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Inspection Summary


Overall summary & rating

Outstanding

Updated 13 November 2019

This service is rated as Outstanding overall. (Previous inspection September 2018 was an initial un-rated inspection.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? – Outstanding

We carried out an announced comprehensive inspection at Tollgate Clinic 29 August 2019 as part of our inspection programme, to follow up and rate the service. Tollgate Clinic Limited provides NHS referred surgery for carpal tunnel syndrome, and non-scalpel vasectomies. They also provide private patient paid surgery for minor skin lumps and bumps, joint injections, carpal tunnel syndrome, and non-scalpel vasectomies.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of the services it provides.

A senior manager at the service is the registered manager. 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.

We obtained feedback from 19 people through completed comment cards. These had been provided by the Care Quality Commission prior to the inspection at the service. Feedback was very positive in regard to the care, treatment, cleanliness, clinicians, administrative staff, and receptionists. We were unable to speak to patients on the day of inspection because it was a non-clinic day.

Our key findings were:

  • The service provider conducted regular well-documented safety and environmental risk assessments.
  • There was a designated lead and systems to safeguard children and vulnerable adults from abuse.
  • The service was well equipped to treat patients and the facilities met standards and patient needs. Emergency equipment and medicines were available, well monitored to guarantee they were safe for use, and signposted to ensure ease of access should an emergency occur.
  • Appropriate standards of cleanliness and hygiene were seen.
  • Patients’ care needs were assessed and delivered according to individual patient needs.
  • Treatment and care was delivered in line with current evidence based guidance.
  • Staff had the skills, capacity, knowledge and experience to deliver effective care and treatment.
  • Information about how to complain was available and easy to understand.
  • The service staff worked proactively with the GP practices that referred patients into their service, to improve patient experience.
  • Patients told us they were treated with genuine compassion, dignity and respect. Patient feedback was clear, they were active partners and fully involved in decisions about their care and treatment.
  • Patient feedback that we received on comment cards was extremely and consistently positive. Many of them told us the care and treatment provided by the staff exceeded their expectations and that they went the extra mile to ensure patients received excellent care.
  • There was a clear leadership structure and staff felt supported by clinicians and management.
  • The service proactively sought feedback from staff and patients, which it acted on.
  • The service used audits to monitor and study every aspect of their service. This ranged from administration, safety incidents, and best practice clinical decisions.
  • The service was aware and complied with the requirements of the duty of candour.
  • Staff told us they felt respected, supported that their work was valued, and proud to work for the service.
  • Leaders were knowledgeable about concerns and priorities relating to the quality and the future of the service. They understood the challenges and knew how to address them. There was a whole team approach to providing high levels of care.

We saw the following outstanding practice:

We saw evidence of a culture that tailored their services to meet the needs of people on an individual basis. They ensured flexibility, and patient centred involved choices in their care and treatment. To enable the service to do this they had developed an audit driven philosophy to monitor and investigate every aspect of the service they delivered. This ranged from service administration, through to patient satisfaction, compliments, comments, and best practice clinical guidance. Audits were run weekly and monthly and discussed with management and clinicians to monitor trends or themes. Actions, improvements and changes were seen as a continual work ethos to improve and develop the service. Staff we spoke with understood this vision and could describe how they were proud to be involved.

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

Inspection areas

Safe

Good

Updated 13 November 2019

We rated safe as

Good because:

We found safe systems to manage risk, safeguarding, medicines, and information safety. The process to monitor safety incidents ensured improvements to the service and that lessons were learned.

