You are here

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 December 2019

Inspection areas

Safe

Inadequate

Updated 24 December 2019

We rated safe as

Inadequate

because:

  • There were examples of poor prescribing which included controlled drugs.
  • Consent to share information with the patients NHS GP was not always obtained before prescribing high risk medicines.
  • Patients were not always risk assessed appropriately.

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 where to report a safeguarding concern. The safeguarding policy contained all the local authority telephone numbers to report any concerns. All the GPs had received level three adult and child safeguarding training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification.

The service treated children. A child under the age of 16 could only consult with the parent or legal guardian present. The service requested evidence that the parent had parental responsibility for the child. A birth certificate or court letter had to be produced to demonstrate parental responsibility in conjunction with the adult verifying their own identification.

Monitoring health & safety and responding to risks

The provider headquarters was located within modern offices which housed the IT system and a range of administration staff. Patients were not treated on the premises as GPs carried out the online consultations remotely; usually from their home. All staff based in the premises had received training in health and safety including fire safety.

The provider expected that all GPs would conduct consultations in private and maintain patient confidentiality. Each GP used an encrypted, password secure laptop to log into the operating system, which was a secure programme. GPs 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. The service was not intended for use by patients with either long term conditions or as an emergency service. However, some long-term conditions were being treated such as occasional prescriptions were given to patients with asthma. In the event an emergency did occur, the provider had systems in place to ensure the location of the patient at the beginning of the consultation was known, so emergency services could be called.

All clinical consultations were rated by the GPs for risk. For example, if the GP thought there may be serious mental or physical issues that required further attention. Consultation records could not be completed without risk rating. Those rated at a higher risk or immediate risk were reviewed with the help of the service manager. All risk ratings, issues that may have arisen the previous week and consultations that may require audit were discussed at weekly meetings between the service manager and the clinical GP based at the service. We found examples of consultations being rated incorrectly. For example, a patient presented with asthma conditions and had symptoms of struggling to breathe was rated as a risk of two out of five (with five being the highest level of risk). The patient had also used the service on four occasions over a period of three weeks

There were protocols in place to notify Public Health England of any patients who had notifiable infectious diseases.

A range of non-clinical meetings were held with staff, where standing agenda items covered topics such as complaints and service issues. Clinical matters were addressed in meetings that took place between the service manager and lead GP but there were no clinical meetings that involved GPs working at the service. A monthly newsletter was sent out to clinicians and the service manager had ad hoc telephone conversations with clinical staff.

Staffing and Recruitment

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

The provider had a selection and recruitment process in place for all staff. There were a number of checks that were required to be undertaken prior to commencing employment, such as references 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 GPs had to be currently working in the NHS (as a GP) and be registered with the General Medical Council (GMC) (on the GP register – if applicable) with a licence to practice. They had to provide evidence of having professional indemnity cover (to include cover for video consultations), an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act.

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

We reviewed six recruitment files which showed the necessary documentation was available. The GPs could 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 GPs and there was a system in place that flagged up when any documentation was due for renewal such as their professional registration.

Prescribing safety

If a medicine was deemed necessary following an on-line video consultation, Doctors issued an electronic prescription which was sent to a pharmacy of the patient’s choice. Doctors would document the consultation onto the patient’s record, however the detail was not always recorded for a patient’s allergy status, past medical history and medication history. Staff informed us that the information discussed in the video was not recorded fully in the patient’s medical notes. If a patient returned to the service for a further consultation, doctors were unable to view the previous video consultations and could only read the medical notes, which was not completed fully.

Doctors were encouraged to prescribe from a set formulary which included controlled drugs, and medicines liable to abuse or misuse. We found one patient had been prescribed a high-risk medication to supress their immune system that was not on the formulary. The medication would usually be prescribed by either the hospital or by their general practitioner who would follow the guidance from the hospital consultant. The medication can damage blood cells and patients have to have regular blood tests to check the medication is safe to be taken before being prescribed. The service did not have a record that the dose of mediation had been confirmed and whether the patient was safe to be given the medication as there was no record of the patient’s last blood tests. The doctor at this service had prescribed a strength of tablet that is only used in certain circumstances to reduce the risk of accidental overdose.

Other controlled drugs such as hypnotics were prescribed. We found an example of a hypnotic being prescribed in too high a quantity for the condition it was being used for and against NICE guidelines.

