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Inspection Summary


Overall summary & rating

Updated 1 April 2019

We carried out an announced comprehensive inspection on 21 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 service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Dr John Keet provides an independent doctors consultation service from premises in the Marylebone area of West London. Patients are typically referred by another medical professional and book appointments in advance. The service provides onward referral to specialist services and liaison with patients’ own GPs and other clinicians as appropriate. The service treats adults only. It typically treats around 5 patients per month.

We received 18 comment cards completed by patients in the days leading up to the inspection. These were wholly positive and described the clinician as thorough and attentive and the environment as clean and safe.

The service is registered to provide the regulated activities of: diagnostic and screening services and treatment for disease, disorder or injury.

Our key findings were:

  • There was a vision to provide a high quality, personalised service with a strong focus on well coordinated care.
  • The doctor was aware of current evidence-based guidance and had the skills and knowledge to deliver effective care and treatment.
  • Patients were able to access the service in a timely way and described the service as caring.

  • The provider had systems in place to protect people from avoidable harm and abuse.

  • The provider had systems in place to record, monitor, analyse and share learning from significant events and safety alerts.

  • The service had arrangements in place to respond to medical emergencies.

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

  • Review and implement appropriate quality improvement activity for example, carrying out documented audits of activity such as prescribing and record keeping.
  • Review the way that notes are stored to ensure these can be safely transported within the premises.
  • Review the process for updating policies so the date of the last or next review is clear.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Updated 1 April 2019

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

Safety systems and processes

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

  • The doctor had conducted various safety risk assessments and had appropriate safety policies, which were regularly reviewed.
  • There were systems to safeguard vulnerable adults and children from abuse. Policies were outlined clearly who to go to for further guidance.
  • The doctor provided examples where he had acted on safeguarding concerns, for example in relation to concerns about a patients’ care workers. He knew how to escalate any concerns to protect patients from neglect and abuse.
  • The doctor’s had received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.
  • A female chaperone could be provided if requested in advance and patients were informed about this. The chaperone (the doctor’s wife) did not have recent training or DBS checks. Patients were informed about the chaperone facility in a written information sheet about the service. The doctor told us that patients who wanted to be accompanied during the consultation were welcome to bring a friend or family member if they preferred.
  • The doctor did not routinely ask patients for proof of identity as they were normally referred by their own doctor along with relevant details of their condition and symptoms.
  • There was an effective system to manage infection prevention and control.
  • The service 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.

  • The doctor was able to manage their caseload to ensure they had the capacity to meet the needs of their patients.
  • The doctor understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
  • The doctor knew how to identify and manage patients with severe infections, for example sepsis and were able to provide an example of doing so.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.
  • The doctor kept emergency medicines on site that could be used to treat the symptoms of anaphylaxis. This was regularly checked to ensure it was in date.

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 recorded and available to the doctor.
  • The service had systems for sharing information with other professionals and agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with DHSC guidance
  • The doctor 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 service had systems and arrangements in place for managing medicines. The service kept prescription stationery securely and monitored its use.
  • The doctor 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 emergency medicines kept on site.
  • The doctor did not prescribe over the telephone.
  • The doctor did not prescribe off-label or unlicensed medicines or controlled drugs. They did not prescribe higher risk medicines that required ongoing monitoring.
  • The doctor shared information when prescribing hypnotics with the patient’s own GP and prescribed short courses only. We also saw evidence that the doctor had sought advice about appropriate antibiotic use from a microbiologist.
  • The doctor did not carry out any formal, documented audits of prescribing although they told us they did review this, for example, to avoid the use of broad spectrum antibiotics when appropriate.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues. The doctor had contracted with an independent health and safety consultant to audit the premises and facilities annually.

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.
  • There were adequate systems for reviewing and investigating when things went wrong.
  • The provider was aware of and complied with the requirements of the duty of candour. The service had systems in place for knowing about notifiable safety incidents.
  • The service had a system to act on and learn from patient and medicine safety alerts.
  • There had been no recently recorded incidents. The last recorded incident had occurred six years previously. The doctor told us they had learned from more recent incidents involving other agencies. They told us they now followed-up any concerns they had, for example, about the quality of social care their patients were receiving after an incident when a patient had developed painful skin ulcers while receiving a home care service.

Effective

Updated 1 April 2019

We found that this service was providing effective care in accordance with the relevant regulations. The service had carried out little formal clinical audit to monitor the quality of care and patient outcomes.

Effective needs assessment, care and treatment

The doctor 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.

  • 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 doctor encouraged patients to share important information about their health with their NHS GP and other relevant professionals. We saw evidence that the doctor had coordinated with GPs, social care staff and pharmacists with the patient’s consent.

Monitoring care and treatment

The service carried out limited quality improvement activity.

  • The doctor obtained written feedback from referring doctors, specialists and patients about the service. We reviewed this and saw that the feedback was very positive.
  • The service did not have a programme of clinical audit or completed audit cycles but the small number of patients limited the scope of potentially useful audit activity.

Effective staffing

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

  • The doctor was appropriately qualified. The service did not use locums or other clinicians on a temporary basis.
  • The doctor was registered with the General Medical Council (GMC) and was up to date with appraisal and revalidation.
  • The doctor maintained up to date records of skills, qualifications and training. The doctor also currently worked within the NHS on a locum basis which provided opportunities to maintain their clinical professional development.

