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Inspection Summary


Overall summary & rating

Updated 12 November 2018

We carried out an announced comprehensive inspection on 2 October 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection 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.

CQC previously inspected the service on 9 January 2018. During this inspection we found that the service was providing caring and responsive care. However, the service was not providing safe, effective, or well-led care and breaches to regulation were identified. A warning notice was issued against regulation 12 (1) Safe care and treatment and regulation 17 (1) Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We inspected the service on 9 May 2018 to confirm that the service was compliant with warning notices issued. We found those relating to regulation 12 had been resolved and the warning notice met, however there was a continuing breach to regulation 17. We checked this area as part of this comprehensive inspection and found this had been resolved.

We received 24 completed comment cards and spoke with three clients who used the service during the inspection. Feedback from clients was consistently positive. We received comments that the staff were friendly, kind and put them at ease. They commented that the service received was caring, informative and efficient. Many clients described how they had used the service on several occasions.

Our key findings were:

  • The service had systems to manage and monitor risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The service ensured that care and treatment was delivered according to evidence- based research or guidelines.
  • Staff maintained the necessary skills and competence for their role and to support the needs of patients.
  • Staff involved treated patients with compassion, kindness, dignity and respect.
  • Feedback from clients who used the service was consistently positive.
  • The practice was proactive in seeking patient feedback and identifying and solving concerns.
  • The culture of the service encouraged candour, openness and honesty.

There were areas where the provider could make improvements and should:

  • Review the processes to manage risks relating to the care of substances hazardous to health (COSHH). Continue to take action to mitigate the risk of legionella.
  • Review the recording methods used to record safety checks for emergency equipment.
  • Review the systems and processes in place to ensure that regular audits are evidenced, including clinical audits of care and outcomes for patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Updated 12 November 2018

We found that this service was providing safe care in accordance with the relevant regulations.

Safety systems and processes

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

  • The provider had systems to safeguard children and vulnerable adults from abuse. They had a designated lead for safeguarding. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance. All staff received up-to-date safeguarding training appropriate to their role. Staff demonstrated an understanding of how to identify and raise a safeguarding concern.
  • The practice ensured that they received identification and written consent from the parents or guardians of children before they would see children accompanied by anyone else. We saw examples of consent that included the parents’ names, that of the child and of the accompanying adult. If vaccinations were given to children they would be recorded in the child’s ‘red book’ (a child’s personal record of immunisations and health checks retained by the parent or guardian).
  • The provider 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. They had a policy that Disclosure and Barring Service (DBS) checks were undertaken for all staff and we saw evidence of this. (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).

  • The provider conducted health and safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff.
  • The service used rooms within a shared building. The landlord was responsible for the maintenance and safety of the overall building. The provider evidenced they had sought assurances about the safety of the building. For example, a fire safety assessment had been conducted, the fire alarms were being regularly tested and the provider had carried out their own fire drills. They also had evidence that the risk of legionella had been assessed. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). They carried out water temperature testing in accordance with the risk assessment and found the temperature was out of the recommended range. They had raised this issue with the landlord and different corrective measures were being considered.
  • There was an effective system to manage infection prevention and control. The provider had conducted an infection control audit in June 2018 and we saw one action required that had been followed up with the landlord. We saw they kept records of cleaning undertaken, although we noted they had not considered a COSHH (control of substances hazardous to health) assessment or data sheets for the products in use. Staff had received training in infection control including handwashing training.
  • 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.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
  • The provider was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. The provider had recently purchased a defibrillator, which was located in the corridor and therefore available for use by anyone in the office building. They had also purchased oxygen and this was appropriately stored in their treatment room. Staff had started a process to ensure that their new emergency equipment would be regularly checked and logged.
  • The service had emergency guidance available based on the Resuscitation Council (UK) Guidelines.
  • 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 clients.

  • The service used a booking form that was completed by clients as a self-assessment prior to their consultation. This included information about their travel plans including the country to be visited, the length of stay and the availability of medical support once they were there. In addition, the form had a section to record personal medical history and included questions relating to medical conditions, vaccination history, regular medicines, family history and allergies.
  • Individual care records were written and managed in a way that kept clients safe. Nurses completed the care record immediately after the consultation. 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. This included sharing treatment details with the person’s GP and we saw evidence that the service obtained consent prior to doing so.
  • The service had a system in place to retain medical records in line with guidance. They were taking steps towards archiving their paper based files as they were aware that space was becoming limited.

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, emergency medicines and equipment minimised risks.
  • Nurses kept up to date on vaccines and immunisations through the use of specialist resources such as the Green Book (Public Health England guidance on vaccines and vaccination procedures).
  • Staff administered 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, which protected patient safety.
  • Processes were in place for checking medicines to ensure they were within their expiry date and staff kept accurate records of medicines stored within the clinic.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • Processes were in place to ensure the safety of lone workers. This included that the service had updated their lone working policy and incorporated risk mitigation to ensure the safety and welfare of their staff.
  • 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
  • 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

Updated 12 November 2018

We found that this service was providing effective care in accordance with the relevant regulations.

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 in line with relevant and current evidence based guidance and standards such as the National Travel Health Network and Centre (NaTHNaC) travel guidance.

  • Clients’ immediate and ongoing needs were fully assessed.
  • Records and discussions with staff demonstrated that assessments included consideration of relevant personal and familial medical history and medicines used.

