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Inspection Summary


Overall summary & rating

Good

Updated 8 August 2019

This service is rated as Good overall.

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 The Mole Clinic as part of our scheduled inspection programme.

Our inspection team was led by a CQC lead inspector. The team included a GP specialist adviser.

The service provides skin checks, including cancer screening, and mole removal. All tissue samples were sent to a local laboratory where the clinic held a third-party contract.

The clinic had two registered managers; the clinic manager and the organisation founder. 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.

Thirteen people provided feedback about the service. This feedback was positive about the care provided and the kindness and compassion of staff. Patients also told us that their dignity was maintained throughout consultations.

Our key findings were:

  • There were clear systems and processes to safeguard patients from abuse. All staff had received training appropriate to their role.
  • The clinic manager was trained to level five in safeguarding.
  • Risks associated with the service, such as fire and legionella, were managed by the building where rooms were rented. The service requested this documentation on a regular basis to ensure all necessary risk assessments and checks had been completed.
  • Staff members were knowledgeable and had the experience and skills required to carry out their roles.
  • The Mole Clinic ensured all staff had received mandatory training and an annual appraisal. The service also completed regular reviews of consultations and competency assessments.
  • Clinical records were detailed and held securely. The service did not keep paper records. The clinical system used by the clinic enabled diagnostic imaging to be shared quickly with specialist doctors.
  • The clinic held regular clinical management meetings and multi-disciplinary team meetings. Minutes were available to all staff via the clinic intranet.
  • The service had systems to manage and learn from complaints or significant events. These were shared with the wider organisation and analysed for trends.
  • Patients were able to book appointments online and told us this was an easy system to use. The service monitored the availability of appointments to ensure urgent referrals were seen in a timely manner.
  • Patients were asked for feedback following each appointment. This feedback was logged, analysed and shared with staff via the clinic intranet.
  • All staff were aware of the clinic values and were passionate about providing high level care. We saw that staff were committed to raising awareness of skin cancers and sun safety.
  • The service had recently developed a team website where staff could access all policies and procedures, learning from incidents, meeting minutes and relevant documents.

  • The clinic had developed a training course for skin cancer screening that was undertaken by all the nursing staff. This was the only course of this nature that had been accredited by the Royal College of Nursing.

The areas where the provider should make improvements are:

  • Embed the process for checking parental consent when providing treatment to children.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 8 August 2019

We rated safe as Good because:

Safety systems and processes

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

  • The service conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff using the internal website. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The clinic manager was the safeguarding lead and had completed level five safeguarding training.
  • All clinical rooms had safeguarding posters with telephone numbers of local advice and referral services.
  • The service did not have systems in place to assure that an adult accompanying a child had parental authority. We were assured at the time of inspection that this would be introduced.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. The service policy included DBS checks being completed for administration and reception staff. Staff records we looked at confirmed this was done. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role.
  • There was an effective system to manage infection prevention and control. The clinic completed daily clinical safety checks to ensure each treatment room was clean and ready to be used. This included monitoring levels of personal protective equipment, such as gloves and aprons, and checking sharps waste bins.
  • The clinic used an external cleaning agency and was visibly clean and tidy. Patients told us through CQC comment cards that the clinic was clean and hygienic.
  • A risk assessment for legionella had been conducted by the building landlord. The service requested this on a yearly basis to assure themselves it had been completed.

  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The service did not calibrate equipment such as blood pressure monitors as they had assessed it was more financially beneficial to replace the equipment on a yearly basis. We saw evidence that this had been carried out.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. The service regularly monitored appointment availability and patient demand to ensure appointments could be offered in a timely manner.
  • There was an effective induction system for all staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example, sepsis. Reception staff were aware of when and how to escalate this to clinicians and all had basic life support training. However, due to the nature of the service acutely unwell patients were not seen.
  • The service held a defibrillator, oxygen and adrenaline to manage medical emergencies. Systems were in place to ensure these were regularly checked.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities

Information to deliver safe care and treatment

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.
  • Information was shared with patients’ NHS GP’s at the patient request. If consent was not given to share information, the service would review and contact patients as necessary. We were told it was rare for patients not to consent to sharing information with their NHS GP.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including emergency medicines and equipment, minimised risks. The service did not hold prescription stationery as prescriptions were printed directly by doctors within the service. The service kept logs of prescriptions and monitored prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues. The building was rented and therefore building maintenance and risk assessments were the responsibility of the landlord. However, the practice regularly requested risk assessments, for example health and safety, security and fire assessments to assure themselves this was being completed appropriately.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements. Due to the high specification of the building and clinic, there were limited safety improvements that were noted in risk assessments.

