1000 of its own patients and an extensive international scientific literature review.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.
  • The service used a range of technology and equipment to deliver treatment in areas such restoring muscle strength, re-building endurance and recovery of co-ordination.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients and we saw clear evidence of action to resolve concerns and improve quality.
  • For example, in January 2018 the service commenced an audit of 48 knee patients undergoing rehabilitation to evaluate quadriceps and hamstrings strength gains. We were told that evidence from studies indicated that it was possible to improve strength by 4-5% per week if the patient was strength training 3 times per week (equating to a target of 1.67% per week).

The first phase of the audit highlighted that weekly quadriceps strength gains were at 1.69% but that that hamstring strength gains were at 0.92%. Following delivery of physiotherapist learning workshops, a June 2019 re audit highlighted that strength gains exceeded 2.5% for both hamstring and quadricep strength indicators (35 patients).

We noted additional quality improvement activity. For example:

  • The service holds annual International Conferences on Sports Rehabilitation and Traumatology which covers specialist topics such as re-injury prevention in high impact sports and sport specific rehabilitation. We were told the 2017 event hosted over 3000 delegates from 94 countries.
  • In addition, a specific health improvement program was provided to local general practitioners in partnership with the Independent Doctors Federation.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical Council (GMC) and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.

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 referred to, and communicated effectively with, other services when appropriate. For example, the Medical Director routinely met with medical consultants to discuss and share knowledge regarding care and treatment.
  • 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.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

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. For example, patients were encouraged to exercise in line with the Chief Medical Officer’s Physical Activity Guidelines.
  • 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

.

  • 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 16 March 2020

We rated caring as

Good

:

  • Feedback from people who used the service was positive about the way staff treated people.
  • People were enabled to manage their own health and to maintain independence.
  • Staff across all sections of the service stressed the importance of putting patients first.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received including customer satisfaction and quality of clinical care received. For example, 

    the service recorded a clinical evaluation in patient records at the beginning of a treatment and at the end; seeking patient feedback on, for example, pain, stability deficit and range of movement deficit. Leaders told us the reason evaluations were stored in clinical records was to ensure accurate feedback from every patient on treatments methods and outcomes, as opposed to relying on the chance of patients completing a questionnaire.

  • Feedback from patients was positive about the way staff treat people.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • Reception staff stressed the importance of treating each patient as an individual and with respect.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also 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.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Clinical leaders spoke positively about how the service focussed upon guiding patients to reach their best outcome.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 16 March 2020

We rated responsive as

Good

:

  • People could access the right care at the right time and access to appointments and services was managed to take account of people’s needs, including those with urgent needs.
  • The appointments system was easy to use and supported people to make appointments.
  • Complaints and concerns were always taken seriously; and responded to in a timely way. Improvements were made to the quality of care as a result of complaints and concerns.

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. For example, following analysis of a recent significant event, the service had increased the availability of doctors at weekends.
  • 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. For example, wheel chair accessible toilets and shower facilities.
  • The provider also produced bespoke information for young people using the service.

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, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns 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. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 16 March 2020

We rated well-led as Good

:

  • Action had been taken since our last inspection such that appropriate arrangements were now in place governing how the service monitored staff pre-employment checks, staff training and annual staff appraisals.

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

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

  • There was a strong emphasis on the safety and well-being of all staff. For example, the service provided a range of staff benefits including private GP access (funded by the company), occupational health and access to in person and phone based clinical psychology services.

  • Governance arrangements now supported the delivery of high quality and patient-led care.

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 and external partners (where relevant).

  • 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.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. We noted that following our February 2019 inspection, the provider had taken action to improve governance arrangements such that all administrative staff had now received an annual appraisal. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team and had also received annual appraisals. They were given protected time for professional time for professional development and evaluation of their clinical work.

  • There was a strong emphasis on the safety and well-being of all staff. For example, the service provided a range of staff benefits including free GP access, occupational health and access to in person and phone based clinical psychology services.

  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff felt they were treated equally.

  • There were positive relationships between staff and teams.

  • Extensive training beyond mandatory requirements for all levels of staff within the organisation. For example, all new staff are required to attend a week of training at the provider's HQ in Bologna; which is followed by an examination.
  • All staff were invited to attend annual conferences (at the expense of the company).
  • The provider supported charities tackling bullying and promoting physical activity; using monies collected from the cancellation fees charged to patients. 
  •  The service also engaged with the local community through its 'Walk with a doctor' physical activity programme and a Scholarship programme. 
  • The service organised its own ‘Walk with a Doc’ event. This is a  weekly, free Regents Park based physical activity programme entailing a doctor giving a brief presentation on a health topic and then leading participants on a walk at their own pace. A patient spoke positively about the mental and physical benefits of the programme.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • We noted action had been taken since our last inspection such that appropriate arrangements were now in place governing how the service monitored staff pre-employment checks, staff training and annual staff appraisals. For example, the service had recently introduced regular governance meetings to oversee these and clinical service areas. The service had also introduced an effective system to monitor mandatory training due dates and compliance by the whole team.

  • 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. 

  • We noted a proactive approach to multidisciplinary meetings to ensure best patient outcomes including, for example, weekly review meetings with each doctor and physiotherapist; and weekly meetings where doctors discussed clinical concerns. The Medical Director also regularly attended multidisciplinary team meetings external to the organisation.

  • 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.

  • Innovative approaches were used to gather feedback from people who used the service

Managing risks, issues and performance

There was clarity around 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. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service 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, the public, staff and external partners 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.

  • Staff could describe to us the systems in place to give feedback. For example, regular supervision meetings, team meetings and annual staff conferences. Staff told us they felt valued as team members.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement. For example, the service was part of a global network of eight centres which routinely shared best practice and examples of innovation.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work including a research department, bi monthly scientific journal and annual conference.
  • In 2019, the service held a clinical conference for the wider clinical community entitled ‘ The Role of the Physician in Patient Wellness’. This conference was held in London with international faculty and delegates to compare best practice. In addition, a specific health improvement program was provided to local general practitioners in partnership with the Independent Doctors Federation.