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Cumbria Medical Services Limited Outstanding

This service was previously registered at a different address - see old profile

Inspection Summary


Overall summary & rating

Outstanding

Updated 16 July 2019

We carried out an announced comprehensive inspection at Cumbria Medical Services on 24 May 2019 as part of our inspection programme.

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.

We have rated this practice as outstanding overall.

We found that:

  • The service provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs. Outcomes for people who used the service were consistently good.
  • People were truly respected and vauled as individuals and were empowered partners in their care. Feedback from people who used the service was continually positive about the way staff treated people.
  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.
  • The way the service was led and managed promoted the delivery of high-quality, person-centred care. There was strong collaboration across all staff and a common focus on engaging with patients and other services to improve quality of care and people’s experiences.
  • The leadership drove continuous improvement and safe innovation was celebrated.

Patient feedback was extremely positive. Forty one people provided feedback about the service during the inspection.

We saw several areas of outstanding practice:

  • People who used the service were active partners in their care and were consulted at each stage about where and when they would like to be seen. Patients told us they felt reassured and cared for by all staff at the service. As as a result, patient feedback about care at the service was highly positive. For example, between 98% and 100% of patients across the various areas (dermatology, minor surgery, ophthalmology, etc.) said they would recommend the service to family and friends.
  • At the time of inspection the average waiting time was four weeks and for some clinics patients were often seen within two weeks, despite the service setting a target of seeing all patients within eight weeks. Extra clinics were scheduled if waiting times reached six weeks, or if patients would have to travel too far to attend. We checked appointment availability during the inspection and saw that there were dermatology and minor surgery appointments available within the following week.
  • Due to the difficulties experienced in recruiting doctors in Cumbria, the service offered a bursary to local students who wanted to study medicine in order to encourage more people from Cumbria to train as medical professionals. They were also funding a dermatology diploma for a local GP to gain more experience in dermatology.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 July 2019

  • Performance showed a good track record in safety.
  • There were clearly defined and embedded systems, processes and practices to keep people safe.
  • Openness and transparency about safety was encouraged.
  • Staff received up-to-date training in systems, processes and practices.

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.
  • 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.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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. They 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.
  • 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.
  • 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.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities

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.
  • Any samples sent for pathology were checked twice to ensure they were correctly labelled. This process had been implemented following a significant event.

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 securely and monitored its use.
  • The service carried out regular medicines audit 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.

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. For example, improvements to waste disposal had been put in place following a sharps injury to a clinician.
  • 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. At the time of inspection individual clinicians were signed up to receive safety alerts. Previously, a system had been in place where alerts were received by the service manager and forwarded to clinicians to ensure they had been read and acted on. This system had been disrupted by the sudden change in service manager, however within a day of the inspection we saw evidence that it had been reinstated with the new service manager.

Effective

Good

Updated 16 July 2019

  • People had good outcomes because they received effective care and treatment than met their needs.
  • People’s care and treatment was planned in line with current evidence-based guidance.
  • People had comprehensive assessements of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing.

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.
  • 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.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and accreditation were proactively pursued.
  • Service Quality and Performance reports were produced for each area of the service (for example, dermatology) on an annual basis to measure performance and monitor where patients were discharged following treatment or referred on to another service. These were available on the service’s website so they could be viewed by patients.
  • Clinical performance was monitored through audit. For example, the accuracy of diagnosis by each clinician against the outcome of histology was measured. The service managed a high level of accuracy in initial diagnoses. In 2017, between 77% and 96% initial diagnoses in dermatology were correct. This remained high in 2018 with between 81% and 90% of initial diagnoses proving correct. For surgery the accuracy of initial diagnoses was between 94% and 98%. The service then reviewed those diagnoses which were initially inaccurate. We saw that no serious conditions had been missed or identified late as a result of an inaccurate initial diagnosis.
  • Post-operative infection rates were monitored. Patients were sent a questionnaire 12 weeks after their operation to ask whether or not they had sought treatment for a post-operative infection. Of the 1719 patients who attended the service for minor surgery between April 2018 and March 2019, 19 (1%) reported a post-operative infection which required antibiotics.

