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Bristol Good Also known as Nomad Travel Clinic - Bristol

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 20 August 2019

We carried out an announced comprehensive inspection at Nomad Travel Clinic - Bristol under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Nomad Travel Clinic - Bristol is a private clinic providing travel health advice, travel and non-travel vaccines, blood tests for antibody screening and travel medicines such as anti-malarial medicines to children and adults. The clinic holds a licence to administer yellow fever vaccines; and in addition the service provides post-exposure Rabies treatment on behalf of Public Health England.

This location is registered with CQC under the Health and Social Care Act 2008 in respect of some, (the provision of advice or treatment by, or under the supervision of, a medical practitioner, including the prescribing of medicines for the purposes of travel health) but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Nomad Travel Clinic - Bristol services are provided to clients under arrangements made by their employer with whom the servicer user holds a policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Nomad Travel Clinic - Bristol we were only able to inspect the services which are not arranged for clients by their employers.

During the inspection we reviewed 53 completed CQC comment cards which described the service as efficient, carried out in a safe and hygienic environment. Clients said staff listened to them and were considerate, friendly, helpful, knowledgeable, caring and respectful.

Our key findings were:

• The clinic had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the provider learned from them and improved their processes.

• The provider routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines and up to date travel health information.

• Each client received an individualised travel health brief containing a risk assessment, health information including additional health risks related to their destinations; and a written immunisation plan.

• Staff involved and treated clients with compassion, kindness, dignity and respect. Care Quality Commission comment cards completed by clients prior to our inspection were all positive about the standard of care received.

• There was a leadership structure in place with clear responsibilities, roles and systems of accountability to support good governance and management. Staff felt supported by the leadership team and worked well together as a team across local branches when necessary.

• The provider was aware of the requirements of the duty of candour.

• Clinic staff were encouraged to plan and develop the service to meet local needs such as responding to local disease outbreaks and visiting schools to provide travel health talks.

We saw the following outstanding practice:

• The clinic provides the rabies post-exposure service for the local area, through a delegated arrangement, on behalf of Public Health England (PHE) for the benefit of patients. Nomad Travel Clinic is one of only two travel clinics in England who have this arrangement that benefits patients through ease of access to assessment and treatment when time is of the essence. Staff are trained to use the PHE Risk Assessment; hold stocks of rabies vaccines on site; and provide treatment directly to clients following an exposure incident without the need for prior contact with PHE or potential delays in accessing vaccines.

Inspection areas

Safe

Good

Updated 20 August 2019

We rated safe as good because:

  • The provider had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • There were effective arrangements in place for the management of medicines.
  • There was a system in place for reporting and recording incidents including significant events. Lessons were shared to make sure action was taken to improve safety in the service.
  • When there were unintended or unexpected safety incidents, people received reasonable support, truthful information, an apology and were told about any actions to improve processes to prevent the same thing happening again.

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. 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 service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support clients and protect them from neglect and abuse. Staff took steps to protect clients 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. (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. For example, nurses had received specific training to recognise and report suspected female genital mutilation (FGM). Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control.
  • 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 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.
  • There was an effective induction system for staff tailored to their role, including staff employed in other Nomad clinic branches who sometimes provided cover for absence.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage clients with severe infections, for example sepsis.
  • The service did not have a defibrillator. However, we saw that they had completed a Resuscitation Council risk assessment in June 2019, to determine whether the service should have a defibrillator on site. The service scored themselves as a moderate risk overall on the assessment, meaning they should reduce risk if reasonably practicable. Staff were aware of where the nearest defibrillator was sited and the actions they should take. The service had identified the locations of the two nearest community defibrillators, the closest being in the adjoining public building that was open the same hours each week as the clinic (except for one hour one morning each week). This enabled emergency defibrillation to be provided within two minutes (or within five minutes during one hour each week). The provider told us they were currently reviewing their risk assessments in relation to having a defibrillator on site.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate professional and medical 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 clients 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. For example, informing the clients own GP of any treatments received, with the client’s consent.
  • 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.