The service encouraged good antimicrobial stewardship by encouraging prescribers to follow national guidance. An antibiotic prescribed to women of child bearing age can affect an unborn child if they were conceived whilst taking the antibiotic. The medical records viewed did not have a record that patients of child bearing age were informed to take extra contraceptive precautions. The medical records did not show that men presenting with UTI symptoms were asked whether their symptoms could be related to an undiagnosed sexual transmitted disease.

It was not clear from patient records whether relevant instructions were given to the patient regarding when and how to take the medicine, the purpose of the medicine, any likely side effects, and what they should do if they became unwell.

The provider did not offer repeat prescriptions; patients had to have a consultation with a doctor every time a medicine was prescribed. The service was not aimed at patients with long term conditions that may need to be monitored. The provider had prescribed a pain killer containing a controlled drug to a patient. One doctor had prescribed it to the patient on the first and third consultation, however a second doctor had refused to prescribe a repeat prescription on the second consultation as they felt the patient was developing an addiction to the pain killer. Despite the consultation notes, the first doctor had prescribed a further supply a few days after the patient had been declined. We found another patient who was under the care of a nephrologist due to them having one kidney, which was failing. A doctor at this provider had prescribed an anti-inflammatory medication which would only be prescribed at the advice of a nephrologist without having the patient’s up-to-date blood tests, which is not safe.

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 however previous records were not always reviewed before prescribing.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating incidents relating to the safety of patients and staff members and regular mailshots were sent to GPs working for the service but there was no evidence to demonstrate that they were involved in discussion around significant events. We reviewed five incidents and found that these had been fully investigated, discussed and taken in the form of a change in processes.

Learning from incidents was discussed with admin staff based at the service but not with remote clinical staff.

We saw evidence from two incidents 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.

At the time of the inspection the provider did not have a robust system in place to receive and act on medicines and safety alerts, such as those issued by the Medicines and Healthcare products Regulatory Agency (MHRA). After the inspection an updated policy was sent to us to ensure alerts were dealt with.

The service had a system in place to assure themselves of the quality of the dispensing process (for onsite pharmacies). There were systems in place to ensure that the correct person received the correct medicine.

Effective

Requires improvement

Updated 24 December 2019

  • Care and treatment was not always delivered in line with relevant guidance and standards.

Assessment and treatment

We reviewed 36 examples of medical records that did not always demonstrate that each GP 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. For example, a patient presenting with a urinary tract infection was not correctly referred to the patients NHS GP after declaring they had already been prescribed three courses of antibiotics by their NHS GP to treat the infection. The patient was then prescribed a further course of antibiotics by the service. We found that there was some GPs that did not give detailed notes within each consultation.

We were told that each online consultation lasted for eight minutes. If the GP had not reached a satisfactory conclusion there was a system in place where they could contact the patient again.

The GPs 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. 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. This was done on a weekly basis.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes. There was a system in place to audit consultations.

Staff training

All staff completed induction training which consisted of health and safety, safeguarding and customer service. The service manager had a training matrix which identified when training was due.

The GPs 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. Supporting material was available, for example, a GPs handbook, how the IT system worked and aims of the consultation process. There was also a newsletter sent out when any changes were made. The GPs 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 GPs received further online training.

Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage. We saw evidence that GPs received an appraisal and GPs were given regular feedback about their performance.

Coordinating patient care and information sharing

All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.

The provider had not risk assessed the treatments they offered and had not identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. We saw evidence after the inspection that GPs working at the service had been informed of it now being a requirement to ensure consent to share was gained before prescribing high risk medicines.

Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.

The service was able to refer patients for private treatment or the service was able to signpost patients to their NHS GP if they had any concerns. For example, if a patient required a two week wait referral, the provider would contact the patients NHS GP with details of the consultation.

The service was also able to offer home testing kits such as for sexually transmitted infections. Results from the home testing kit would be reviewed by a clinician at the service and the results given to the patient with any follow up advice as necessary.

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 app such as healthy eating.

Patients treated for sexually transmitted infections (STIs) were not always correctly signposted to GUM clinics or given advice on STI prevention.

Caring

Good

Updated 24 December 2019

Compassion, dignity and respect

We were told that the GPs undertook video 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 GPs were complying with the expected service standards and communicating appropriately with patients. Feedback arising from these spot checks was relayed to the GP. Any areas for concern were followed up and the GP was again reviewed to monitor improvement.

