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Inspection Summary

Overall summary & rating

Updated 15 February 2019

We carried out an announced follow-up comprehensive inspection on 23 January 2019 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

CQC inspected the service previously on 16 February 2018 and asked the provider to make improvements regarding regulations 12 safe care and treatment and regulation 13 safeguarding. This was because emergency medicines were not available in keeping with best practice guidance; there were insufficient steps taken to liaise with the patients NHS GP; suitable background checks had not been conducted for staff and the provider did not take sufficient steps to ensure adults accompanying children had parental responsibilities.

We checked these areas as part of this comprehensive inspection and found these had been resolved.

At Ultima Vitality the aesthetic cosmetic treatments that are also provided are exempt by law from CQC regulation. Therefore, we were only able to inspect the treatment for the GP services and not the aesthetic cosmetic services.

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

Feedback from patients was positive about accessibility and the flexibility of the service.

Our key findings were:

  • Patients were treated in line with best practice guidance and appropriate medical records were maintained.
  • The environment was clean, a cleaning schedule was in place and this was monitored.
  • An induction programme was in place for staff and staff had access to all policies and procedures.
  • Information about services and how to make a complaint was available in the clinical and on the website however, this information did not include the next steps the patient should take if they were dissatisfied with the outcome of an investigation.
  • Systems were in place to protect personal information about patients. The company and GP were registered with the Information Commissioner’s Office.
  • The service had clear systems to keep people safe and safeguarded from abuse and protect children from harm. This information had been updated and improved since the last inspection.
  • Governance systems and processes were in place; however, the provider did not complete clinical audits.
  • The provider followed the policies and procedures in place.
  • The service encouraged patients to feedback through the website, however, they did not seek direct feedback for example through a comment box, patient survey or questionnaire.
  • The provider did not maximise the dignity and privacy of patients because a privacy screen was not available in the consultation room.

There were areas where the provider could make improvements and should:

  • Review patient feedback processes.
  • Review how privacy and dignity is preserved for patients who need to undress during their consultations.
  • Prioritise the introduction of audits as a part of reviewing the effectiveness of the service, for example, clinical outcomes, seeking consent and completeness of records.
  • Update the complaints policy to include information about independent organisations who would review the outcome of a complaints investigation carried out by the service.
  • Introduce a process to ensure clinical skills are refreshed and updated.
  • Take steps to provide an appropriate sink in the consulting room.
  • Formalise the business continuity plan.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas


Updated 15 February 2019

Safety systems and processes

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

  • The provider conducted safety risk assessments for the service.

  • It had appropriate safety policies, which were regularly reviewed and communicated to staff. 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. Policies were regularly reviewed and were accessible to all staff, the service did not use locums. They outlined clearly who to go to for further guidance.

  • The service had systems in place to assure that an adult accompanying a child had parental authority. This was an improvement from the previous inspection. The policy was to check photo identification and match the child’s birth certificate and details with that of the accompanying adult.

  • The policy promoted contact with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.

  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, this was an improvement since the previous inspection. Disclosure and Baring Service (DBS) checks were undertaken when required.

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check. (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).

  • There was an effective system to manage infection prevention and control.

  • 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.

Risks to patients

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

  • There were arrangements in place for planning and monitoring the number and skill mix of staff needed. 

  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention, a medical emergency flow chart was in place for staff to follow. They used best practice guidance to identify and manage patients with severe infections, for example sepsis.

  • When dealing with medical emergencies the provider had equipment and medicines in place which were in keeping with best practice guidance.

  • There were appropriate indemnity arrangements in place to cover all potential liabilities including medical indemnity insurance.

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.

  • 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 vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery for controlled medicines securely and monitored its use.

  • 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 to protect patient safety.

  • There were effective protocols for verifying the identity of patients including children.

Track record on safety

  • There were comprehensive risk assessments in relation to safety issues.

  • The service did not monitor and review activity. This meant they did not have a clear understanding of risks. However, audits and monitoring activity was one of the actions planned for the immediate future.

Lessons learned and improvements made

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses.

