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360 Health- London Bridge Good

Inspection Summary


Overall summary & rating

Good

Updated 30 December 2019

We carried out an announced comprehensive inspection at 360 Health-London Bridge on 11 November 2019. The service was previously inspected on 25 May 2018. In accordance with CQC policy at the time, this service was not rated following that inspection. We found whilst most of the standards were being met, the systems to manage risks at the service were not always effective and there was limited evidence of quality improvement. These issues impacted negatively on the overall standard of governance at the service. A Requirement Notice was made in relation to breaches of regulation 17 of the Health and Social Care Act 2008 (Regulate Activities) Regulations 2014. We also said the provider should formally document risk assessments and leadership roles within the practice policies. We checked these areas as part of this comprehensive inspection and found they had all been resolved.

360 Health-London Bridge is a travel clinic which provides a range of travel vaccinations, medical assessments and health screening offered on an appointment and a same-day, walk-in basis. The service is operated by 360 Health, also known as London Vaccination Clinic. They own seven sites across London which are satellite sites, London Bridge being the main site for the purposes of oversight, management and governance. We did not visit the other sites which operate at differing times of the day and year, depending on patient demand, some consisting of a single room.

The leadership team at the clinic includes the co-founder and chief executive officer who is a nurse prescriber and the medical director who is also 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. There is also an operations director who manages the day to day running of the service.

Clinical services are provided by two nurses, one being the lead nurse, who are overseen by the co-founder and medical director.

Feedback we received through 21 comment cards completed by people who used the service were positive and a patient we spoke with. One commented about some difficulty finding the clinic but was positive about their experience of using the service.

Our key findings were

:

  • There was a system in place for acting on significant events.
  • Risks associated with the premises and the delivery of care and treatment were well managed.
  • There were arrangements in place to protect children and vulnerable adults from abuse.
  • Care and treatment was provided in accordance with current guidelines.
  • Patient feedback indicated that staff were compassionate, the care provided of a high standard and that it was easy to access appointments.
  • The service had a system to receive and respond to complaints.
  • There was a clear vision and strategy and staff spoke of an open and supportive culture. There was effective governance to ensure risks were addressed and patients were kept safe.

Dr Rosie Benneyworth BM BS BMedSci MRCGP


Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 30 December 2019

  • The service

    had

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

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

    At the previous inspection of 25 May 2018, we found not all relevant staff had Disclosure and Barring Service (DBS) checks. We also found

    the risks associated with the lack of a defibrillator and emergency medicines had not been assessed and e

    lectrical safety tests for equipment had not been carried out. At this inspection we found this had been resolved.

    Staff

    had

    the information they needed to deliver safe care and treatment to patients. The service

    had

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

    had

    a good safety record and learned and made improvements when things went wrong.

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 including locums. 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.
  • Parent’s were asked to bring the child’s red book for immunisation appointments or details of immunisations the child already had. They made a note of the parent’s name or asked for a letter of consent from the child’s parent if they were not going to be accompanying them.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. At the previous inspection of 25 May 2018, we found not all relevant staff had Disclosure and Barring Service (DBS) checks. At this inspection we found this had been resolved. It was the service’s policy to undertake Disclosure and Barring Service (DBS) checks 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 adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. The doctor and nurses had been trained to level three in child safeguarding, non-clinical staff were trained to level two or one depending on their responsibilities. Staff knew how to identify and report concerns.
  • There was a notice on display at reception about the availability of chaperones. We were told there had been no requests for a chaperone but the receptionist or operations manager could act as a chaperone if none of the other nurses were available. These members of staff had not had specific training to undertake this role, however this risk was mitigated by the nature of the service which made it unlikely that one of these staff members would be required to undertake this role. The provider undertook to carry out a review and assess whether any non-clinical staff should be trained to enable them to undertake this role.
  • Staff were aware of the issues around human trafficking and female genital mutilation (FGM) and had undergone relevant training. We saw a flow chart setting out the reporting procedure for reporting any such concerns.
  • There was an effective system to manage infection prevention and control. Infection control audits were carried out annually. The most recent audit identified a requirement to obtain a covered bin. This had been sourced.
  • At the previous inspection we found the chairs in the treatment room were made of material and the floor was carpeted. At this inspection we found wipeable plastic chairs were in use and we saw evidence of plans to laminate the floor. We saw a quotation had been accepted and it was expected the work would be completed by the end of the year. To minimise the immediate risk the provider had covered a section of the flooring with a large plastic mat where the patient would be seated during the vaccination procedure. Spillage kits were available and staff knew how to use them.
  • The service had a contract with a professional company to supply sharps bins and collect clinical waste.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. At the inspection of 25 May 2018 we found electrical safety tests for equipment had not been carried out. At this inspection we found this had been addressed.
  • 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. For example, they had carried out an assessment in relation to accessing the building and identified this could be challenging for parents with pushchairs and considered options to mitigate this risk.

