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Go Global Vaccinations and Travel Health Clinic Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 December 2019

This service is rated as Requires improvement overall. (Previous inspection September 2018 (not rated)).

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Go Global Vaccinations and Travel Health Clinic on 23 October 2019 as part of our inspection programme.

The travel health specialist nurse 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.

We received 22 comment cards from clients who had used the service. All were positive about the care received. Many clients commented how professional and knowledgeable the travel health specialist nurse was and how quickly they were responded to when they requested information and advice regarding their travel needs.

Our key findings were:

  • There were some processes in place to identify and review safety risks and issues, although others had not been identified or considered. For example, there was no infection control audit and we found some infection control issues that would have been identified had an appropriate assessment taken place.
  • The process for prescribing using a Patient Specific Direction was not in line with legal requirements.
  • Health and safety risks had not been identified or formally assessed and we found some items of equipment had not been calibrated in accordance with manufacturers’ instructions.
  • Governance arrangements were inconsistently identified and reviewed, and we found there was little evidence of monitoring, clinical audit or quality improvement activity to ensure services were safe or effective.
  • There were appropriate safeguarding arrangements in place to keep clients safe and safeguarded from abuse.
  • Client risk assessments were thorough and determined the most up to date travel health recommendations supported by guidance.
  • The provider utilised resources and information from reliable and evidence based sources and used these to inform decision making processes.
  • Training, regular updates and opportunities to develop had been fully established within effective processes.
  • Clients were supported to make decisions and advised where to go for additional sources of support and information, when required.
  • Patient feedback was positive about the care and treatment received.
  • The provider had considered the needs of the population using the service and offered flexible appointments.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

The areas where the provider should make improvements are:

  • Develop methods of gaining client feedback to include an assessment of the quality of clinical care received. Also consider how verbal concerns received as feedback can be utilised in analysing patient satisfaction trends.
  • Patient feedback should be actively sought. Identify how feedback can be retained for an appropriate length of time.
  • Improve how clients can access the complaints process online.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Inspection areas

Safe

Requires improvement

Updated 20 December 2019

We rated safe as

Requires improvement because:

There were some processes in place to identify and review safety risks and issues, although others had not been identified or considered.

Safety systems and processes

The service

had systems in place to keep people safe and safeguarded from abuse. However, infection control processes and health and safety risks required a review.

  • The provider had appropriate safeguarding policies, which were regularly reviewed and updated. They outlined clearly who to go to for further guidance or information. Both the travel health specialist nurse and the GP had been trained to the appropriate level for child and adult safeguarding. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service had arrangements with other agencies to help support patients and protect them from neglect and abuse. The service took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The travel health specialist nurse had undertaken additional training to protect clients from abuse, including recognising young female clients at risk of female genital mutilation and an awareness of modern day slavery.
  • Both the travel health specialist nurse and the GP had a Disclosure and Barring Service (DBS) check for their role. (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 were no other staff who worked for the provider.
  • The provider did not offer a chaperone service as they were the sole clinician with no other staff working in the clinic. They had assessed there were limited occasions when someone would need a chaperone due to the nature of the consultation and subsequent vaccination process. If a client requested a chaperone, they were asked to bring a friend or relative they trusted to the consultation.
  • The travel health specialist nurse had not carried out an infection prevention and control audit or undertaken any monitoring. We were shown a hand hygiene audit which did not identify the travel health specialist nurse was wearing nail polish (infection control standards recommend clinicians are bare below the elbows, including not wearing wrist watches, jewellery (other than a plain wedding band) and nail polish).
  • The travel health specialist nurse undertook the cleaning duties and showed us their cleaning schedules. We noted the window blinds had not been included in the cleaning schedule. This could have been identified through an appropriate audit and monitoring of infection control.
  • There were systems in place for safely managing and disposing of healthcare waste.
  • Regular legionella water sample testing and hot water temperature checking was being carried out in line with guidance and following a suitable risk assessment. (Legionella is a particular bacterium that can be found in water supplies).
  • The provider had arranged for equipment checks to be carried out (such as calibration and portable appliance testing). We noted the equipment used was safe and maintained according to manufacturers’ instructions. We found a blood pressure machine and a set of weighing scales had not been calibrated. The travel health specialist nurse told us these items were not frequently used. They had not considered the risk associated with using equipment that had not been appropriately maintained.