  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For example, the service had completed audits into fasciectomy under local anaesthetic and adrenaline for Dupuytrens Contracture in a community, basal cell carcinoma management in a community-based dermatology service, and glaucoma management. All of these audits were presented nationally as well as locally and internally within the organisation.

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 and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council 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.
  • Healthcare assistants were given in-house training in areas such as sterile technique, assisting with minor surgery, and post-operative wound care.

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.
  • 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. 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. The service produced information leaflets and published information on their website to help patients to manage their conditions after treatment and to promote improvement. For example, there was a patient newsletter available on the website which included pictures and information about when to seek advice about skin lesions and moles.
  • 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. Since the last inspection in 2018, the service had invested in a digital solution to ensure that clinicians took written consent from patients who were having vasectomy operations. All patients received detailed information to allow them to give informed consent to a procedure, at which point they signed a digital document which went straight into their patient record on the computer system.

Caring

Outstanding

Updated 16 July 2019

  • This data was similar to the feedback received from patients who attended the service for other treatments, with between 85% and 100% of patients rating the service as excellent, and between 98% and 100% saying they would recommend the service to family and friends.

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.
  • People who used services were active partners in their care. Staff always empowered people who used the service to have a voice. 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. Of the patients who underwent minor surgery between April 2018 and March 2019 and responded to the request for feedback, 100% reported they were involved as much as they wanted to be in their care and treatment. This aligned with comments left on the service’s website and iwantgreatcare.com.
  • 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.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

The service monitored the premises at which clinics were held and had service level agreements in place with the people responsible for those premises in order to ensure patients’ privacy and dignity could be maintained while they were operating at those sites.

Responsive

Outstanding

Updated 16 July 2019

  • People could access appointments and services in a way and at a time that suited them.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity 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 service understood the needs of its population and tailored services in response to those needs (for example: online services, advanced booking of appointments, and advice for common ailments treated by the service.)
  • The service had service level agreements in place to ensure that facilities and premises were appropriate for the services delivered.
  • Translation services and hearing loops were available at all sites used by 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. Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment. The service aimed to see all patients within eight weeks. At the time of inspection the average waiting time was four weeks, however, for some clinics they were often seen within two weeks. Extra clinics were scheduled if waiting times reached six weeks, or if patients would have to travel too far to attend. We checked appointment availability during the inspection and saw that there were dermatology and minor surgery appointments available within the following week.
  • The service aimed to deliver care as closely as possible to the patients’ home, offering services from 11 different locations across the county. Patients could choose the venue and the time of appointment that was most suitable to their needs.
  • There was no set length for appointment times, instead referrals were assessed by clinicians and appointments were set depending on the complexity of the case. Therefore longer appointments were available for anyone who needed them, and appointments for new patients were often longer to give time for a full assessment.
  • The service made reasonable adjustments when patients found it hard to access services. For example, some visits were carried out in patients’ own homes if they had difficulty travelling to the service and if the visit could be appropriately carried out there. Doctors at the service would also call patients, if this was appropriate, to avoid them having to travel to clinics.
  • Patients with the most urgent needs had their care and treatment prioritised. There were same day appointments available for those who urgently needed them. Patients could request an earlier appointment if they felt they needed one. Patients we spoke to told us this was often accommodated.
  • The service employed a team of administrators who answered calls and made bookings. There was a cancellations board in the central office where bookings were made. This meant that as soon as an appointment was cancelled it could be offered to another patient.
  • Patients could email the service through the website. These emails were monitored daily and responded to promptly.
  • The service had previously run clinics on a Saturday over a four-week period to help clear the waiting lists of patients who were scheduled to be seen in secondary care.
  • The service operated from 8.30am to 5pm from Monday to Friday. From July 2019 evening clinics were due to be offered in Cockermouth and additional daytime clinics will be offered in Egremont.
  • Patients we spoke to or who left comment cards or reviews on I Want Great Care stated they were happy with access to the service. Patients told us they were always able to get an appointment when they needed one. We saw multiple examples of positive feedback from patients which showed the impact of timely access to care. Patients highlighted the benefits of having a choice of locations where they could be seen, reducing the need to travel for services in an area with low provision of public transport. We saw examples of cases where the level of access provided by the service had resulted in patients avoiding hospital admissions.

