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Archived: Health Bridge Limited London Good

Inspection Summary


Overall summary & rating

Good

Updated 7 June 2019

Letter from the Chief Inspector of General Practice

We rated this service as Good overall. (Previous inspection May 2017, when we found the provider was meeting the relevant standards).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Health Bridge Limited London on 18 April 2019 as part of our inspection programme.

Health Bridge Ltd was established in 2011 and registered with the Care Quality Commission in 2011. Health Bridge Ltd operates an online clinic for patients. Within the UK the service has recently been re-branded as Zava, and offers a service to UK based patients via the following websites: www.zavamed.com; and www.onlinedoctor.superdrug.com (providing online doctor services on behalf of Superdrug). The service provides consultations and private prescriptions.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 7 June 2019

  • There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members.
  • All clinical consultations were rated by the doctors for risk.
  • All medicines prescribed to patients from online forms were monitored by the provider to ensure prescribing was evidence based.

Keeping people safe and safeguarded from abuse

Staff employed at the headquarters had received training in safeguarding and whistleblowing and knew the signs of abuse. All staff had access to the safeguarding policies and how to report a safeguarding concern. The service had contact details for the local (Islington Council) adult and children’s safeguarding teams. However, it did not have contact details for local authority safeguarding teams throughout the UK. As, unlike NHS GP practices, the service provided care and treatment for adults and children who resided throughout the UK the service recognised it was important that any necessary contact was direct with the appropriate local authority safeguarding team where a patient resided. Accordingly, during our inspection the service updated its policies and safeguarding posters to include a link to all local authority adult and children safeguarding teams throughout the UK.

It was a requirement for the doctors registering with the service to provide evidence of up to date safeguarding training certification. All the doctors employed by the service had received adult and level 3 child safeguarding training, together with any necessary updates.

The online service did not treat children, it had safeguards in place to ensure it identified patients accessing the service and was able, via identity checking, to confirm their ages.

Monitoring health & safety and responding to risks

There were a variety of checks in place to monitor risks. Prescribing patterns and behaviours were monitored by means of data analytical software to check for any over-prescribing and prescribing behaviours. The IT system was setup to alert the medical director of any prescribing by the doctors which was outside of clinical guidelines. The information from these checks was discussed at regular clinical team meetings.

The providers headquarters was located within modern offices which housed the IT system, clinical staff and a range of administration staff. Patients were not treated on the premises as doctors carried out the consultations via review of online treatment requests, usually from the service’s offices. It was only possible to access the services systems using logged computers and any computer activity emanating from outside of the service’s offices or the users normal working hours was logged and investigated. All staff based at the premises had received training in health and safety including fire safety.

The provider expected that all doctors would conduct consultations in private and maintain patient confidentiality. Each doctor used an encrypted, password secure laptop to log into the operating system, which was a secure programme. Any doctors working remotely were required to complete a home working risk assessment to ensure their working environment was safe.

There were processes in place to manage any emerging medical issues during a consultation and for managing test results and referrals. In the event the consultation request gave rise to any need to urgently contact the patient the GP was able to message or phone the patient. Patient records also contained their home address so emergency services could be alerted to attend their address if necessary. The service was not intended for use by patients with either long term conditions or as an emergency service.

All clinical consultations were rated by the doctors for risk, for example, if the doctor thought there may be serious mental or physical issues that required further attention. Consultation records could not be completed without a risk rating. Those rated at a higher risk or immediate risk were reviewed with the help of the support team and clinical director. All risk ratings were discussed at weekly clinical meetings. There were protocols in place to notify Public Health England of any patients who had notifiable infectious diseases.

A range of clinical and non-clinical meetings were held with staff, where standing agenda items covered topics such as significant events, complaints and service issues. Clinical meetings also included case reviews and clinical updates. We saw evidence of meeting minutes showing where some of these topics had been discussed.

Staffing and Recruitment

There were enough staff, including doctors, to meet the demands for the service and there was a rota for the doctors. There was a support team available to the doctors during consultations and a separate IT team. The prescribing doctors were paid on a sessional basis.