Lessons learned and improvements made

The service learned made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. Staff we spoke with felt comfortable with raising concerns and confident that they would be dealt with.
  • 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. Learning was shared from significant events across the various organisation’s locations at regular clinical meetings.
  • The service 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.
  • When there were unexpected or unintended safety incidents the service gave affected people reasonable support, truthful information and a verbal and written apology.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team.

Effective

Good

Updated 8 August 2019

We rated effective as

Good

because:

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • The clinic held multi-disciplinary meetings when patients had complex needs or a cancer diagnosis. These were held on an ad-hoc nature when needed and minutes were available to staff via the intranet.
  • Clinicians had enough information to make or confirm a diagnosis where necessary. patients were provided with results and recommendation within 3 days of screening by a nurse and formal diagnosis within 5 days if a biopsy was undertaken by a clinician
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.
  • Patient records were electronic and could be accessed remotely by clinicians. Each mole or lesion was given a unique identification number to allow clinicians to group together records and pathology results appropriately. Any signed paperwork was scanned onto the computer system.
  • Pathology results were sent directly to the requesting doctor for review. The clinic operated a buddy system for another doctor to process results if the relevant doctor was away from the clinic, for example on leave.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. For example, the service regularly completed post-treatment infection audits. The rates of infection following treatment was consistently low and no trends had been seen.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. Newly appointed staff told us that the induction process was supportive and they were clear on their roles and responsibilities.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or Nursing and Midwifery Council (NMC) and were up to date with revalidation. The service checked this on a regular basis.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Nursing staff were able to attend national conferences and workshops with experts in the field of skin cancer. Newly appointed nurses completed skin cancer screening training that was developed by the clinic and is the only training of this nature than had been approved by the Royal College of Nursing.
  • Nursing staff completed skin cancer screening competency assessments on a yearly basis. They also completed surgical support training that allowed them to assist the consultants during minor surgical procedures.
  • The service held a full record of staff immunisation history. They held a contract with a local occupational health service to provide additional vaccinations where required.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, letters were sent to NHS GPs with patient consent.
  • 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.
  • 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. However, if consent was not given, the service reviewed and signposted the patient as appropriate. The service told us this was rare. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Due to the nature of the service, patients whose situation may make them vulnerable were not often seen, however, the service had policies in place to support these patients if needed.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave patients advice so they could self-care. Self-care information, including safe sun information, was available both in the clinic waiting areas and on the website.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. This included patients with a family history of cancer.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance however, did not have systems in place to check parental authority for children using the service.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. However, due to the nature of the service this was rarely needed.
  • The service monitored the process for seeking consent appropriately.
  • At the time of our inspection, the service did not have systems in place for checking parental authority when children were brought for treatment. However, shortly after the inspection, the service provided documentary evidence of a new protocol where parents were asked to bring in the relevant identification to enable the service to check parental authority for adults attending with children. This had been put into place immediately following the inspection.

Caring

Good

Updated 8 August 2019

We rated caring as

Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. They told us that staff were friendly, reassuring and professional.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

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

  • Information regarding fees of services was displayed clearly on the website and within clinic areas. Patients were aware of the full cost of treatment at the time of booking.
  • Interpretation services were available for patients who did not have English as a first language. Information leaflets were available to help patients be involved in decisions about their care.
  • Patients told us through comment cards that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Patients told us through CQC comment cards that full body skin checks were completed in a dignified and respectful way.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 8 August 2019

We rated responsive as

Good

because:

Responding to and meeting people’s needs

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

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. This included offering evening and weekend appointments at a variety of satellite locations.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people with mobility issues could access and use services on an equal basis to others. The service has ensured that ramps were available so that patients with limited mobility are able to access the clinic.
  • All clinic staff wore name and role badges to ensure patients felt comfortable.
  • All patients were sent feedback questionnaires through an automatic computer system after their appointment. The clinic website also had a feedback function. All responses and comments were logged, analysed and discussed at clinical meetings. Most of these comments were positive about the service provided. Negative comments were acted on where appropriate, for example, staff were reminded to be vigilant about which consent forms to give to patients after a mistake was made.