Safety systems and processes

The service

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

  • The service provider conducted regular well-documented safety and environmental risk assessments.
  • Appropriate safety policies were regularly reviewed, and updates were communicated to staff with guidance about who to go to for further assistance.
  • Staff received safety information from the service as part of their induction and update training, this was seen when updates and reviews were finished.
  • The service had a designated lead and systems to safeguard children and vulnerable adults from abuse.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff continuously looked to improve and took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • Staff checks were carried out at the time of recruitment and were an ongoing process where appropriate. It was the service providers policy that a disclosure and barring service (DBS) checks were undertaken for all staff members (DBS checks identify whether a person had a criminal record or on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • We found documented evidence that all staff had received up-to-date safeguarding, and safety training that was appropriate for their role. They knew how to identify and report safeguarding concerns.
  • Staff who acted as chaperones were trained for the role and had received a DBS check. Evidence seen showed staff had received the level of safeguarding training appropriate for their role. The service was aware that new intercollegiate guidance on safeguarding required all clinicians; nurses, mental health workers, etc to be trained to safeguarding level 3 by August 2021 and met that expectation.
  • We saw an effective system to manage infection prevention and control. There were monthly infection control audits to demonstrate the effectiveness of this work.
  • Legionella risk assessments were undertaken, and no risk was seen.
  • The service provider ensured facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions.
  • There were systems to safely manage healthcare waste, its disposal, and clinical specimens to keep staff and patients safe.

Risks to patients

There

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

  • There were sufficient staff numbers, including clinical staff, to meet demand for the service.
  • The service was not intended for patients requiring treatment for long term health conditions or an emergency treatment service.
  • An effective induction system ensured it was tailored to administrative and clinical staff roles.
  • There were arrangements for planning and monitoring the number and mix of staff needed for the service.
  • We talked with a bank staff member who explained the effectiveness of the induction process they had received and how it was 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.
  • There were suitable medicines and equipment to deal with medical emergencies, they were well sign-posted, stored securely at the correct temperature to keep them safe and checked regularly.
  • When there were changes to services or staff, the service assessed and monitored the impact on safety.
  • We found appropriate organisational indemnity arrangements to cover all potential liabilities associated with delivery this service.

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 to an exemplary high standard and managed in a way that kept patients safe. The care records we looked at showed information needed to deliver safe care and treatment was readily available to relevant staff in an accessible way. Records were audited monthly to ensure they were consistently documented with no gaps in information standards held by the service, to deliver safe care.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and any follow-on treatment requirements.
  • 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.
  • We saw clinicians had 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.

  • Minimal prescribing was carried out by the service clinicians. Treatment was mainly to reduce the possibility of post-operative infection, and/or to provide pain relief. The process in place followed best practice guidelines for the appropriate and safe handling of medicines. Prescription stationery was stored securely, and its use was carefully monitored.
  • The service carried out regular medicine audits to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • The service did not prescribe controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence or schedule 4 or 5.
  • When clinicians prescribed, administered or supplied medicines to patients they gave advice on medicines in line with legal requirements and current national guidance. Patients told us on the comment cards medicines prescribed had been carefully explained and a telephone number to call if they needed any further reassurance had been provided.
  • Processes were in place to check medicines were safe for use, and accurate records of medicines monitoring was seen.

Track record on safety and incidents

The service

had a good safety record.

  • There were comprehensive risk assessments carried out in relation to safety issues.
  • The service monitored and reviewed safety incidents with weekly and monthly auditing. This helped them to understand any risks and gave a clear, accurate, and current picture that led to safety improvements. For example; when a sample went missing, a double checking process was initiated for each stage of the sample taking and handling process to reduce the risk of any reoccurrence.

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 effective systems for reviewing and investigating incidents when things went wrong. The service provider learned, and shared lessons identified and took action to improve safety in the service. The service had a structure to provide affected people with reasonable support, truthful information and a verbal and or written apology. We were told there had been no serious or notifiable incidents to report in the last 12 months.
  • We saw that the service provider was aware and complied with the requirements of the duty of candour. A culture of openness and honesty was seen to be encouraged.
  • The registered manager at the service had a process in place, to notify the Care Quality Commission of notifiable safety incidents.
  • External safety events, including patient and medicine safety alerts were seen to be acted on appropriately and learning recorded. There was an effective mechanism to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 13 November 2019

We rated effective as

Good

because:

There were effective systems to monitor and manage care and treatment. All patients were included in decisions about their care and treatment decisions. Staff had the skills, knowledge and experience to deliver the services delivered. Staff worked with stakeholder organisations, to deliver effective care and treatment for patients.

Effective needs assessment care and treatment Patient needs were assessed, and care was delivered 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, mental, and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate. For example; post-operative painkillers were prescribed including antibiotics when appropriate, and a post-operative telephone contact number was available from Monday to Sunday till 10pm each evening.

Monitoring care and treatment

The service was involved in quality improvement activity.