The provider had a selection and recruitment process in place for all staff, and a number of checks were required to be undertaken prior to commencing employment, such as gathering and reviewing references, qualifications, experience and Disclosure and Barring service (DBS) checks. 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.

Potential Doctor employees were not required to be currently working in the NHS, however they were required to be registered with the General Medical Council (GMC). They had to provide evidence of having professional indemnity cover, an up to date appraisal and certificates relating to their qualifications and training in a range of subjects, including: safeguarding and the Mental Capacity Act.

Newly recruited doctors were supported during their induction period and an induction plan was in place to ensure all the services processes had been covered. We were told that doctors did not start consulting with patients until they had successfully completed several test scenario consultations.

We reviewed three recruitment files for a range of clinical and non-clinical staff, these showed the necessary information was recorded and supporting documentation was available. The doctors were not be registered to start any consultations until these checks and induction training had been completed. The provider kept records for all staff including the doctors and there was a system in place that flagged up when any documentation was due for renewal such as their professional registration, and updating of training.

Prescribing safety

All medicines prescribed to patients from online forms were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation, the doctors could issue a private prescription to patients. The doctors could only prescribe from a set list of medicines which the provider had risk-assessed. There were no controlled drugs on this list. When emergency supplies of medicines were requested, the doctor would contact the patient to assess the patient before prescribing. The service kept a clear record of the decisions made and, with consent, it contacted the patient’s regular GP to advise them. For example, if an existing patient contacted the service to advise they needed an emergency prescription for a previously prescribed medicine, the doctor would contact the patient to assess what level of intervention was required. Where necessary, the doctor would advise the patient if they needed immediate attention and would, if necessary, contact the emergency services to request an ambulance be dispatched to the patient. Where patients sought medicines for treatment of long-term conditions, the service required that patients consented to information sharing with their NHS GPs.

Once the doctor prescribed the medicine and dosage of choice, relevant instructions were given to the patient regarding when and how to take the medicine, the purpose of the medicine and any likely side effects and what they should do if they became unwell.

The service provided patients with repeat prescriptions for several long-term conditions such as hypertension and diabetes which would need to be monitored. Each repeat prescription request was accepted on its own merit, there was no automated system to simply authorise repeat prescription requests. In addition, a system was in place to monitor the frequency of such requests. For example, where the service had prescribed sufficient medicine to cover a period of time, if the patient then requested a further prescription within that time, the doctor received an alert and contacted the patient to establish the circumstances, and whether a further prescription was warranted.

The service encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics which was based on national guidance. For example, in accordance with updated national guidelines from the British Association for Sexual Health and HIV (BASHH), the service had recently updated its prescribing of an alternative antibiotic for chlamydia treatment.

The service prescribed some off-label medicines, for example for the treatment of traveller’s diarrhoea and premature ejaculation. Medicines in the UK given licences after trials have shown they are safe and effective for treating a particular condition. Use of a medicine for a different medical condition than that listed on their licence is called unlicensed (off-label) 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 medicines were being used outside of their licence, and the patient was required to acknowledge they understood this information. Additional written information to guide the patient when and how to use these medicines safely was supplied with the medicine. When prescribing off-label medicines a note was made for patients that this was unlicensed, and the service made the impact of this clear to patients.

There were protocols in place for identifying and verifying the patient and General Medical Council guidance, or similar, was followed.

We were advised patients could choose a pharmacy where they would like their prescription dispensed. The prescription could be dispensed and delivered direct to the patient or sent to their preferred local pharmacy to be dispensed. Where patients preferred, the dispensed medicines could be securely posted to their nominated address. In such circumstance’s a signature was required for receipt of the delivery. The service had a system in place to assure itself of the quality of the dispensing process. There were systems in place to ensure the correct person received the correct medicine.

Information to deliver safe care and treatment

On registering with the service, and at each consultation patient identity was verified. The GPs had access to the patient’s previous records held by the service.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We reviewed 10 incidents and found these had been fully investigated and discussed and where necessary action was taken to change processes.

All incidents and complaints were discussed in regular monthly clinical governance meetings. Minutes of meetings were emailed to the management team and available to all staff, who were signposted to the minutes on the shared drive, to ensure anyone who had been unable to attend received a copy.