Risks to patients

There

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for agency staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. Staff had received training in basic life support and anaphylaxis (serious allergic reaction).
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. At the previous inspection of 25 May 2018, we found risks associated with the lack of a defibrillator and emergency medicines had not been assessed. At this inspection we found this had been resolved. Adrenaline was the only emergency medicine held by the service and we saw this decision had been risk assessed. The service had oxygen but did not have its own defibrillator. However, we saw this decision had been appropriately risk assessed and took into account factors such as the service’s proximity to a hospital (one-minute walk) and a main London rail and tube station which had several defibrillators available on site.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place. The service had a policy which covered all staff.

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. On registration patients were asked to provide a full medical history prior to any vaccines being administered. If any concerns were highlighted, patients were asked to obtain confirmation from their doctor that they could safely receive the vaccination, for instance in the case of patients with immunosuppressant conditions.
  • Patients were provided a printout of all vaccinations administered for them to give to their GP.
  • 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. All medical records were held electronically and saved in an online storage system meaning they were accessible online from any location, subject to the appropriate security protocols, should the service 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 vaccines, controlled drugs and emergency medicines and equipment minimised risks.
  • 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.

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 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.
  • 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
  • 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 including sessional and agency staff.

Effective

Good

Updated 30 December 2019

The provider had systems to keep clinicians up to date with current evidence-based practice. At the previous inspection of 25 May 2018, we found limited evidence of clinical audit. At this inspection we found this had been resolved. Staff had the skills, knowledge and experience to carry out their roles.

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

They were consistent and proactive in empowering patients.

The service obtained consent to care and treatment in line with legislation and guidance

.

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 Travel Health Network and Centre (NaTHNaC) and TRAVAX (NHS website providing up to date health information for UK health care professionals who advise the public about avoiding illness and staying healthy when travelling abroad). The service was also a designated Yellow Fever Clinic.
  • 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.
  • The service stored patient’s records online and was due to move to a new electronic clinical records system which was easier to attach documents and certificates to. This was to meet the needs of their corporate clients in particular, who needed to see up to date data protection certificates, for example.

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. Clinical audit had a positive impact on quality of care and outcomes for patients. For example, clinical skills audits were carried out twice a year to ensure nurses were up to date and correct with regards to record keeping, patient group directives (PGDs) and protocols. Clinical practice was observed, for example for intradermal rabies vaccinations where nurses were required to take photographs of themselves undertaking the procedure in order to check their technique. Document audits were audits carried out randomly to ensure the correct process was being followed.
  • There was clear evidence of action to resolve concerns and improve quality. For example, the service carried out audits of phone calls from patients to the service to ensure receptionists were giving correct information to patients and not trying to provide any clinical advice.

Effective staffing

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

  • All staff were appropriately qualified. Nurses were asked to provide portfolios with evidence of registration with the Nursing and Midwifery Council and of training before they were able to work for the service.
  • The provider had an induction programme for all newly appointed staff. This included a personalised assessment of training needs and they were given an induction pack which included details of the requirements of the role. Staff were presented with a certificate on completion of the induction.
  • Staff checks carried out for bank staff were the same as those for permanent staff. Checks included DBS, national insurance, identification, NMC registration, revalidation, training and appraisals.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation had received specific training and could demonstrate how they stayed up to date.

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, where abnormal test results were received, patients were contacted, the results described and they were signposted to the appropriate service, to interpret the results, for example their GP.
  • 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.
  • 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. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • 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.

Supporting patients to live healthier lives

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

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • 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 30 December 2019

Staff treated patients with kindness, respect and compassion. They

helped patients to be involved in decisions about care and treatment. The service respected patients’ privacy and dignity.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received. All patients were sent a request to review the service on an online consumer review website.
  • Feedback from patients was positive about the way staff treat people. Feedback we received through 21 comment cards completed by people who used the service were positive and a patient we spoke with.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language. They were also offered longer appointments.
  • 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.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • 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. Windows were frosted to aid patients’ privacy and doors were locked if the patient had to remove any clothing.
  • 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 30 December 2019

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

It took account of patient needs and preferences.

