Archived: RPM Health Clinic Warwick

On this page

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

We assessed all quality statements in the safe key question. This is the first inspection for this provider since their registration with CQC. This key question has been rated as requires improvement.Staff were knowledgeable within their role. People were provided with support and information on their care and treatment. However, we found the provider did not always follow national, evidence-based guidelines when providing care and treatment. The provider did not always share information with other healthcare organisations or have embedded, supervised pathways agreed with specialist departments within local NHS institutions. The provider did not always manage infection prevention and control optimally. Some clinical and environmental risks were not well-managed or sufficiently mitigated.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had systems to deal with complaints openly and honestly. The service had not received any complaint or recorded any significant clinical events since it registered with CQC in 2023, so we could not review how these were managed or the outcomes. However, policies were in place, and the provider could describe how information was shared across the organisation. Staff understood the complaints procedure and encouraged people to provide feedback about services. At the time of our assessment the provider was not carrying out any clinical audits of the outcomes of treatment for people. This meant there was no mechanism by which they could continuously monitor, learn and improve the quality of care they provided to people. We found some examples of events that met the definition of a significant clinical event which had not been recorded as such. This evidenced that the provider did not have well-developed and comprehensive systems to enable continuous learning. The provider understood the Duty of Candour (a responsibility to open and transparent with people when things go wrong) and how and when to apply it.

The provider had some systems in place to share important or urgent information with NHS services when required. We saw examples of referral letters to GPs when people required further investigations or follow up in the NHS. However, the provider did not routinely contact people’s general practitioner to verify their medical information or to inform the GP about the treatment being given to the person. We found the provider did not have clear, agreed and embedded referral pathways into local specialist NHS departments such as dermatology. Guidance from the National Institute for Clinical Excellence (NICE), the British association of Dermatology (BAD) and the Royal College of General Practitioners (RCGP) recommends a collaborative approach between community-based healthcare practitioners and their local secondary teams. This is in order to ensure effective clinical oversight and competency and to facilitate referral for complex or emergency cases. The provider informed us that they would continue to notify GPs only with people’s consent. Where consent is given, they will contact the GP directly. Additionally, they plan to explore with people the reasons for withholding consent and ensure that people fully understand the potential risks involved. The provider also stated their intention to engage a specialist GP to provide clinical oversight for their dermatology services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

The provider worked with people to understand and manage risks by providing clear information about their proposed treatment. The provider had adequate emergency equipment and procedures in place to deal with medical and surgical emergencies. There was no oxygen cylinder or defibrillator permanently on-site. However, the provider brought a defibrillator with them for each minor surgery clinic and a council-owned defibrillator was available outside the clinic and easily accessible. Staff were trained in basic life support and in the event of an emergency would call 999 for a paramedic ambulance.
However, we were concerned that not all clinical risks were being managed appropriately. For example, the provider was prescribing a medicine used to treat acne which has been identified as having potential risks if prescribed to people of child-bearing age. To mitigate the identified risks, people who take this medicine and may become pregnant are required to be on a pregnancy prevention programme and have regular pregnancy tests. The provider did not have a robust process for ensuring that pregnancy tests were timely, accurate and from the individual person. The provider did not take all possible steps to confirm that people were on a suitable pregnancy prevention programme, such as contacting the healthcare professional that was prescribing the contraception. The provider did give clear verbal and written information to people about the risks associated with this medicine and asked people to sign a pregnancy prevention agreement. Following our assessment the provider ceased prescribing this specific medicine for acne treatment and so this risk was removed. In response to our concerns, the provider reviewed people that were currently receiving this treatment and provided assurances that appropriate pregnancy prevention plans were in place and pregnancy testing had been carried out.
 

Mostly the equipment, facilities and technology supported the delivery of safe care. The provider was located in the centre of Warwick in an historical building which prevented any alterations to the external appearance. This meant for example, that the provider was unable to install air conditioning systems or window screens and made cooling the clinical rooms difficult during hot weather. The premises were situated on the first floor accessed by a narrow, steep staircase. There was no lift. The provider made these access issues clear on their website and could accommodate wheelchairs users or those with mobility issues at one of their other locations. The service detected and controlled potential risks in the care environment. Contracts were in place to ensure the premises were maintained safely and appropriately.