  • There were adequate systems for reviewing and investigating when things went wrong. The service had systems in place to learn from and share lessons identified and themes. However, no serious incidents had occurred.

  • 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 robust systems in place for knowing about notifiable safety incidents.

Systems were in place to ensure that in the event of an unexpected or unintended safety incidents:

  • The service would give affected people reasonable support, truthful information and a verbal and written apology.

  • Written records of verbal interactions as well as written correspondence were stored.

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 share alerts with all members of the team.


Updated 15 February 2019

Effective needs assessment, care and treatment

  • The provider had systems to keep clinicians up to date with current evidence based practice. 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.

  • 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 patients who were not good candidates for the service. For example, people at risk of drug misuse requesting private prescriptions.

  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

  • The service was not actively involved in quality improvement activity. However, the completion of clinical audits was high on the providers on going action plan and risk register.

  • The service used information from outside sources about care and treatment to make improvements.

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 (medical) 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. However, the provider had not reviewed their own training needs in relation to keeping their skills completely updated.

  • Staff whose role included immunisation 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, the patients’ NHS GP’s and test laboratories.

  • 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.

  • The detail of the consultation was shared with patients registered GP unless the patient opted out and refused for this happen. 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, and those for the treatment of long term conditions such as asthma. 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.

  • There were arrangements for following up on people who have been referred to other services.

Supporting patients to live healthier lives

  • Where appropriate, staff gave people advice so they could self-care.
  • Systems were in place to ensure risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients need 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 decide.

A sample of notes were reviewed during the inspection and consent had been appropriately sought, however the service did not monitor the process for seeking consent.


Updated 15 February 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • 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.

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. 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.

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

  • Staff mostly recognised the importance of people’s dignity and respect, however a privacy screen was not provided in the consulting room.

  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.


Updated 15 February 2019

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, the provider had changed the profile of services offered and highlighted the services for sexual health in response to an increased demand.

  • Except for the sink in the clinical room, the facilities and premises were appropriate for the services delivered. This sink had an overflow outlet which did not meet best practice guidance for clinical facilities.

Timely access to the service

Patients could 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. The provider telephoned the patients GP to ensure referrals were received when they expected them to make a referral into NHS services.

Listening and learning from concerns and complaints

  • Information about how to make a complaint or raise concerns was available.

  • The services leaflet did not inform 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 had not received any complaints.


Updated 15 February 2019

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 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.

Vision and strategy

The service had vision and a credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a 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 did not monitor progress against delivery of the strategy.


  • Staff felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients.

  • 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. Staff received regular annual appraisals in the last year.

  • Clinical staff took protected time for professional continual development; however, they did not evaluate their clinical work.

  • There was a strong emphasis on the safety and well-being of all staff and a detailed lone working policy had been introduced since the previous inspection.

  • The service actively promoted equality and diversity and there were positive relationships between staff.

Governance arrangements

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.

  • Staff were clear on their roles and accountabilities.

  • Leaders had established proper policies and procedures, however, activities to ensure safety, and assurance that they were operating as intended were not in place.

Managing risks, issues and performance

  • There was an effective, process to identify and understand current and future risks including risks to patient safety.
  • The were no systems for monitoring processes or to manage future performance. Performance of clinical staff was not audited, there were no examples of audits with regards to consultations, prescribing and referral decisions.
  • Leaders, however, had oversight of safety alerts, incidents, and complaints.
  • The provider had an informal business continuity plan in place for dealing with major incidents, staff could articulate the plan and confirmed the plan had been used on occasion.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.
  • Quality and sustainability were discussed and staff had sufficient access to information.
  • Information about 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 staff and external partners to support high-quality sustainable services.

  • The staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. The service had responded positively and made improvements in response to the CQC inspection in February 2018.

  • Staff could describe to us the systems in place to give feedback for example through the social media. However, the provider did not periodically seek feedback from patients about their experience of using the service and possible areas of improvement.

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 made use of external reviews of incidents and complaints. Learning was shared and used to make improvements.

The leader encouraged staff to take time out to review individual and service objectives and processes.