We saw evidence from the incidents we reviewed which demonstrated the provider was aware of and complied with the requirements of the duty of candour by explaining to the patient what went wrong, offering an apology and advising them of any action taken.

Effective

Good

Updated 7 June 2019

  • If, following a consultation, the GP had not reached a satisfactory conclusion there was a system in place to enable them to contact the patient again.
  • The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes.
  • All staff completed induction training which varied depending on the role to be undertaken.

Assessment and treatment

We reviewed five examples of medical records that demonstrated that each doctor assessed patients’ needs and delivered care in line with relevant and current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice.

If, following a consultation, the GP had not reached a satisfactory conclusion there was a system in place to enable them to contact the patient to seek any necessary further information.

Patients completed an online form, the contents of which varied according to the issue, all patients were required to provide their past medical history. There was a set template to complete for the consultation which included the reasons for the consultation. It also provided for the outcome to be manually recorded, along with any notes about past medical history and diagnosis. We reviewed five anonymised medical records which were complete records. We saw adequate notes were recorded, and the doctors had access to all previous notes.

The doctors providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely from patients. They worked carefully to maximise the benefits and minimise the risks for patients. If a patient needed further examination, they were directed to an appropriate agency. Doctors used a decision-making tool to standardise care. If the provider could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes. The service undertook regular audits of its prescribing, the outcomes were used to improve service delivery and to train doctors. Where an audit found that prescribing could be improved, the service, where appropriate, reviewed its practices against national guidelines, and made changes to improve the service it delivered.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes.

  • The service used information about patients’ outcomes to make improvements.
  • The service took part in quality improvement activity, for example audits, reviews of consultations and prescribing trends. For example, the service audited its prescribing for cystitis. It did not provide treatment for anyone who was diagnosed with cystitis who had already received treatment for cystitis within a month, to avoid people receiving treatment for partially treated cystitis. The audit it had carried out related to patients requesting treatment for cystitis more than once in a month. During the first cycle it had treated 77 patients, and had refused requests, in line with its own guidelines, from 46 patients. However, it had provided multiple treatments to two patients. On review of the patient records it found that both patients had made the second request to ensure they were prepared for a future need for treatment. The service reviewed the results and concluded that prescribing was within its own guidelines. It committed to re-auditing the prescribing in 12 months.

During the second cycle the service provided treatment to 95 patients, refused treatment, in line with its guidelines, to 31 patients, and provided multiple treatments to six patients. On review of the records it found that, two requests related to a change of delivery method, two patients had made the second request to ensure that were prepared for a future need for treatment, one patient had accidentally disposed of the treatment and one had failed to complete the first course of treatment. The service reviewed the results and concluded that it was prescribing within its own guidelines.

Staff training

All staff completed induction training which varied depending on the role to be undertaken. In addition to induction training for the role, and to familiarise them with the business, all staff induction training included a minimum of : Safeguarding (Adults level 2 and Children level 1 ( doctors received level 3 training in safeguarding of vulnerable children)), Mental Capacity Act, Data Protection Policy, Confidentiality Policy, Health and Safety Policy, Employee Data Protection Policy, Medical Emergencies, Internet and Email Acceptable Use Policy, Role of Doctors and Clinical Team Training, Care Pathways Training and Zava/Superdrug Terms and Conditions. Staff also completed other training on a regular basis, for example, clinical staff (doctors and pharmacists) attended weekly clinical teaching sessions. Topics covered in recent weeks before the inspection included: Clinical Governance, asthma and hypertension. The personnel manager had a training matrix which identified when individual members of staff were due to receive training.

The doctors registered with the service received specific induction training prior to treating patients. An induction log was held in each staff file and signed off when completed. Doctors also had access to supporting material, including, a GP handbook, how the IT system worked and aims of the consultation process. The doctors told us they received excellent support if there were any technical issues, or clinical queries and could access policies. When updates were made to the IT systems, the doctors received further online training.

Administration staff received regular performance reviews. All the doctors had to have received their own appraisals before being considered eligible at recruitment stage. All staff employed by the service received six-monthly performance reviews, in addition doctors received an external annual appraisal as part of their revalidation process. The service required doctors to provide it with a copy of their external appraisal document, to ensure that it took account of their online work.