Risks to patients

There

were systems in place to assess, monitor and manage risks to patient safety, although not all risks had been appropriately identified or reviewed.

  • The travel health specialist nurse understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. We were shown an example of an emergency which had been added to the significant events log.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. The provider had purchased an automated emergency defibrillator since the last inspection and had received training in its use. We saw the oxygen cylinder was checked regularly, although the checking process did not include opening the valve to ensure there was a flowing oxygen supply. (Checks of the flow of oxygen are important to mitigate the risk of there being an issue with the valve or the indicator of the amount of oxygen remaining).
  • There were appropriate indemnity arrangements in place for both the GP and the travel health specialist nurse.
  • We saw an up to date fire risk assessment with no urgent actions required to be completed. There was a record of fire alarm system checks and firefighting equipment checks. The provider had also ensured utilities checks had been undertaken including boiler servicing, a gas system inspection and an electrical installation condition report.
  • An overall health and safety risk assessment for the premises and environment had not been carried out. The inspection team noted loop cord blinds that had not been appropriately secured in the waiting area and there was no lone working policy or protocol in place. The travel health specialist nurse told us they would review this after the inspection and sent us a template for the health and safety risk assessment they would use.

Information to deliver safe care and treatment

The travel health specialist nurse and the GP had

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

  • Individual patients were requested to complete a health assessment questionnaire at the time of the first consultation and the travel health specialist nurse undertook a risk assessment to ensure all their travel health requirements were being met.
  • 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 the clinicians in an accessible way.
  • The service had systems for sharing information with external agencies, such as the patient’s NHS GP service.
  • The provider did not have 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. (There is a risk that not having a suitable arrangement in place could affect future patient care and access to records if the organisation ceased to exist).

Safe and appropriate use of medicines

The service

had systems for appropriate and safe handling of medicines, although the prescription process for Patient Specific Directions was not in line with legal requirements.

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. When required, the GP wrote private prescriptions on headed paper.
  • Patient Group Directions (PGDs) had been written and adopted by the clinic to allow the travel health specialist nurse to administer vaccinations in line with legislation. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment).
  • When a PGD was not appropriate for the travel health nurse to offer or recommend a vaccination, the vaccination was given under a Patient Specific Direction (PSD). (A PSD is a written instruction, from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis). The travel health specialist nurse would undertake a risk assessment of the travel needs of the client and contact the GP by telephone to request a PSD be written. The GP gave a verbal authorisation which the travel health specialist nurse would document as being given in the care record. The vaccination was then administered, and the PSD prescription would be given or sent to the clinic at a later time (usually within a few days of the PSD being given). This was not in line with legal requirements as the PSD should be written at the time of the consultation and be appropriately signed. The GP told us they had reviewed the process after the inspection and would commence with an email PSD, with the original prescription being sent to the clinic to add to the clinical record.
  • The travel health specialist nurse routinely sent information to the National Travel Health Network and Centre (NaTHNaC) to advise of patients receiving a specific vaccination. The travel health specialist nurse told us they kept a log of all these separate from the patient individual records to refer to, if necessary. There were no other audits or monitoring of vaccines given.
  • Vaccines were stored in medical fridges which had been appropriately maintained and temperature checked. All the vaccines we viewed were in date and stock was rotated regularly.
  • The service prescribed some vaccines for unlicensed indications, for example for the treatment of rabies. (Vaccines are given licences after trials have shown they are safe and effective for treating a particular condition. Use of a vaccine for a different medical reason than is listed on their licence is called unlicensed use and is a higher risk because less information is available about the benefits and potential risks). There was clear information on the consultation form to explain that the vaccines were being used outside of their licence, and the patient had to acknowledge that they understood this information. Additional written information was also given to patients.

Track record on safety and incidents

There was limited evidence the provider monitored or reviewed its own safety processes and performance.