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 vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff provided, administered or supplied medicines to clients 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. Where there was a different approach taken from national guidance there was a clear rationale for this that protected client safety.
  • On registering with the service, and at each consultation client identity was verified and recorded in client records.
  • The service provided some medicines outside of their licenced use, for example for the treatment of pre and post exposure for rabies. (Medicines are given licences after trials have shown that they are safe and effective for treating a particular condition. Use for a different medical condition is called unlicensed or ‘off-label’ use and is a higher risk because less information is available about the benefits and potential risks). Clients were asked to read information, provided during the consultation, about the use of medicines outside of their licensed use; and the client consent that the information had been read and understood was recorded within the clients’ medical notes.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • 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.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology.
  • They kept written records of verbal interactions as well as written correspondence.

Effective

Good

Updated 20 August 2019

We rated effective as good because:

  • Clinicians kept up to date with current evidence-based practice.
  • The service was actively involved in quality improvement such as clinical audits.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. They assessed needs and delivered care in line with current evidence based guidance.
  • Clients received an individualised travel risk assessment, health information including additional health risks related to their destinations and a written immunisation plan specific to them. Staff were consistent and proactive in empowering clients and supporting them to manage their own health and maximise their independence.
  • Nursing staff understood the requirements of legislation and guidance when considering consent including parental consent.

We saw the following outstanding practice:

  • The provider had established a close working relationship with Public Health England (PHE) who had delegated arrangements to Nomad Travel Clinic – Bristol to provide rabies post-exposure service on behalf of PHE for the local area.

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). For example, NaTHNac (National Travel Health Network and Centre), a service commissioned by Public Health England.

  • Clients received a travel health assessment which provided an individualised travel risk assessment, health information including additional health risks related to their destinations and a written immunisation plan specific to them.
  • A comprehensive assessment was undertaken which included an up to date medical history.
  • Additional virtual clinical support was available during each consultation from the medical team.
  • Latest travel health alerts such as outbreaks of infectious diseases were available. Specific additional training was available at times of disease outbreak such as Ebola and Zika virus.
  • We saw no evidence of discrimination when making care and treatment decisions. The nursing staff had recently undertaken a study day which included the challenges faced by travellers who were pregnant and/or living with disabilities.

Monitoring care and treatment

  • The service used information about care and treatment to make improvements. For example, face to face consultations were reviewed every three months during peer review sessions.
  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for clients. There was clear evidence of action to resolve concerns and improve quality. For example, notes from 20 consultations were audited annually covering four different scenarios such as care for paediatric patients, Yellow Fever, anti-malarial and rabies treatments. In April 2019 this had identified that further training was needed in some areas and some documentation that could be improved. We saw that discussion had been held with staff, improvements implemented; and follow up audits carried out to ensure improvements had been embedded. Peer reviews of clinical consultation notes were also carried out.

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.
  • Relevant professionals (pharmaceutical and nursing) were registered with GPhC (The General Pharmaceutical Council) and the NMC (Nursing and Midwifery Council) and were up to date with revalidation. These were checked annually by the provider.
  • 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.
  • Staff whose role included immunisation had received specific training could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

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

  • Clients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate and supported national campaigns. For example, the provider had established a close working relationship with Public Health England (PHE) who had delegated arrangements to Nomad Travel Clinic - Bristol to provide rabies post-exposure service on their behalf for the local area.

This is one of only two arrangements by PHE with travel clinic providers in England and benefits patients through quick and easy access to assessment and treatment when time is of the essence. The Bristol Nomad clinic is open six days a week, including evenings and most bank holidays. Nurses on site were trained in use of the PHE Risk Assessment (RA); and hold stocks of rabies vaccines on site for PHE. They provide assessment and treatment directly to clients following an exposure incident without the need for prior contact with PHE or potential delays in accessing vaccines; and an internet based dynamic form was used to keep PHE informed.

The typical process elsewhere in England requires a patient to contact PHE’s central rabies team; be referred to a GP or A&E department, who are then supported by PHE by phone to complete the PHE RA and determine appropriate treatment. Vaccine stock then has to be obtained before post-exposure treatment can commence, posing increased risks as rapid administration of vaccine is vital to ensure effective treatment.