Coordinating patient care and information sharing

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 NHS GP on each occasion they used the service.

The provider had risk assessed the treatments they offered. They had identified, and did not prescribe, medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions. Where patients agreed to share their information, we saw evidence of letters sent to their registered NHS GP in line with GMC guidance.

Any tests the service asked patients to take were sent out as test kits to patients nominated addresses. The tests were limited to samples that patients could provide themselves, for example by using a fingerpick to gather a small amount of blood for testing. All tests were sent to an independent laboratory who notified the service as soon as a test was received and contacted the doctor who had requested the test directly with results. Doctors reviewed the results and communicated these to patients, including where there was any further need for investigation, or access to support services. If the test had not been returned to the laboratory within a time limit the service ascertained whether there were any technical issues, such as mis-labelled tests, or if the patient had not returned it for testing. In such circumstances, the service contacted the patient to clarify the situation. Where the patient advised they had returned the test, but it had not been received by the laboratory, the service sent out a replacement kit. Patients who had not returned the test but still intended to do so were given more time to return the test. If that time expired the review process was repeated to ensure that results were received for all tests that patients returned for testing.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support and had a range of information available on the website (or links to NHS websites or blogs). For example: the advice offered to patients wishing to stop smoking included: explanations of the benefits of quitting, options for treatment (including options not offered by the service), the likely withdrawal symptoms that patients might suffer during treatment, side-effects and the likelihood of relapse.

In their consultation records we found patients were given advice on healthy living as appropriate.

Caring

Good

Updated 7 June 2019

  • The service used an independent service to gather patient feedback.
  • Patient feedback direct to CQC at the time of our inspection was positive with all forty-eight respondents providing positive feedback and only three respondents also giving some negative feedback.

Compassion, dignity and respect

We were told the doctors undertook consultations in a private room and were not to be disturbed at any time during their working time. The provider carried out random spot checks to ensure the doctors were complying with the expected service standards and communicating appropriately with patients. Feedback arising from these spot checks was relayed to the doctor. Any areas for concern were followed up and the doctor’s performance was again reviewed to monitor improvement.

We did not speak to patients directly on the days of the inspection. However, we reviewed the latest survey information. Following all consultations, patients were sent a message asking them to provide feedback. The service also used Trustpilot to obtain independent feedback from patients. The most recent Trustpilot results showed the service had received 1,352 responses with 93% of respondents finding the service they received as great or excellent. As part of our inspection preparation we asked the service to contact patients to provide them with an opportunity to give feedback direct to CQC about their experiences of using the service. We received 48 responses, of which 45 were positive and three contained mixed responses, including some concerns. Positive feedback comments included: the speed and thoroughness of the service, the convenience of using the service compared to waiting for an NHS GP appointment, when having direct contact with the service by phone all staff were very helpful. Mixed comments mentioned: one patient was concerned that with an online service it was difficult to check if there were actual doctors, however the patient also said as they had a busy life they found the service convenient; another patient had wanted to be offered another, unbranded, version of the medicine the service was able to prescribe.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical issues were available on its website. There was a dedicated customer support team to respond to any enquiries.

Patients had access to information about the doctors working for the service and could book a consultation with a doctor of their choice. For example, whether they wanted to see a male or female doctor. The doctors available could speak a variety of languages.

Patients could access all of their records by logging into their personal account.

Responsive

Good

Updated 7 June 2019

  • There was clear information on the service’s website with regards to how the service worked and what costs applied
  • Patients could sign up to the service from any interconnected device.
  • Patients could access a brief description of the doctors available and could specify if they wanted a male or female doctor.

Responding to and meeting patients’ needs

Consultations took place Monday to Friday between 9.00am and 6.00pm and 9.00am to 5.00pm on Saturdays and 10.00am to 4.00pm on Sundays. Patients could access the website 24 hours a day to request a prescription. There were doctors working for the service every day of the week. The service aimed to respond to all patient requests for a prescription within 24 hours, and to complete orders placed during a working day within the same day. There was a system in place to prioritise urgent prescriptions for patients.