  • The provider did not engage in formal reviews or monitoring of activity and we were told the travel health specialist nurse and GP discussed these on an ad-hoc basis as required. The discussions were not documented.

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. The provider 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 learned and shared lessons identified themes and took action to improve safety in the service. For example, following an incident the travel health nurse specialist reviewed their history taking and questioning processes.
  • We noted there were two incidents that had not been documented or reviewed as a significant event but had been reflected on and learning opportunities identified and acted on. The provider had not documented which types of incidents should be raised or escalated using this process.
  • 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 provider acted on and learned from external safety events as well as patient and medicine safety alerts. They were aware of, and told us they had discussed, an alert regarding Yellow Fever vaccination.

Effective

Good

Updated 20 December 2019

We rated effective as

Good

because:

The provider utilised resources and information from reliable and evidence based sources and used these to inform decision making processes. Training, regular updates and opportunities to develop had been fully established within effective processes. Clients were supported to make decisions and advised where to go for additional sources of support and information, when required.

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, including Public Health England’s best practice guidance.
  • The travel health specialist nurse attended training courses throughout the year and received updates from the National Travel Health Network and Centre (NaTHNaC). (NaTHNaC is a service commissioned by Public Health England to provide resources to clinicians who administer travel vaccinations). They also belonged to the international society of travel medicine (a member’s only community where travel vaccine updates and alerts are produced. These alerts are international and may not always be in line with England’s standards and guidance). In addition, the travel health specialist nurse attended conferences and external events as well as undertaking online training and updates.
  • The travel health specialist nurse carried out comprehensive travel assessments for each client including their medical history and their travel requirements prior to recommending or administering treatments.
  • The clinic offered consultations to anyone who requested one, and paid the appropriate fee, and did not discriminate against any client group.

Monitoring care and treatment

The service was not actively involved in quality improvement activity.

  • We reviewed service policies and saw no reference to reviewing, auditing or monitoring the service against the policies, guidelines or standards. The health and safety policy outlined the responsibility of the “practice manager” (in this case the travel health specialist nurse) to undertake inspections, but this had not taken place.
  • There had been no clinical audits undertaken. The travel health specialist nurse told us the service was small and quality was monitored on a daily basis and discussed weekly with the GP. The provider could not demonstrate these discussions had taken place.
  • The travel health specialist nurse had not made arrangements for formal peer review or clinical supervision to take place. We saw their Nursing and Midwifery Council (NMC) revalidation documentation from 2017, including reflective practice and continuing professional development, which highlighted some areas of learning had been used to improve quality.

Effective staffing

The travel health specialist nurse and GP had the skills, knowledge and experience to carry out their roles.

  • Both the GP and travel health specialist nurse were appropriately qualified and registered with the General Medical Council (GMC) and NMC (respectively). Both were up to date with revalidation.
  • Up to date records of skills, qualifications and training were maintained. The travel health specialist nurse had received specific training for their role and could demonstrate how they stayed up to date. This included specialist training from NaTHNaC to allow them to administer the yellow fever vaccine.
  • The provider had access to online learning and training modules and we saw certificates of training including basic life support, mental capacity act, infection control, health and safety, fire safety, safeguarding (adults and children) and confidentiality.

Coordinating patient care and information sharing

The travel health specialist nurse and GP worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care.
  • All patients were asked for consent to share details of their consultation and any medicines or vaccinations prescribed with their registered NHS GP on each occasion they used the service. Once consent had been given, a letter was sent, or hand delivered by the provider.
  • Patient information was available to the GP, if they required to have access to any records, prior to prescribing a medicine or vaccine.
  • The information needed to plan and deliver care and treatment was available to the travel health specialist nurse in a timely and accessible way. They had computer access to assess travel requirements and hand written records were securely stored and available to refer to.