Clients were informed that it was possible to start the post-exposure vaccine process immediately with Nomad; and they were also offered the option to continue with their own GP. The process ensured that the client’s GP details were documented; and their GP was informed in all rabies post-exposure cases.

  • All clients 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.
  • Client information was shared appropriately and the information needed to plan and deliver care and treatment was available to staff in a timely and accessible way.

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 people advice so they could self-care; and risk factors were identified and highlighted to clients.
  • Nomad had developed a booklet entitled “Sexual Violence Guidance for Travellers” which had been found to be particularly useful for humanitarian workers.
  • Where clients’ 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 .

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported clients to make decisions. Where appropriate, they assessed and recorded a client’s mental capacity to make a decision. All staff had received training in the Mental Capacity Act (2005).
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 20 August 2019

We rated caring as good because:

  • Information for clients about the services available was easy to understand and accessible.
  • We were assured that staff treated clients with kindness and respect; and maintained client and information confidentiality. The service respected client's dignity and privacy. The service could evidence client feedback from surveys undertaken and compliments received. All the survey results we saw and CQC comments cards we received, reported positive experiences and outcomes.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from clients was positive about the way staff treated people.
  • We received 53 CQC comment cards that were all positive about the way staff treat people.
  • Staff understood clients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all clients.
  • The service gave clients timely support and information.

Involvement in decisions about care and treatment

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

  • Interpretation services and information leaflets were available for clients who did not have English as a first language.
  • Clients 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.
  • For clients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if clients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Clients’ care records could include both public or private notes, to ensure that only those staff members who needed to see sensitive information (such as clients’ current medicines or health conditions) would have access.

Responsive

Good

Updated 20 August 2019

We rated responsive as good because:

  • The service understood its client profile and had used this to meet their needs and preferences.
  • Clients said they found it easy to make an appointment.
  • The clinic was well equipped to treat clients and meet their needs.
  • Information about how to complain was available and easy to understand. The service took complaints and concerns seriously; and learning was shared with staff to improve the quality of care.

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 clients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered. For example, the waiting area was moved within the store following client feedback.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

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

  • Clients had timely access to initial assessment, test results, diagnosis and treatment. Those with the most urgent needs had their care and treatment prioritised.
  • Waiting times, delays and cancellations were minimal and managed appropriately.

The appointment system was easy to use.

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 clients who made complaints compassionately.
  • The service informed clients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 20 August 2019

We rated well-led as good because:

  • Leaders had the capacity and skills to deliver high-quality, sustainable care.
  • There was a clear vision and credible strategy to deliver high quality travel healthcare and promote good outcomes for clients. Staff were clear about the vision and their responsibilities in relation to it.
  • The service had a culture of high-quality sustainable care and encouraged openness and honesty.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management; and staff felt supported by management.
  • There were clear and effective processes for managing risks, issues and performance and improve quality.
  • Staff had received comprehensive inductions and attended staff meetings and training opportunities. There was a strong focus on continuous learning and improvement at all levels.
  • The service acted on appropriate and accurate information; and was aware of and complied with the requirements of the duty of candour.
  • The service involved clients, the public, staff and external partners to support high-quality sustainable practices.
  • Leaders and staff strived for continuous learning, improvement and innovation such as partnership working with Public Health England (PHE); university research projects; and developed services locally to meet client needs. For example, the Bristol clinic served a significant local cluster of wildlife film & TV production organisations who had many staff travelling frequently to diverse global destinations.

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.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. For example, a process for lead nurse training was in place; and all clinical staff had a senior mentor.

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.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • 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 clients.
  • 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. 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 need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • 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.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear 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 client safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for clients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

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 clients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • 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 client identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • The service encouraged and heard views and concerns from the public, clients, 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. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • The service contracted the services of an external human resources (HR) company who were able to provide HR assistance in complex situations. Staff were also able to access an employee assistance programme, which included counselling, private legal and financial advice through this. An employees’ family were also given access to this support.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external 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.
  • Development opportunities were available for non-clinical staff.