Timely access to the service

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised. The practice monitored appointment availability and ensured that all urgent two weeks wait referrals for suspected cancer diagnosis were seen within this time frame.
  • Patients reported that the appointment system was easy to use. All appointments were booked via an online booking portal.
  • Referrals and transfers to other services were undertaken in a timely way.
  • Patients were given wound care advice and telephone numbers for doctors that could be used outside of clinic hours for emergency advice.
  • Following a consultation, all patients were sent a report of findings within three days. This was sent via e-mail and was password protected.
  • The practice had developed a computer system to share diagnostic scans with consultants quickly and easily allowing preliminary diagnosis to be made within three to five days.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint. They subscribed to the Independent Sector Complaints Adjudication Service, an external organisation who acted as an ombudsman. Patients were directed to this service if they were unhappy with the clinic response to their complaint. The service told us that no complaints had been escalated in this manner.
  • The service had a complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from an analysis of trends. It acted as a result to improve the quality of care. The service had received five complaints in the last year and three of these related to pricing. The service regularly monitored the cost of treatment against local similar services to ensure they are comparable. The cost of treatments was published on the website and within the clinic.
  • Complaints were logged and analysed across all of the organisation’s locations to ensure learning was transferred across the organisation.
  • Records we looked at showed that complaints were responded to in a timely manner.

Well-led

Good

Updated 8 August 2019

We rated well-led as

Good because:

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. This included an increase in staff due to the growth of the business. The clinic manager remained vigilant to ensure all staff were supported and had adequate training opportunities.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. Staff we spoke with felt that management teams were approachable, and they were happy to raise any concerns.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

  • The service had a board of directors that included an accountant and marketing specialist. This board reviewed the financial and business standing of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.

  • The service monitored progress against delivery of the strategy.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients. All staff we spoke with showed commitment to patient care and raising awareness of skin cancers and sun safety.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We saw examples where samples had been damaged and the service had contacted the patient in a timely manner to provide reassurance and appropriate treatment.

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

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

  • There were processes for providing all staff with the development they needed. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff we spoke to reported there were also regular informal opportunities to speak to management teams where necessary.

  • Staff were supported to meet the requirements of professional revalidation where necessary. They were given protected time for professional development and evaluation of their clinical work.

  • There was a strong emphasis on the safety and well-being of all staff.

  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.

  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.

  • Staff were clear on their roles and accountabilities. Newly appointed staff told us that the induction process adequately prepared them for their role.

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. All policies were accessible to staff on the clinic intranet.

  • The practice had developed a set of ‘clinical rules’ which was a short document that laid out the main points of key policies and could be used as a quick reference guide.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality. This included six monthly audits of scanning reports by the lead clinician.
  • The provider had plans in place and had trained staff for major incidents. The service also held a printed copy of the business continuity plan at each location.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • Clinical management meetings were held on a monthly basis and minutes were available to all staff via the intranet.
  • The service used performance information which was reported and monitored and management and staff were held to account

  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.

  • The service submitted data or notifications to external organisations as required.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public and staff to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture.

  • Staff could describe to us the systems in place to give feedback and were able to direct patients to the complaints procedure or online feedback mechanisms. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. Live patient feedback data was available to staff via the intranet.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work. For example, the service had developed a patient record system that enabled fast sharing of diagnostic imaging. The system also had built in templates that had to be completed before the clinician could move on with the consultation. This ensured that all data was captured for audit and treatment was in line with the relevant guidance. The service had also integrated a risk assessment into the clinical records system so that patients at a higher risk of skin cancer would receive the appropriate advice and care.

The service had developed a team intranet where all necessary staff information was held in one place. This included policies and procedures, patient feedback, learning from significant events, meeting minutes and any relevant documents.