Supporting patients to live healthier lives

The service was consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, the service gave people advice so they could self-care. Patients were given general and specific travel health advice and could purchase mosquito nets, sterile needle packs and other equipment needed to keep them safe whilst travelling.
  • Risk factors were identified and highlighted to patients. For example, during a consultation the travel health specialist nurse recognised a client had not received an immunisation recommended as part of the UK immunisation schedule for children and adults. They had recognised there was an outbreak of one of these communicable diseases in the clients travel schedule and recommended they have the immunisation as well as their travel vaccines.
  • Where appropriate care or treatment concerns were highlighted to their normal care provider for additional support. For example, a client had been assessed by the travel health specialist nurse and was found to be taking a medicine that contraindicated the use of a travel vaccine. The client was referred back to their NHS GP for further advice and support.
  • Where clients’ needs could not be met by the service, they were redirected to their NHS GP.

Consent to care and treatment

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

.

  • The travel health specialist nurse understood the requirements of legislation and guidance when considering consent and decision making.
  • Clients were supported to make decisions, including an assessment under the principles of Gillick competency, for under 16 year olds.
  • Each consultation required informed and signed consent from clients before vaccinations or other medicines could be administered or recommended. This included any off licence prescriptions and parents consenting for their child.

Caring

Good

Updated 20 December 2019

We rated caring as

Good

because:

Patient feedback was positive about the care and treatment received.

Kindness, respect and compassion

Patients told us they were treated with kindness, respect and compassion.

  • We received 22 Care Quality Commission (CQC) comment cards from clients who had used the service. All the cards contained positive feedback about the service, including how caring the travel health specialist nurse was and treated clients with dignity and respect.
  • The provider had requested feedback from patients during September 2018. We were told the results were positive about the service provided. The provider had not kept the completed survey forms and had not analysed the feedback or documented the overall themes. The survey was structured to request client satisfaction and did not include feedback on the quality of clinical care provided.
  • We were told there was additional patient feedback available on the search engine and social media sites. All the comments and feedback we saw was positive about the care provided.

  • The service gave clients timely support and information.

Involvement in decisions about care and treatment

The travel health specialist nurse helped patients to be involved in decisions about care and treatment.

  • From the 22 CQC comment cards received from clients who had used the service, we were told information provided about travel vaccines and travel health was helpful and informative. Clients told us 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.
  • There was clear and detailed information available on the service website outlining the types of services offered and the variety of vaccinations available. The website also provided clear guidance about the cost of vaccinations and service fees.
  • The travel health specialist nurse communicated with people in a way that they could understand, and undertook to offer information in an effective way. If a client required additional support to understand the information during a consultation, they were offered to take reading materials home with them for a member of their family or a carer to go through with them.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • The service recognised the importance of people’s dignity and respect.
  • The consultation room door was closed during client consultations and windows were suitably dressed to ensure privacy.
  • Clients had to book an appointment to be seen which minimised cross client contact in the waiting room, as the appointments were managed solely by the travel health specialist nurse who could control timings and assess if longer appointments were required.

Responsive

Good

Updated 20 December 2019

We rated responsive as

Good

because:

The provider had considered the needs of the population using the service and offered flexible appointments. Patient feedback was positive about the service.

Responding to and meeting people’s needs

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

It took account of client needs and preferences.

  • The provider offered flexible appointments (including outside of core clinic hours, by arrangement) in response to client needs.
  • The service was a dedicated Yellow Fever centre and was able to accommodate client needs around demand for this vaccination.
  • The facilities and premises were appropriate for the services delivered.
  • There was level access, for clients with a reduced mobility, to the waiting room and clinical room.

Timely access to the service

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

  • Clients could access information, make an enquiry or request to book an appointment using an online contact form, through the service website.
  • The clinic was provided solely by the travel health specialist nurse. When the clinic was closed, the telephone number was diverted.
  • From the 22 CQC comment cards received from clients using the service, we were told that appointments were easily available and at a time to suit them.

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 in the waiting room. The information was not available on the service website. The provider told us they would arrange for this to be added after the inspection.
  • The provider told us they had not received any formal written complaints in the preceding 12 months. The travel health specialist nurse told us about two informal complaints regarding clients who had arrived at the clinic without a pre-arranged appointment. They had raised concerns that the clinic door had not been answered. The service did not see walk-in clients and had made this clear on the service website. They had responded to these complaints verbally and discussed the need to make an appointment. They were considering placing a notice on the entrance door to the clinic stating the same.
  • The service had complaint policy and procedures in place. The policy included details of an external stakeholder that could be contacted if a client was not satisfied with a complaint response.