  • The practice had an extensive range of clinical audit and quality assurance. Clinical audits seen, demonstrated quality improvement. For example: World health organisation (WHO) theatre checklist audit, association of surgeons in primarycare(ASPC) carpal tunnel syndrome (CTS), patient reported outcome measures (PROMS) Audit, ASPC vasectomy PROMs audit, and hand washing audit, infection control audit, and medicine management audit.

  • The service used information about care and treatment to make improvements. For example: after clinicians attended the ASPC conference, they changed the time frame to process samples provided post vasectomy procedure.
  • The service made improvements through the use of completed audits.
  • Clinical audit had shown to have a positive impact on the quality of care and improved outcomes for patients. For example, reduced post-operative infection was seen, since a procedural change had been made. Another example was the placement of sharps boxes had changed to improve staff safety.
  • There was clear evidence of action to resolve concerns and improve quality.
  • Care treatment was monitored by collecting patient feedback from every patient that had utilised the service.
  • There were systems to monitor laboratory samples and a protocol regarding the receiving and acting on sample test results.
  • Clinical staff assessed patient needs and delivered care in line with relevant and current evidence based guidance and standards. When standards were updated these were shared at quality clinical meetings.

Effective staffing

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

  • We saw all staff were appropriately qualified for their role and had received an appropriate induction programme when newly appointed. Staff told us they felt confident once they had completed their bespoke induction programme.
  • Relevant professionals (medical, surgical, and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation. This was seen in the staff records we reviewed.
  • The learning needs of staff were understood by the service and protected time and training was provided to meet the needs of their individual roles. Up to date records of skills, qualifications and training were maintained. We saw staff were encouraged and given opportunities to develop.

Coordinating patient care and information sharing

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

  • The patient treatment records viewed at inspection contained all the information needed to deliver patient’s person-centred care and treatment.
  • Patients were provided all the information about their treatment this included the benefits and any known risks.
  • Staff communicated effectively with other services when appropriate. For example, with the referring patients registered NHS GP, the laboratory service to process procedure samples, and the local commissioning group.
  • The service ensured they had, adequate information regarding patient’s health, relevant test results, and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where appropriate. For example, if the patient needed specialist monitoring not available at the clinic.
  • Consent to share details of their consultation and any medicines prescribed with their registered NHS GP was sought on each occasion that they used the service.
  • 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.

  • Patients received an initial assessment appointment before receiving any treatment. This gave clinicians the opportunity to evaluate that the treatment was appropriate, and beneficial, taking existing conditions into consideration.
  • Risk factors were identified, highlighted to patients, and where appropriate highlighted to their normal care provider for further support. For example: Advice to the patients registered GP regarding wound and dressing management.
  • Where appropriate, staff gave people advice, so they could self-care.
  • 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

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff we spoke with told us they supported patients to make decisions when appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately. For example: We saw an audit undertaken to show consent was consistently obtained and recorded in patient records.
  • The cost of treatment (where appropriate) and the treatment plan was fully explained, and written copies were given to patients. We were told patients were given the opportunity to ask questions and make informed decisions before receiving their treatment.

Caring

Good

Updated 13 November 2019

We rated caring as

Good

because:

Staff were courteous, demonstrated a patient centred approach, and treated people with dignity and respect. Patients told us they were truly respected and valued as individuals. Staff helped patients to be involved in decisions about their care and treatment. The importance of people’s dignity was recognised by all staff at the service particularly in respect of the sensitive nature of some treatments delivered.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We observed that members of staff were courteous and helpful to patients and treated people with dignity and respect. Staff we spoke with demonstrated a patient centred approach to their work. Patients were truly respected and valued as individuals, they were empowered to be partners in their care by staff working at the service.
  • The service sought feedback regarding the quality of clinical and emotional care patients received. For example; patient feedback was sought a few days after their surgical procedures to ensure they had time to provide a constructive opinion.
  • We received extremely consistent positive feedback from 19 people that had been provided a service at the clinic. This feedback was on comment cards we had provided the service prior to our inspection.
  • We found examples given on the cards where staff had exceeded patient expectations and gone the extra mile to provide excellent care to their patients. For example; a patient commented that when they felt dizzy in the car park after a procedure, staff reacted immediately to administer oxygen. They further commented that the support had gone above and beyond any expected care, as the clinical team had stayed much later than the clinic opening hours, until they were confident that the dizziness had passed and was well enough to leave.
  • Patients told us about their pre-assessment, their treatment, and the follow-up care they had received. Many of the cards mentioned the clinicians and administrative staff by name for their kindness and help.
  • We were told on the comment cards, patients were treated with dignity and respect. We were also told the service gave patients timely support, and information to enable them to make an informed choice about their treatment.
  • Staff provided emotional support to all patients to minimise their distress. Staff recognised that patients’ emotional and social needs were as important as their physical needs.
  • Staff understood patients’ personal, cultural, social and religious needs. They demonstrated an understanding and non-judgmental attitude to all patients. For example, whether the patient was provided with NHS or private treatment.
  • Patients indicated they were very satisfied with the service they had received, as part of the service providers own feedback survey.