The provider directly employed 2 members of staff and had 4 self-employed contractors who provided services. Staff received appropriate training relevant to their role. The provider kept records of staff vaccinations, and all staff were immunised as required. The provider had processes in place to ensure staff maintained the appropriate professional registrations. All staff had up-to-date training and were responsible for maintaining their own continuing professional development.
The provider did not have an appraisal system as the only employee had been employed a few weeks before our visit. Self-employed staff had not had appraisals. The provider had access to copies of appraisals for some staff who also worked for other organisations such as locum agencies. The provider was not certain whether they would introduce regular appraisals for all staff
However, the provider had not followed their own recruitment policy for their most recent staff member. The job was not advertised and the provider did not obtain references for the person being considered for the post. However, they did obtain a full employment history and a standard Disclosure and Barring Service (DBS) check. These shortfalls in the recruitment process meant that the process was not fair and equal as it excluded other potential candidates and the provider had not gathered satisfactory evidence of this staff member’s conduct in previous employment concerned with the provision of services relating to healthcare.
We found that staff prescribing a specific medicine for acne could not demonstrate how their training and experience aligned with those required by national guidelines from the Medicines and Healthcare Products Regulatory Agency (MHRA), the Nursing and Midwifery Council (NMC) and the British Association of Dermatologists (BAD). The MHRA stipulates that an advanced nurse practitioner prescribing this specific medicine should work within a consultant dermatologist agreed and supervised pathway. The provider could not provide evidence to show that they had worked with a consultant dermatologist to agree a suitable pathway or that there was any clinical supervision of their prescribing by a consultant. When we highlighted this, the provider told us that they used a variety of peer networks to provide informal clinical supervision and that they could refer people to the local NHS hospital dermatology department via their GP. Following our assessment, the provider voluntarily ceased prescribing this medicine and so the risk has been mitigated. However, should prescribing re-commence, we would need to revisit the matter to ensure compliance with relevant standards.
At the time of the assessment there was insufficient clinical oversight of the minor skin surgery service offered by the provider. The provider could not evidence how the ongoing clinical competence of staff would be assessed and maintained.
 

The provider mostly assessed and managed the risk of infection. There were some systems in place to detect and control the risk of infection spreading and concerns were shared with appropriate agencies promptly.
Observational audits and action plans had been completed. Cleaning schedules were in place and were followed. Risk assessments and audits were completed, and actions taken to mitigate risks. All staff had completed infection prevention and control training to a level suitable for their role. All surgical equipment was single-use and disposable. A suitable range of personal protective equipment was available.
At our inspection we found that the only clinical sink did not meet infection prevention and control standards, as it had an overflow which is potential source of bacteria and taps that were not elbow operated. When we raised this, the provider told us that the sink could not be changed and that the taps could be operated by the wrist, when wearing gloves for example. Following our assessment the provider mitigated the risk of the overflow, by putting in place a schedule of regularly flushing the overflow with water and a suitable disinfectant
As staff were only on the site for one day a week sealed clinical waste bags and full, sealed, sharps containers were transported by staff in their personal vehicles to the main location for collection by an approved waste disposal contractor. The NHS Health Technical Memorandum 07-01 states that bags of clinical waste should be placed in a sealed, lockable, leak-proof container for transportation to mitigate the risks to both the staff member transporting the waste and the public should the car be in an accident. The provider had not risk assessed this process. We raised this with the provider but the provider told us they did not plan to change this arrangement.
 

The provider had effective systems to manage and respond to safety alerts and medicine recalls. People could communicate regularly with the provider via messaging app if they experienced side effects or had concerns about medicines. However, the provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
The provider prescribed some unlicensed medicines for the treatment of skin conditions. These medicines are ones that are licensed for use for a specific condition but can be used “off license” (or “off label”) for another condition for which there is some evidence that they have been found to be beneficial. This is common practice within the medical profession. For example, the provider prescribed a medicine that is licensed as a diuretic (a medicine which treats the build-up of fluid in the body). It was prescribed “off license” for the treatment of acne because it affects the level of a male hormone and can be effective for hormonal acne. We found that when the provider prescribed “off label” medicines, they did not explain to people that these were not licensed for their treatment or discuss the associated risks and benefits.
The provider held a stock of appropriate emergency medicines in a locked cupboard within the clinic room. However, the provider had not risk assessed why they did not stock some medications recommended on the Resuscitation Council UK’s quality standards list. In order to maintain their safety all medicines should be kept at a temperature below 25 degrees Celsius. On the day of our assessment the temperature in the clinic was above 25 degrees and the only way of cooling the room was with electric fans. Due to the movement of air and dust fans must not be used during surgical procedures and the provider did not have any other method for maintaining the medicines at a suitable temperature. As the provider only spent 1 day a week at the clinic, there was also no way of monitoring the temperature when there was no one there. Following our assessment the provider installed a smart thermometer which alerted staff via mobile phone when the temperature rose and purchased a medical grade cool bag in which to store medicines when necessary.