Monitoring care and treatment

The provider had initiated quality improvement activity and reviewed the effectiveness and appropriateness of the care provided. They provider had carried out two audits. For example, the service conducted an audit on the technique used for administering the rabies vaccine. The service also conducted their own monthly reviews of the feedback forms completed by clients and took action where necessary to improve quality of service.

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 and this included supervised practice and competency assessments.
  • Nursing staff were registered with the Nursing and Midwifery Council and were up to date with revalidation
  • 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. All nurses had received immunisation training and there was evidence of specialist travel vaccination training for all nurses.
  • Staff had access to appropriate training to meet their learning needs and to cover the scope of their work. This included ongoing support, one-to-one meetings, coaching, mentoring and clinical supervision. For example, they had closed the clinic to enable all nursing staff to attend a nursing conference in London.
  • Staff were encouraged and given opportunities to develop. For example, one of the nurses was being supported to complete a qualification in travel medicine.
  • The service had organised a training session for basic life support and fire training. They had invited other staff from businesses within their building, to ensure they had the skills and knowledge necessary in case of an emergency. They had also invited other GP practices in the area and were joined by GPs, nurses and health care assistants. They were hoping to provide this training annually.

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.
  • Before providing treatment, nurses at the service ensured they had adequate knowledge of the patient’s health and their medicines history.
  • 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.
  • Staff ensured they stayed up to date with the latest information by working with other travel and health organisations.

Supporting patients to live healthier lives

Staff were consistent in supporting clients to manage their own health and offered advice, where appropriate, so they could self-care whilst travelling. The service identified clients who may be in need of extra support and gave them more time and encouraged them to discuss their needs and share information with their general practitioner.

Consent to care and treatment

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

  • Staff demonstrated they 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 patient’s mental capacity to make a decision.
  • Written and verbal information was given to clients using the service. This included information on medicines and vaccines including risks and benefits prior to administration. Treatment forms included a section for clients to sign their consent.
  • The service had a system in place to verify the identity of parents or guardians of children under the age of 18.

Caring

Updated 12 November 2018

We found that this service was providing caring services in accordance with the relevant regulations.

Kindness, respect and compassion

Staff treated clients with kindness, respect and compassion.

  • During our inspection we observed that all members of staff were professional, courteous and very helpful to clients, treating them with dignity and respect.
  • We spoke with three clients and received 24 comments cards. Feedback from clients was positive about the way staff treated clients.
  • Four out of five reviews were five stars on Facebook and they had received 17 recommendations. We noted the service had responded to comments and taken steps to gain more details on opportunities to improve.
  • 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 clients to be involved in decisions about care and treatment.

  • 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.

  • The service ensured that clients were provided with all the information, including costs, they required to make decisions about their treatment prior to treatment commencing.
  • Fees were clearly displayed and the service advised clients which treatments were available free of charge on the NHS.

Privacy and Dignity

The service respected clients’ privacy and dignity.

  • Staff recognised the importance of clients’s dignity and respect.
  • Consultations took place in the treatment room and we noted the door was kept closed so that conversations could not be overheard.
  • The practice complied with the Data Protection Act 1998. All confidential information was stored securely on computers. Any documents retained as hard copies were locked in cupboards.

Responsive

Updated 12 November 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

Responding to and meeting people’s needs

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

  • The facilities and premises were appropriate for the services delivered. The clinic was located on the first floor of a shared office building and a lift was available.
  • Information was available on the service website, informing people about the services available and providing a booking portal for appointments.
  • Consultations were provided flexibly and they tailored services in response to clients’s needs and preferences. For example, they opened outside of office hours in order to provide services to a person who had limited time in the UK. Appointments were generally booked for 20 minutes but longer appointments were available for complex travel advice or for family groups

Timely access to the service

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

  • Clients had timely access to initial assessment and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Clients reported that the appointment system was easy to use. The provider used a company who provided a remote receptionist service as their appointment system. All calls were recorded and they had access to reports regarding performance. For example, we saw that 141 appointments had been booked for the month of September using 146 clinic hours. The provider told us that they conducted ad hoc quality audits on the service. This included that they called and tested aspects such as time taken to answer the call and waiting time for an appointment. They told us the results were consistently positive, however the audits results were not always recorded and stored.
  • Walk-in appointments were available for advice and information.

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 a complaint policy and procedures in place. The service learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. For example, the service refused to administer a vaccine to a patient as the recommended timescale between doses had not been reached. The patient stated they changed their appointment date and this was not challenged at the time. Although this was not received as a formal complaint, the service ensured they fully investigated and acted on the concerns. As a result, the service updated the guidance provided to the appointment booking company to ensure that appointments were not changed without their permission.
  • Learning from complaints was disseminated through discussions with staff.

Well-led

Updated 12 November 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

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.

Vision and strategy

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

  • The service had a vision to provide treatment, information and advice to help reduce the risks involved in travel.
  • They were exploring solutions to address the challenges of balancing the clinical aspects of the service with governance requirements.

Culture

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

  • Staff we spoke with felt respected, supported and valued. They enjoyed working at the service and found the work to be varied and interesting.
  • The service focused on the needs of clients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so.
  • 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. All 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 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. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • 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 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.
  • 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 and audit to assessment the performance and outcomes, but we found these were not always well documented.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service encouraged and valued feedback from clients, the public, staff and external partners.

  • The publics’, clients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. For example, the service used feedback cards that were regularly monitored and acted upon.

  • Staff were able to describe to us the systems in place to give feedback. The service held regular directors’ meetings and whole staff meetings, which included clinical supervision and updates on the service.
  • 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.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement for all staff.
  • 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.