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ToHealth Limited Inadequate Also known as Waterloo Health Clinic

Inspection Summary


Overall summary & rating

Inadequate

Updated 4 July 2019

Inspection areas

Safe

Inadequate

Updated 4 July 2019

Safety systems and processes were not monitored effectively. Lessons were not learned, and action was not taken and shared to improve safety. For example, we were told no significant events had occurred, however it later emerged that a significant event had occurred. We saw no policy for handling pathology results. We saw no evidence of the service being monitored, not all clinical staff were receiving MHRA alerts. The safeguarding lead had not been not been present since October 2018 and there was no one covering this role in the interim. The infection control lead had not been present since October 2018 and there was no one covering this role in the interim.

(See full details of the action we asked the provider to take in the Requirement Notices at the end of this report).

Safety systems and processes

The service did not have clear systems to keep people safe and safeguarded from abuse.

  • The provider had conducted some safety risk assessments, for example a Legionnaires risk assessment; however, on the day of the inspection, this could not be found. It was submitted after the inspection.
  • The service only saw adults.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • Due to transition of the service moving over to PAM Group, and management being absent on the day of the inspection, we were unable to see if the provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. This information was not submitted after the inspection. We were informed that the new company PAM Group was now responsible for recruitment processes. At the inspection in April 2018, we did see that the service had carried out staff checks, including checks of professional registration where relevant. We did not see evidence that Disclosure and Barring Service (DBS) checks were undertaken for all staff. (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).
  • Not all staff received up-to-date safeguarding and safety training appropriate to their role. We checked three files, (two clinical, one non-clinical) we did not see any evidence that one clinical and one non-clinical staff member had undertaken safeguarding and safety training After the inspection, in June the provider submitted evidence that the clinical staff member had completed Adults safeguard training levels 1 and 2, and that the non-clinical staff member had completed safeguarding children and adults’ levels 1 and 2, both staff members had completed the training after the inspection in June. The service had a policy to safeguard children and vulnerable adults from abuse. One staff member spoken to was not aware of the safeguarding policy. The safeguarding lead had not been present since October 2018 and there is no one covering this role in the interim. When we provided feedback on this, we were told the registered manager was the safeguarding lead this had been the case since 2017 and there had been no changes.
  • Staff who acted as chaperones were trained for the role.
  • The system to manage infection prevention and control required development, the service had undertaken an audit in May 2018, however staff were unable to show us this on the day of the inspection, it was submitted to us after the inspection. Curtains in the travel room were last changed January 2018, curtains in the doctor’s room appeared to be clean however they were not dated, and the date they were put up was unknown. When we provided feedback on this, we were told there had not been any incidence of known infectious disease patients that is why the curtains had not been changed, and the organisation would now look into the frequency of curtain changes and document appropriately. Weekly cleaning logs were signed but not dated. When we provided feedback on this, we were told, the cleaning logs should have been dated; this would be followed up with the cleaning company. We were also informed the new computer system under the management of PAM Group, held the new infection control policy and this would be briefed to staff during the migration in May 2019.
  • There were effective protocols for verifying the identity of patients.

  • The provider had ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The systems for safely managing healthcare waste required development, for example there were only yellow top bins for non-medicines and medicines. The GP room had a non-clinical bin with a black bag. When we provided feedback on this, we were told the waste system was not as it should be due to the acquisition by PAM Group and the transfer of their services. There was confusion about which organisation this sat with, this was now being addressed by the new proposed registered manager.

Risks to patients

There were not clear systems to assess, monitor and manage risks to patient safety.

  • The arrangements for planning and monitoring the number and mix of staff required assessing. Whilst, the service had a part time GP and a part time nurse, there were no managers present. The registered manager had been on sick leave since October 2018 and there were no interim arrangements. Staff mentioned the need for a manager to be present to provide direction, staff mentioned they were able to email or ring the new proposed registered manager. After the inspection the service manager informed us that although she was off sick she was still in place, and a managing director was also present until February 2019.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention, however we saw no evidence of sepsis training, the lead GP and staff had a policy never to turn away any patients, however this was not documented. After the inspection the provider told us the service was not previously aware of the need for sepsis training and this was not previously highlighted to them. Clinical staff were now being asked to complete a sepsis in primary care course.
  • We saw no policy for handling pathology results, when we provided feedback on this, we were told pathology results were usually only generated as part of the corporate health screening and this was managed by a separate process that did not involve ToHealth limited. Pathology results were generated as part of occupational health work but not usually as part of the GP service. Whilst there was a process in place, this was not explicitly documented.
  • There were emergency medicines available and staff knew where they were located. The service did not have all the standard emergency medicines found in a GP practice, however the service had conducted a risk assessment for not having these.
  • There was oxygen with adult and children’s masks. There was a first aid kit, and accident book.
  • Patient records were stored securely on the service computer, which was backed up.
  • Most of the medicines we checked were in date and stored securely, however we found five batches of out date glucose bottles, the service told us they would dispose of them and order new bottles.
  • When there were changes to services or staff the service did not assess and monitor the impact on safety, for example the transition of the PAM Group company taking over and implementing their new processes and systems, registered manager being absent since October 2018.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.
  • Staff did not know if spill kits were available, or where to find them if the service had any, when we provided feedback on this, we were told spill kits were available and staff have previously been trained on this. The new proposed registered manager would recap with staff.