Involvement in decisions about care and treatment

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

  • Patients were provided with information about procedures including the benefits and risks.
  • Interpretation services were available for patients who did not have English as a first language.
  • Staff members at every level within the service had received training to answer the questions that patients had about the treatment options available at the clinic.
  • Patients told us through comment cards that they felt listened to and supported by staff. They also told us sufficient time was provided during consultations to make an informed decision about the choice of treatment available to them.
  • We were told by patients that staff members always empowered people to who use the service to have a voice. For example: Even after patient consent had been given, if they felt unable to go through with the procedure, staff did not pressure or persuade them. The patients decision was honoured, and an open proposal to reconsider at a later date was offered.
  • Individual patient preferences and needs, were reflected in their records about how their care was delivered.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Treatment and assessment clinic room doors remained closed during treatment sessions to ensure it was not possible to hear what was happening inside.

  • Staff recognised the totality and importance of people’s dignity particularly in respect of the sensitive nature of some treatments they delivered. Staff were highly motivated and inspired to offer care that promoted dignity for their patients.
  • Staff told us that if a patient felt uncomfortable having a conversation in the reception area, they could provide a private room available where they could speak with patients to ensure confidentiality.
  • Computer screens faced away from patients in the reception area and staff could explain to us how they kept patient’s confidentiality when speaking on the telephone.
  • The service had recently added sound proofing screens to the reception/waiting area to ensure that telephone conversations could not be over heard by waiting patients.

Responsive

Outstanding

Updated 13 November 2019

We rated responsive as

Outstanding

because:

The provider tailored services to deliver individual patient preferences. This was central to the planning and delivery of their customised treatments, flexibility, choice of care, and follow-up care. Accessible care and treatment was provided within quicker timescales than other providers providing the same procedures . Quarterly meetings with contract commissioners ensured the provider could offer, respond and meet patient needs. Concerns and complaints were treated seriously, investigated, and lessons were learned. The learning from complaints and concerns was shared with all staff members.

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 service providers involvement with other organisations and the local community was integral to the way their services were planned and ensured that services met people’s needs and preferences. Work with local GP practices and the clinical commissioning groups had ensured the services provided met the needs and service provision gaps in the North-East Essex and Mid Essex healthcare populations.
  • The service provider tailored the service to deliver individual preferences that were central to the planning and delivery of their customised services. They provided flexibility, choice of treatment, and follow-up care support where appropriate.
  • We found that the premises were accessible and suitable for people in vulnerable circumstances to enable them access and use of the services on an equal basis to others. For example; the service was located on the ground floor, and the corridors and door frames were suitable for those using mobility equipment. This included the clinical rooms where regulated activities (surgical procedures) were carried out, the reception and waiting area, were all accessible.
  • Further examples of responding to patient needs occurred following a survey of patients feedback after surgery. The service made the decision to increase the time that had elapsed after surgery before they requested feedback. By waiting to request the feedback it allowed patients to comment on any follow-up treatment or care that they may also have received, thus providing greater information for the service to develop and improve.
  • The service worked proactively with the services that referred patients to them to improve patient experience.
  • The service received feedback from numerous sources to support them making decisions about the service. We noted comments on the NHS Choices website for example; I would like to say thank you for my treatment today. I did not feel like a number as I have previously in the hospital, but a person with a problem that was listened to and given a good explanation of treatment available. When the consultation was concluded, and treatment jointly agreed this was carried out immediately. To be honest I came away astounded I have never been so well cared for and so promptly. So, a huge thank you for having such an outstanding clinic and staff that excel in their work.
  • The service reviewed the needs of patients in the local area to ensure services were designed to meet their needs. For example, an additional location was added in Clacton to improve access for older patients with transport issues. The minor skin surgery service had also recently been remodelled to offer a more affordable access to the ‘face to face’ initial assessments with the clinicians.