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

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

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 told us their patients prioritised flexibility, convenience and speed as well as accessible online services. As such the service ensured patients could be seen and treated on the same occasion and that appointments could be booked online (the process had been streamlined). Saturday and late appointments until 8pm were available to meet the needs of working patients.
  • The service monitored usage to understand when it was busiest and used this information to adjust opening hours, lunch breaks and staff training days. They also ensured patients were assigned the most appropriate nurse, for example children were not assigned to a new or inexperienced nurse.
  • The performance of the service was monitored weekly which included an analysis of occupancy, number of patients seen and the number of patients who failed to attend. This information was used to plan opening hours and the staffing requirements.
  • 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, when patients were initially booked in they were asked whether they had and mobility challenges to ensure these could be met. If children were attending the service parents were advised to come on a Saturday when it was less busy for their comfort.

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. The provider was aware that patients did not always understand the turn around time for test results and they were reviewing how patients could be educated around this to manage patient expectation.
  • 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.

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. Complaints were discussed at weekly meetings and reviewed annually. Learning was shared with all staff.
  • The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, the service had received eight complaints in 2018 mainly about delayed blood test results. As a result, the service had changed the service provider they used to a locally based one and made the information about test results on their website clearer to help patients better understand the time frames involved.

Well-led

Good

Updated 30 December 2019

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

The service had a clear vision and credible strategy in place

.

It had a culture of high-quality sustainable care and there

were clear responsibilities, roles and systems of accountability

. At the previous inspection of 25 May 2018, we found the service did not have a documented business continuity plan in place and leadership roles were not clearly documented. At this inspection we found this had been resolved.

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

learning, continuous improvement and innovation.

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, for example, competition, running costs, miseducation about vaccines and political uncertainty which may impact upon vaccine stocks and supplies. They were able to describe the plans they had in place to address these issues.
  • The service’s co-founder was the chair of the British Global Travel Health Association (BGTHA) and a consultant and educator in immunisation and travel health theory and practice. As part of this role they ensured they were at the cutting edge of travel medicine and regularly presented at and ran conferences and training events on the topic. They also trained nurses to train other nurses in travel medicine and vaccinations.
  • 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. They planned and adapted the service depending on the priorities and requirements of their 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. For example, where patients complained about perceived delays with receiving test results, the service responded and took positive action to expedite the receipt of the results where possible and explained to patients where they had misunderstood the information about turn around times for test results. 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 supervision, 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 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 prioritised supporting staff to pursue other interests they had such as travelling and working with Non-Governmental Organisations (NGOs). The leaders had joined a mentorship and people management programme to ensure best practice and further support for staff.
  • At the time of this inspection there were two nurses directly employed by the service, one being the lead nurse. An additional nurse had been recruited to release the lead nurse from day to day patient duties and allow them more time to oversee the clinical operations of the service and mentor the other nurses.
  • 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.
  • At the previous inspection of 25 May 2018, we found staff leadership roles were not clearly documented. At this inspection we saw a clearly documented team structure which detailed the areas of accountability for each role.
  • 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.
  • For example, the service had identified the main areas of risk for its business which included lone working, security (due to its location), political uncertainty and competition (from other services such as pharmacists). It had plans in place to address these.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through online patient reviews and observed practice. 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 a written business continuity plan 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 service carried out price checks regularly to ensure they remained competitive and used analytics tools to monitor usage of its website in order to make adjustments where required.
  • 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 the public, patients, staff and external partners and acted on them to shape services and culture.
  • The service did not carry out internal surveys but collected feedback through a consumer review website. All patients were sent a link to complete a survey online. We saw that all reviews posted were reviewed and any requiring investigation were followed up on and responded to.
  • Staff could describe to us the systems in place to give feedback. Meetings were held weekly and monthly. Staff were able to give feedback and take part in discussions about the operation of the service and future plans. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement. The service prioritised learning and innovation in the field of vaccination and had a view to training practice nurses and work with Clinical Commissioning Group (CCGs) to improve the understanding and uptake of vaccinations.
  • The co-founder ran external training events about vaccinations and travel medicine and also hosted events where external speakers who were experts in the field presented on various related topics.
  • 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.