The customer services team were available Monday to Friday between 9.00am and 6.00pm, 9.00am to 5.00pm on Saturdays and 10.00am to 4.00pm on Sundays. The service monitored patient telephone calls and the telephone call dropout rate to ensure they were responsive to inbound calls.

This was not an emergency service. The provider made the limitations of the service clear to patients. Patients who had a medical emergency were advised to seek immediate medical help via ‘999’; to dial ‘111’ for emergency medical questions or advice and ‘116 123’ to talk to the Samaritans if they were feeling depressed, anxious, or having a panic attack, or if they were worried about harming themselves or others. Where appropriate the service would recommend patients contacted other services, for example, where a patient disclosed they had been, or might have been, exposed to HIV infection within the preceding 72 hours they were advised to contact a genitourinary medicine clinic (GUM clinic) immediately.

The UK service offering allowed people to contact the service from abroad, but all medical practitioners were required to be based within the United Kingdom. Any prescriptions issued were delivered within the UK to a pharmacy of the patient’s choice or dispatched direct to the patients nominated UK address. Such deliveries required a signature to confirm safe receipt.

Patients signed up to receiving this service on a mobile phone or other internet connected device. Patient prescription requests were dealt with in order of receipt, with the exception of urgent requests.

The provider made it clear to patients what the limitations of the service were.

Tackling inequity and promoting equality

The provider offered consultations to anyone who requested and paid the appropriate fee and did not discriminate against any client group.

Patients could access a brief description of the doctors available. Patients could choose either a male or female doctors or one that spoke a specific language or had a specific qualification. Next Generation Text Service (NGTS) was available for the benefit of patients who were unable to use a phone due to hearing difficulties.

Managing complaints

Information about how to make a complaint was available on the service’s web site. The provider had developed a complaints policy and procedure. The policy contained appropriate timescales for dealing with the complaint. There was escalation guidance within the policy. A specific form for the recording of complaints has been developed and introduced for use.

Patients were instructed to send a message via their online patient record to give any feedback, suggestions and to make complaints about the service. It was the provider’s policy to acknowledge complaints received within 48 hours and to respond in full within five days. The providers complaints procedure contained appropriate timescales for dealing with the complaint. We reviewed the complaints system and noted comments and complaints made to the service were appropriately reviewed and recorded. We reviewed 40 complaints received in the past 12 months. There was evidence of learning, changes to the service had been made following complaints, and these had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website explaining how the service worked and what costs applied, together with a set of frequently asked questions containing further supporting information. The website had a set of terms and conditions and details on how the patient could make contact with any enquiries. Information about the cost of the consultation was known in advance and paid for before the consultation appointment commenced. The costs of any resulting prescription or medical certificate were handled by the administration team at the headquarters following the consultation. Where the consultation did not result in a prescription being given, the service refunded the patient’s payment.

All patient facing staff had received training about the Mental Capacity Act 2005. Staff understood and sought patients’ consent to care and treatment in line with legislation and guidance

Well-led

Good

Updated 7 June 2019

  • There was a clear organisational structure and staff were aware of their own roles and responsibilities.
  • There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service.
  • Patients were encouraged to provide feedback following each consultation.

Business Strategy and Governance arrangements

The provider had a clear vision for staff to work together to provide a high-quality responsive service that put caring and patient safety at its heart. We reviewed business plans that covered the continued existence and development of the service.

There was a clear organisational structure and staff were aware of their own roles and responsibilities. There was a range of service specific policies which were available to all staff. These were reviewed annually and updated when necessary.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included random spot checks of consultations. The information from these checks was used to produce a clinical weekly team report that was discussed at weekly team meetings. The service also held “Company Town Hall” meetings on Wednesday evenings to provide all staff with updates and announcements, for example, company performance was shared with staff in these meetings. This ensured a comprehensive understanding of the performance of the service was maintained.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions.

Care and treatment records were complete, accurate, and securely kept.

Leadership, values and culture

The Chief Executive Officer, supported by a senior management team, had overall responsibility for the service and they attended the service daily. The Medical Director, supported by a deputy Medical Director, had responsibility for any medical issues arising. There were systems in place to address any absence of this clinician. The Chief Operating Officer was the lead for any pharmaceutical issues arising. On a daily basis one of the doctors was nominated as a duty doctor.