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.
  • People could access services and appointments in a way and at a time that suited them.
  • Waiting times from referral to assessment were consistent and significantly better than the National Institute of Clinical Excellence (NICE) quality standard guidance for the surgery provided, and arrangements to treat and discharge patients were greater than recognised good practice.
  • Follow-up support surpassed conventional accessibility, for the procedures undertaken by the service.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. For example: To patients registered NHS GP for dressings that needed to be changed or continuation of pain relief.

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.

  • The service treated concerns and complaints seriously, we saw they had investigated them, and lessons had been learned from the results. The learning from complaints and concerns was shared with all staff members who were able to recall changes that had been as result. For example; when patients were paying privately for their care, the costs were fully explained, they also advised patients of the timeframe for payment.

  • Information about how to make a complaint or raise concerns was available on the service providers website and in the service reception area.
  • There was a system with a complaint policy and procedures in place. The service had learned lessons from individual concerns, complaints and from the audit and analysis of them. It acted as a result to improve the quality of care. Four complaints had been received in the last 12 months. We saw the changes that had been made as a result. For example:

    • The service improved the procedure for setting patient expectations when clinics were running late should an unexpected complication delay the next patients appointment. The patients were given a clear choice of continuing to wait or re-booking their appointment.
    • A clearer procedure was produced showing patients how to complain. Improved information was added to patient information leaflets, letters, and the service website.
    • A review of patient undressing requirements was improved to meet the balance between patient dignity, and environmental temperature control, to ensure patients were comfortable.

  • The service informed patients of any further action they could take when they were not satisfied with the response, and the actions undertaken to deal with their complaint.
  • Learning and service changes from complaints were shared and minuted during team meetings and individually when needed.

Well-led

Outstanding

Updated 13 November 2019

We rated well-led as

Outstanding because:

Clinical leaders were knowledgeable about issues and priorities relating to the quality and future of the service. They understood the challenges and knew how to address them. Leaders at all levels were visible and approachable. There was a realistic statement of purpose and supporting plans to achieve service priorities. The vision values and service strategy had been formed with staff and external partners. There was a culture of high-quality sustainable care, with structures, processes, and systems in place to support good governance and effective management had been developed.

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 the future of the service. They understood the challenges and knew how to address them.
  • Leaders at all levels were visible and approachable to support staff and patients. 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; the service ‘Strategic Business Plan’ included completion of the integration with ‘PROVIDE’ through staff consultation, alignment of roles and support within the larger organisation, streamlining of processes, efficiencies, and improved customer experience.
  • There was a clear leadership structure in place and staff were aware of their roles and responsibilities.
  • Staff told us they felt supported and could access support from the managers at all times.

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 statement of purpose and supporting plans to achieve priorities. For example; at Tollgate Clinic we see our role as partnering the NHS in providing a high standard of care to our patients. This was done through a speedy, efficient, and friendly service, thereby reducing the pressure on both the acute services and the patient. Thus, enabling the patient to have their minor surgery at a time and place of their convenience.
  • The service developed its vision, values and strategy, jointly with staff and external partners (where relevant). For example: with the North East Essex clinical commissioning group and Mid Essex clinical commissioning group.
  • Staff were aware of and understood the vision, values and strategy of the service and their role in achieving them.
  • The service monitored progress against delivery of the strategy. With a number of audits, for example: Consultation note completeness, referral letter completeness, and audits to monitor administrative workflow timeliness.