Well-led

Requires improvement

Updated 20 December 2019

We rated well-led as

Requires improvement because:

Governance arrangements were inconsistently identified and reviewed, and we found there was no monitoring or oversight of the service to ensure it was consistently safe and effective.

Leadership capacity and capability

The travel health specialist nurse had the capacity and skills to deliver high-quality, sustainable care.

  • The travel health specialist nurse was knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • The travel health specialist nurse was the registered manager of the service and understood their role and responsibilities relating to this.

Vision and strategy

The service had a vision and 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.
  • There was no formal written business continuity plan to support any disruptions or changes in the service. However, the travel health specialist nurse held contact numbers on their mobile telephone for various utility services, if they needed to contact them urgently or in an emergency.
  • The travel health specialist nurse and GP discussed progress of the service during quarterly business meetings. We saw these had been minuted.

Culture

The service had a culture of high-quality sustainable care.

  • The service focused on the needs of patients.
  • 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.
  • The provider had ensured the travel health specialist nurse and GP had received all the training and development they needed.
  • The travel health specialist nurse had revalidated in 2017 and was working towards their next revalidation in 2020. They had had an appraisal with the GP and identified areas for development through additional training.

Governance arrangements

The

governance systems and arrangements were inconsistently applied

.

  • Governance arrangements had not identified the process for Patient Specific Directions was not in line with legal requirements.
  • The provider had not made arrangements to monitor processes or identify areas requiring a review. For example, there was no evidence of quality improvement activity or clinical audits to drive improvements within the service.
  • The provider had established proper policies and procedures, although not all areas had been considered. For example, there was no document of the types of significant events/incidents that required escalation and there was no lone working policy or risk assessment.
  • The policies we saw had been reviewed and updated within an appropriate timescale. The policies did not include any reference to undertaking reviews or monitoring arrangements to ensure they were being adhered to.

Managing risks, issues and performance

There were some processes and arrangements for managing risks, issues and performance, but some areas of risk had not been identified or reviewed.

  • There were some processes in place to identify, understand, monitor and address current and future risks including risks to patient safety, such as fire safety risk assessment and legionella checking processes. However, there had been no health and safety assessment and we found loop cord blinds had not been secured, some equipment used by the service had not been calibrated or maintained according to manufacturer’s guidance and infection prevention and control processes had not been fully reviewed or audited.
  • There was a clear fire evacuation plan and meeting point. A fire risk assessment had been carried out in September 2019 by an external provider. There were no high risk or urgent actions that required completing.
  • The provider had oversight of safety alerts, reported incidents, and complaints.

Appropriate and accurate information

The service did not have appropriate and accurate information.

  • There was a lack of oversight of quality and operational information used to ensure and improve performance.
  • The travel health specialist nurse told us quality and sustainability was discussed in regular meetings. We were shown quarterly business meeting minutes, but the provider did not have any other documented records of meetings between the GP and the travel health specialist nurse.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. However, the provider did not have arrangements in place to ensure the storage and accessibility of records in the event the organisation ceased to trade.

Engagement with clients and external partners

The service involved clients and external partners to support sustainable services.

  • The service encouraged client feedback and had forms available for clients to fill out after their appointment. There was also a comments form on the website clients could use to contact the service. However, there had been no analysis of these to understand themes or trends.
  • The majority of the feedback we saw and had collected from our comment cards was positive. When an issue was raised the travel health specialist nurse contacted the client to discuss and offer help and support.
  • The service was transparent, collaborative and open with stakeholders about performance. For example, the travel health specialist nurse was required to provide details of Yellow Fever vaccinations administered to NaTHNaC and could only remain registered as a Yellow Fever centre if they continued to provide this information.

Continuous improvement and innovation

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

  • The travel health specialist nurse was a member of the international travel society of medicine and belonged to an international forum for travel medicine. They attended regular updates and identified additional learning and courses to undertake to improve their skills and knowledge.
  • The travel health specialist nurse attended conferences and events and utilised networking opportunities to remain up to date with travel health issues and understand new processes.