Information to deliver safe care and treatment

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service kept the patients’ GPs informed about their treatment if required. The service would ask patients to provide their vaccine history, if patients were unable to provide this they would treat patients as providing incomplete vaccination history.
  • Patients provided personal details at the time of registration including their name, address and date of birth. Staff checked patient identity by the information supplied on the registration form, this information was verified by the service requesting photographic identity.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • We observed referral letters included all the necessary information; however, these were rarely done and generally patients would be referred back to their GP.

Safe and appropriate use of medicines

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

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.

Track record on safety and incidents

The service did not have a good safety record.

  • There were some comprehensive risk assessments for example a legionella risk assessment, a general risk assessment, however when we asked to see a premises/security risk assessment, we saw no evidence of this, we were told this was probably undertaken by PAM Group.
  • We saw no evidence that the service monitored and reviewed activity.

Lessons learned and improvements made

The service did not learn and did not make improvements when things went wrong.

  • For example, we were told no significant events had occurred, however it later emerged that a significant event had occurred, staff were all aware of the event, however staff were not sure if it was documented, the event itself could not be found documented, the significant event policy could not be found. We were told the manager that was involved in the event at the time had left. The lead GP and nurse said that they would revisit and discuss the event and any learning from it. When we provided feedback on this, we were told significant event reporting was completed through the PAM Group system. Some staff had already completed a PAM significant event form and all staff were briefed on this at the PAM induction in February. The provider acknowledged there was a need for further training on the process.
  • Not all clinical staff were receiving MHRA alerts, when we provided feedback on this, we were told the current registered manager who had been away since October 2018 received alerts, examined them in case any devices or drugs were highlighted and if so, disseminated to the team and under take the necessary action to withdraw the item.

Effective

Requires improvement

Updated 4 July 2019

The service had not undertaken any audits, not all staff had received role specific training including safeguarding, and training on sepsis awareness. Some staff reported they had no official appraisal or feedback since starting.

Effective needs assessment, care and treatment

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

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. The lead GP also showed us that they followed guidance from the Independent Doctors Federation.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their 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.

Monitoring care and treatment

The service was not actively involved in quality improvement activity.

  • The service had not completed any audits. The service provided a limited private GP service including travel immunisation. The majority of the service provided was occupational health procedures which are not regulated by the CQC; less than 10% of the business was GP work, more than 90% was occupational health and health screening. The service explained they had only seen 30 patients for the services CQC regulates in the last 12 months. We were told the Compliance and Governance mechanisms within PAM Group have audit and appraisal schedules. ToHealth staff had now been added to these schedules and would be briefed.

Effective staffing

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

  • Not all staff received up-to-date safeguarding and safety training appropriate to their role. We checked three files, (two clinical, one non-clinical) we did not see any evidence that one clinical and one non-clinical staff members had undertaken safeguarding and safety training. We also did not see evidence of training regarding information governance and infection control.
  • The provider had an induction programme for all newly appointed staff, we saw an email documenting induction training for all staff on the new PAM Group system.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) Nursing and Midwifery Council and were up to date with revalidation.
  • The provider told us they understood the learning needs of staff and provided protected time and training to meet them, however a staff member informed us they had no protected time or support with professional development. When this was fed back to the provider, they informed us the staff member had the opportunity for protected time and support with professional development. In January 2019, they were given approximately one week of protected time to shadow health surveillance. Also, the staff diary is shorter than the working day to ensure at least 30 mins protected time at the start and end of the day.
  • A staff member reported that they had had no official appraisal or feedback since starting, when this was fed back to the provider, they informed us the compliance and governance mechanisms within PAM Group have audit and appraisal schedules. ToHealth staff had now been added to these schedules and would be briefed.

Coordinating patient care and information sharing

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

  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • Where patients’ consent was provided, all necessary information needed to deliver their ongoing care was shared with other services and patients received copies of referral letters.
  • We observed referral letters contained the necessary information.

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.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Staff were consistent and proactive in helping patients to live healthier lives.

Consent to care and treatment

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

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  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 4 July 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people, six patient Care Quality Commission comment cards we received were wholly positive about the service experienced.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • Consultation room doors were closed during consultations; conversations taking place in the room could not be overheard.

Involvement in decisions about care and treatment

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

  • Interpretation services were not available for patients who did not have English as a first language, however we were told that some staff members were able to speak other languages.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • The service’s website provided patients with information about the range of treatments available including costs.
  • There was evidence in the treatment plans of patients’ involvement in decisions about their care.

Privacy and Dignity

The service respected respect patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 4 July 2019

Responding to and meeting people’s needs

The service organised delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, there were longer appointments available for patients who needed them; for example, patients with a learning disability.
  • All patients attending the service referred themselves for treatment. There were processes in place to refer patients for onward treatment or to NHS GP services where required.
  • Information about how to make a complaint was displayed in the reception area.

Timely access to the service

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The service was open Monday to Friday between 9am and 5pm. Services were not provided outside of these times. The service did not offer out of hours care.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously.

  • Information about how to make a complaint or raise concerns was available, this was displayed in the reception area.
  • There had been no complaints in the previous year. There was a policy for managing complaints. The provider showed us how the complaint would be dealt with and the processes that were in place for learning from complaints.

Well-led

Inadequate

Updated 4 July 2019