Culture

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

  • We saw evidence of a culture that tailored their services to meet the needs of people on an individual basis. They ensured flexibility, and patient centred involved choice in their care and treatment. To enable the service to do this they had developed an audit driven philosophy to monitor and investigate every aspect of the service they delivered. This ranged from the service administration, through to patient satisfaction, and included incidents, and best practice clinical decisions.
  • The service promoted the duty of candour, openness and honesty.
  • Staff told us they felt respected, supported and their work was valued. All staff told us they were proud to work for the service. They were able to raise concerns without fear of retribution and felt confident that actions would be taken. Staff also told us that since the organisation had joined with ‘Provide’ they felt better supported with regard to, training occupational health, and staff survey in line with the NHS staff survey.
  • The service was focused wholly on the needs of their patients. For example; monitoring of patient feedback showed there was a need to provide more local assessment to patients with transport issues. The service had added provision in Clacton to address this issue. The addition of a dedicated reception and waiting room had improved patient experience, as people using the service previously had waited in a shared area with patients attending the GP practice that worked in the same building.
  • The addition of a clinical face to face assessment prior to treatment, had allowed the service to ensure each procedure was tailored to the persons personal needs. For example; consideration for nervous patients and the support they need to assist them before, during, and after their procedure. Consideration was also tailored to meet patients on-going treatment of chronic disease management to provide an appropriate time for the procedure to be undertaken.
  • Leaders and managers acted on behaviour and performance consistent with their vision and values.
  • There were processes for providing all staff with any development needs. This included an appraisal and career development conversations. All staff had received regular annual appraisals in the last year.
  • Staff were supported to meet the requirements of professional revalidation where necessary. Clinical and non-clinical staff were all considered valued members of the team. They were given protected time for professional development and evaluation of their 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 told us they felt all were treated equally.
  • There were positive relationships between clinical staff, administrative staff, and management.

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. For example: the service level agreement with the sample laboratory.
  • Staff were clear and knew what their roles and accountabilities were within the service.
  • 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 and effective processes for managing risks, issues and performance.

  • We found effective processes 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. 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, through regular meetings. The actions taken, and the discussions were seen in the minutes from each meeting.
  • 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.
  • 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 patients to evaluate a holistic analysis of performance.
  • Quality and sustainability were discussed in relevant meetings where all staff were provided sufficient access to information.
  • Audits were run weekly and discussed with management and clinicians to monitor trends or themes. Actions, improvements and changes were seen as a continual work ethos to improve and develop the service. Staff we spoke with understood this vision and could describe how they were proud to be involved.
  • The service used performance information to monitor and manage staff when held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and valuable.
  • The service submitted data or notifications to external organisations as required.
  • Data security was in line with the recognised standards for the availability, integrity and confidentiality of patient identifiable data, of 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 listened to views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example: Staff told us they felt able to provide feedback and ideas for service improvements.
  • Patients were encouraged to provide feedback of the service at an appropriate time after each treatment/consultation. Patient feedback was monitored monthly via audit and acted on to improve the service where appropriate.
  • We saw extremely positive feedback with regard to the service on the NHS Choices website.
  • The service was transparent, collaborative and open with stakeholders about performance. The service provider worked with both the local clinical commissioning groups (CCGs) to develop services that were accessible and appropriate for patients in the North East Essex and Mid Essex areas.

Continuous improvement and innovation

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

  • It was clear when talking with staff members and management they continually sought ways to improve the services being delivered.
  • The service provider was continuously looking for future developments to undertake procedures and treatments to benefit the population of Essex.
  • We were shown more than 20 different audits including internal and nationally recognised audits. These evidenced that the service used an audit driven philosophy to monitor and investigate every aspect of the service they delivered. Audits ranged from the service administration, incidents, and best practice clinical decisions to keep people safe. For example; the world health organisation (WHO) theatre checklist audit, this was a worldwide audit to confirm that each step of the surgical process had been conducted. This checklist was performed for each procedure conducted. The carpal tunnel service (CTS) and vasectomy patient reported outcome measure (PROMS) audits were nationally recognised patient satisfaction surveys asking set questions about patient provided information, service convenience, staff attitude, clinician ability to put patients at ease, pain control, and operation expectations.
  • The service objective was to provide safe care, closer to home, within a community environment.
  • Improvements were seen in the use of a primary care community based software record keeping system (SystmOne), this provided staff support, training, reporting, auditing facilities, and assurance to deliver security for patient records.
  • Integration with a community health care provider had ensured greater access to human resources for staff.

Integration had also supported and standardised the service providers governance framework.