The service had a set of values, as part of these values the service had declared itself a clinically-led company and was working to ensure there were doctors working in every team across the organisation. In addition, the service encouraged and celebrated its values via weekly ‘Value Champions’. All staff were encouraged to nominate colleagues who had excelled in one of the values in the previous week. The individual selected, and their work, was celebrated in a weekly company-wide presentation.

The service had an open and transparent culture. We were told if there were unexpected or unintended safety incidents, the service gave affected patients reasonable support, truthful information and a verbal and written apology. This was supported by an operational policy.

Safety and Security of Patient Information

Systems were in place to ensure all patient information was stored and kept confidential.

There were policies and IT systems in place to protect the storage and use of all patient information. In addition, the service worked with external IT experts, employed to look for weaknesses in its IT security, who had been unable to breach the service’s secure systems. The service could provide a clear audit trail of who had access to records and from where and when and reviewed any access outside of an individual’s normal working hours. The service was registered with the Information Commissioner’s Office. There were business contingency plans in place to minimise the risk of losing patient data.

Seeking and acting on feedback from patients and staff

Patients were encouraged to provide feedback following each consultation and were instructed if they had any questions or experienced any unexpected side effects, to contact the service via their online patient account. This initial feedback request was followed up by a second email seven days later to ask patients how they were and if they were experiencing any side effects. Patients could also contact the service directly to ask questions or raise a concern and the contact email and telephone number was clearly displayed on the Zava and Superdrug online doctor websites. Patient feedback was constantly monitored and if it fell below the provider’s standards, this would trigger a review of the consultation to address any shortfalls.

The service used two survey tools, Net Promoter Score (NPS) and Trustpilot, to gain independent verification of patient feedback. Its current NPS rating was +78 (NPS is an index ranging from -100 to +100 that measures the willingness of customers to recommend a company's products or services to others. It is used as a proxy for gauging the customer's overall satisfaction with a company's product or service and the customer's loyalty to the brand.). The most recent Trustpilot results showed the service had received 1,352 responses with 93% of respondents finding the service they received as great or excellent.

There was evidence the doctors could provide feedback about the quality of the operating system and any change requests were logged, discussed and decisions made for the improvements to be implemented.

The provider had a whistleblowing policy in place. A whistle blower is someone who can raise concerns about practice or staff within the organisation. The Chief Executive Officer was the named person for dealing with any issues raised under whistleblowing.

Continuous Improvement

The service consistently sought ways to improve. All staff were involved in discussions about how to run and develop the service and were encouraged to identify opportunities to improve the service delivered.

We saw from minutes of staff meetings where previous interactions and consultations were discussed.

Staff told us team meetings were the place where they could raise concerns and discuss areas of improvement. The service held a variety of regular meetings. For example, there was a weekly “town Hall” meeting that was open to all staff to attend, for the purpose of sharing information. In addition, there were weekly clinical meetings for doctors and a separate one for pharmacists. Non-clinical staff meetings were held weekly. There were also management meetings held twice weekly. As the management team and IT teams worked together at the headquarters there were also ongoing discussions at all times about service provision.

There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, through clinical audit. For example, the service did not offer treatment to patients with poorly controlled asthma. To review this, it audited patients suffering from asthma who had requested more than six of a particular inhaler within the preceding six months. During the first cycle it found that it had prescribed the inhaler to 13,673 patients, of which 73 (0.005%) had been prescribed more than six inhalers in the preceding six months. On review of these higher levels of requests it found: 37 patients had lost their inhalers, 22 wanted spares for travel or other locations, nine wanted extra inhalers due to illness or increased seasonal use, one each wanted a spare inhaler, or to replace a damaged inhaler or was worried about running out and two had not been asked why they had ordered another inhaler. Following this cycle, the service established new guidelines including, inter alia, alerting the clinical team to always gather information about the reason for requesting additional inhalers, and to implement a system alert where a patient requested more than six inhalers in six months. The service subsequently provided clinicians with additional training to support use of the new guidelines. The service committed to re-auditing this issue within six months.