Coordinating patient care and information sharing

The doctor worked with other organisations to deliver effective care and treatment.

  • Patients received coordinated and person-centred care.
  • Before providing treatment, the doctor ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. Patients were asked to bring relevant test results and evidence of prescriptions with them to the consultation. The doctor carried out medicines reconciliation with new patients.
  • 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.
  • 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 insofar as possible.
  • 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 in a timely and accessible way.
  • The service relied on paper records and had systems in place to retrieve, update and file these following a consultation. Records were transported between the consulting room and the records storage room on the third floor in cardboard folders when the consultation was completed. Records were not always well secured within the folders however and there was a risk that pages might become misplaced during transfer.

Supporting patients to live healthier lives

The was a focus on all aspects of patients’ health and wellbeing in relation to their particular condition, symptoms or diagnosis.

  • Where appropriate, the doctor 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.
  • Some patients who completed comment cards for the inspection

Consent to care and treatment

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

  • The doctor understood the requirements of legislation and guidance when considering consent and decision making.
  • The doctor 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.

Caring

Updated 1 April 2019

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

Kindness, respect and compassion

Patients were treated with kindness, respect and compassion.

  • Feedback from patients was positive about the way they were treated. Patients consistently described the doctor as attentive and thorough and several said they had experienced good outcomes as a result of attending the service.
  • The doctor told us they considered patients’ individual needs including cultural, social and religious needs. We were told that an initial consultation would typically take two to three hours and include a comprehensive assessment with the patient.
  • The service provided patients with written information about the service.

Involvement in decisions about care and treatment

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

  • We were told that patients had almost always been able to communicate well in English. The doctor told us that if this was not not the case, patients were asked if they could bring an appropriate family member or friend who could translate.
  • Patients told us through comment cards, that they felt involved and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • The service was small in scale and patients were able to discuss sensitive issues in privacy.

Responsive

Updated 1 April 2019

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

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.
  • 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, the doctor could see patients with mobility difficulties in alternative premises in Harley Street. They had also carried out home visits when the patient was unable to attend the clinic.

Timely access to the service

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that the service was accessible.
  • Referrals and transfers to other services were undertaken in a timely way, for example, diagnostic testing was done the same day if possible.

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.
  • The service had complaint policy and procedures in place.
  • The doctor used complaints and patient feedback to improve. For example, a patient had commented on the doctor’s medical bag being disorganised which made it difficult for them to locate equipment quickly. As a result the doctor had reorganised the contents of the bag.

Well-led

Updated 1 April 2019

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

Leadership capacity and capability

The clinic was run by the doctor as a sole provider. The service had been established for several years.

  • The doctor was clear about issues and priorities relating to the quality and future of services. They understood the challenges to the business.

Vision and strategy

The service had a vision and a strategy to deliver high quality care.

  • There was a clear vision which was set out in a mission statement. The service had a realistic strategy and supporting plans to achieve priorities.
  • The service monitored progress against its goals and objectives.

Culture

The service had a positive working culture with a strong focus on co-ordinating care with other providers for the benefit of patients.

  • The doctor was aware of and had systems to ensure compliance with the requirements of the duty of candour.

Governance arrangements

There were clear organisational structure to support governance. The doctor had systems to maintain the professional development; comply with appraisal and registration requirements. Service policies and procedures were documented and accessible.

Managing risks, issues and performance

The clinic had a range of policies and processes to manage risks. These were not always clearly dated but the doctor was able to describe the process they used to ensure policies were reviewed and up to date.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had some processes to manage current and future performance. The doctor sought feedback about his service from referring clinicians and colleagues in both his private and NHS work.
  • There were processes in place to review incidents, and complaints. There had been few recent incidents or complaints about the service but we saw evidence of action taken to improve as a result of feedback and safeguarding issues.
  • There was limited use of clinical audit to drive improvement for example in relation to clinical record keeping or prescribing audits. The small scale of the service limited the types of audits that could be meaningfully be undertaken.
  • The service had plans in place for major incidents and an arrangement with another clinic in Harley Street should the premises become unavailable at short notice.
  • The doctor contracted with an independent health and safety consultation to carry out an audit of the premises and facilities. This audit included infection control arrangements, fire safety and legionella testing. All recommended actions from the most recent audit had been implemented.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • The service maintained detailed and thorough clinical records. Relevant information was shared with other providers with patients’ consent.
  • The service was aware of the requirements to submit data or notifications to external organisations as required.
  • The service used paper records to manage clinical information. Records were securely filed and stored but we were concerned the file folders were not sufficiently robust to minimise the risk of accidental loss during transfer between the consulting room and records storage area.
  • The service had systems in place to facilitate patient requests to see their own medical records.

Engagement with patients, the public, staff and external partners

The service used feedback from patients, staff members and external partners to improve the range and quality of services.

  • The doctor provided all patients with feedback forms to complete and reviewed the completed feedback about the service. We reviewed the most recent 20 completed forms which were wholly positive.
  • We also reviewed the feedback provided by referring doctors and colleagues. Again this was positive about the doctor’s consultation skills and manner with patients.

Continuous improvement and innovation

There was some focus on learning, continuous improvement and innovation.

  • There was scope to develop more formal clinical quality improvement work including prescribing and records audits.
  • The doctor was able to demonstrate how they kept up to date with relevant guidelines and training and put that into practice in their consultations.