After each consultation, patients were sent a feedback survey link to rate the service. We looked at survey data from the last three months and found most patients were satisfied with the service. The survey was based on 154 respondents.

  • 89% of patients were satisfied or very satisfied when asked how polite the clinician was.
  • 83% of patients were satisfied or very satisfied when asked if the clinician made them feel at ease.
  • 82% of patients were satisfied or very satisfied when asked if the clinician listened and understood their issue.

Involvement in decisions about care and treatment

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

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

Patients could have a copy of their video consultation only if they made a written request for a copy of the recording to the provider.

Responsive

Good

Updated 24 December 2019

Responding to and meeting patients’ needs

Consultations were provided seven days a week, 6am to 12am, but access via the app to request a consultation was all day every day. This service was not an emergency service. Patients who had a medical emergency were advised to ask for immediate medical help via 999 or if appropriate to contact their own GP or NHS 111.

The digital application allowed people to contact the service from abroad but all medical practitioners were required to be based within England. Any prescriptions issued were delivered within the UK to a pharmacy of the patient’s choice or the service could use their in-house pharmacy to dispense for next day delivery.

Patients signed up to receiving this service on a mobile phone (iPhone or android versions that met the required criteria for using the app). The service offered flexible appointments between 6am and 12am to meet the needs of their patients.

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

Patients requested an online consultation with a GP and were contacted at the allotted time. The maximum length of time for a consultation was eight minutes.

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 GPs available. Patients could choose either a male or female GP or one that spoke a specific language.

Managing complaints

Information about how to make a complaint was available on the service’s app. 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. We reviewed the complaint system and noted that comments and complaints made to the service were recorded. We reviewed two recent complaints out of 29 complaints received in the last 12 months.

The provider was able to demonstrate that the complaints we reviewed were handled correctly and patients received a satisfactory response. There was evidence of learning as a result of complaints, changes to the service had been made following complaints, and had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The app had a set of terms and conditions and details on how the patient could contact them 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.

All GPs 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. When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance. Where a patient’s mental capacity to consent to care or treatment was unclear the GP assessed the patient’s capacity and, recorded the outcome of the assessment. The process for seeking consent was monitored through audits of patient records.

Well-led

Requires improvement

Updated 24 December 2019

We rated well-led as

Requires improvement

because:

  • Patient safety and MHRA alerts were dealt with effectively.
  • Clinical meetings were not happening with GPs working at the service

Business Strategy and Governance arrangements

The provider told us they had a clear vision 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 next two years.

Staff were aware of their 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 for consultations and ensuring all clinicians held valid registration.

There were arrangements for identifying, recording and managing risks but risks were not always dealt with appropriately, such as patient safety and MHRA alerts.

Care and treatment records were not always complete and there were examples of records not being full reviewed by clinicians before patient consultations. A GP told us they do not always put as much detail in the clinical notes as required because the consultations are stored digitally on a server. GPs did not have access to previous video consultations, and only had access to clinical notes stored in the patient record.

Clinical meetings did not include GPs working for the service but clinical issues were discussed between the service manager and lead GP. We were told that discussions happened with GPs on an ad hoc basis and significant events were not discussed with clinical staff unless they were directly involved.

Leadership, values and culture

The registered manager had overall responsibility for any medical issues arising but during the inspection the registered manager was on long term sick. We were told that another GP was covering this in the interim, but that GP was not aware they had been given this responsibility.

The registered manager was available to the service manager by the telephone if required.

The service had an open and transparent culture. We were told that if there were unexpected or unintended safety incidents, the service would give 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 that 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. The service could provide a clear audit trail of who had access to records and from where and when. 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 could rate the service they received. This was constantly monitored and if it fell below the provider’s standards, this would trigger a review of the consultation to address any shortfalls. In addition, patients were emailed at the end of each consultation with a link to a survey they could complete or could also post any comments or suggestions online. Provide examples of questions asked.

There was evidence that the GPs 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 Clinical Director was the named person for dealing with any issues raised under whistleblowing.

Continuous Improvement

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

Some of our feedback from the inspection had been taken on board and the service had begun to implement improvements, such as removing controlled medicines from the formulary. The service manager had also implemented a new policy for dealing with MHRA alerts.