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. For example, as a result of a complaint all patients who had a punch biopsy had a suture to ensure it remained closed.

Well-led

Outstanding

Updated 16 July 2019

  • There was strong collaboration across all staff and a common focus on engaging with patients and other services to improve quality of care and people’s experiences.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality, person-centred care.
  • Rigorous and constructive challenge from people who used services, the public and stakeholders was welcomed and seen as a vital way of holding services to account.
  • The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new ways of providing care and treatment.

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.
  • A new service manager had recently taken up their post. They received a comprehensive handover from the outgoing manager, who had compiled an “A-to-Z” service handbook to help them with all aspects of role. The new manager had been in post 7 weeks by the time of inspection but she was fully up-to-speed due to the handover and they systems the service had in place.

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.
  • 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. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. 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.
  • 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.
  • Staff were clear on their roles and accountabilities. Members of the administrative booking team had their own lead areas for which they were responsible.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • There were monthly service meetings with the service manager and the three lead partners. Administrative meetings were also held monthly.

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.
  • 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.
  • There were service level agreements in place to ensure that facilities and premises were appropriate for the services delivered.

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. There was strong collaboration across all staff and a common focus on engaging with patients and other services to improve quality of care and people’s experiences.

  • Rigorous and constructive challenge from people who used services, the public and stakeholders was welcomed and seen as a vital way of holding services to account.
  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. The service had worked with a patient to set up an active virtual patient participation group (PPG), while patients were also sent a text message after their appointment to ask for feedback on their experience. The service had a patient newsletter which included information on how to join the PPG as well as health promotion information.
  • We spoke with the patient who had helped to establish the virtual PPG. They told us that the service was very open to ideas and receptive to feedback. They reported that there were lots of channels for feedback open to patients and that it was clear to them that the clinicians and staff at the service exchanged ideas.
  • The service was transparent, collaborative and open with stakeholders about performance. Service Quality Reports, which detailed performance in each of the key areas of the service, were publicly available on the service’s website.
  • The service was keen to work with other services to share the knowledge they had in their areas of expertise. To this end, the service ran a number of events throughout the past year including a dermatology study day, minor surgery skills, upper limb orthopaedic study evening, ophthalmology conditions and other talks to physiotherapists and practice nurses in the area. They also ran two dermatology teaching sessions for physician associates.
  • GPs, GP trainees and general surgery registrars were regularly invited to observe clinicians at the service to promote learning.
  • The service had promoted their model for community-based surgery to other clinical commissioning groups and providers from across the country who had expressed an interest.
  • Staff could describe to us the systems in place to give feedback. 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.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation. The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new ways of providing care and treatment.

  • There was a focus on continuous learning and improvement at all levels within the service. Performance was continually monitored to look for ways to improve, and the results of audits which had led to improvements were presented to external agencies.
  • 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.
  • Due to the difficulties experienced in recruiting doctors in Cumbria, the service offered a bursary to local students who wanted to study medicine in order to encourage more people from Cumbria to train as medical professionals. They had also funded a dermatology diploma for a local GP to gain more experience in dermatology.
  • There were plans in place for the service to move into new premises, which would allow them to offer services from their own site.
  • The service offered a range of in-house learning to their staff, such as teaching sessions on dermoscopy for clinicians.
  • The service had been in conversation with a local acute hospital to discuss the possibility of moving towards an integrated dermatology service.
  • The service continued to expand and treat more patients. The service treated 18,826 people in 2018-19, an increase of 1,315 from the preceding 12 months.