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Inspection Summary


Overall summary & rating

Updated 24 June 2019

This service is rated as Good overall. (Previous inspection July 2018- met the requirements).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at CountryHealth Ltd on 28 May 2019. This inspection was to rate the service.

CountryHealth Ltd is an independent provider of GP services, which specialises in thyroid health. They offer a range of specialist diagnostic services and treatments, which include complementary therapies, with a focus on functional medicine. They offer health screening for individuals and companies.

This practice is registered with Care Quality Commission (CQC) under the Health and Social Care Act 2008 in respect of some, but not all, of the practices it provides. There are some exemptions from regulation by CQC which relate to particular types of services and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At CountryHealth Ltd, some services, such as health checks are provided to clients under arrangements made by a local council government department. These types of arrangements are exempt by law from CQC regulation. At CountryHealth Ltd, health schemes (that do not involve treatment requiring admission to hospital) organised through an employer, where these are for the benefit of the employee only are exempt from regulation. Therefore, at CountryHealth Ltd, we were only able to inspect the services which are not arranged for patients by a government department. The practice refers patients to affiliated practitioners, for example a Life and Mindfullness Coach, a counsellor, a reflexologist and a QiGong teacher. (QiGong is a holistic system of coordinated body posture and movement, breathing, and meditation). We did not inspect the affiliated practitioners as they are out of the scope of CQC regulation.

The practice is registered with the CQC under the Health and Social Care Act 2008 to provide the following regulated activities:

  • Diagnostic and screening procedures
  • Treatment of disease, disorder or injury.

The GP is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the practice. 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 practice is run. The GP is also the nominated individual. (A nominated individual is a person who is registered with the Care Quality Commission to supervise the management of the regulated activities and for ensuring the quality of the practices provided).

As part of our inspection we asked for CQC comment cards to be completed by clients prior to our inspection visit. We received two comment cards, and spoke to one patient, all were wholly positive about the service. The cards reflected the kind and caring nature of staff, how informative staff were, the pleasant environment and the positive effects of the treatment received. Other forms of feedback, including patient surveys and social media feedback was consistently positive.

Our key findings were:

  • We saw there was leadership within the service and the team worked together in a cohesive, supported, and open manner.
  • There was an effective system in place for reporting and recording significant events.
  • Information about services and how to complain was available and easy to understand.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • Risks to patients were assessed and monitored.
  • The service held a range of policies and procedures which were in place to govern activity; staff were able to access these policies easily and staff had signed each one.
  • To ensure and monitor the quality of the service, the service completed audits which showed the effectiveness of the service.
  • Staff assessed patients’ needs and delivered care in line with current evidence-based guidance.
  • Staff had the skills, knowledge, and experience to deliver effective care and treatment.
  • All patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • The service proactively sought feedback from staff and patients, which it acted on. Regular surveys were undertaken, and reports collated from the findings and action taken where required.

The areas where the provider should make improvements are:

  • Embed the system for the documenting of actions relating to patient safety alerts.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 24 June 2019

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance and were specific to the clinic. Policies had the lead doctors name, email address and phone number detailed. Staff received safety information from the service as part of their induction training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority. This included checking identification and reviewing this if another adult accompanied a child on a follow up appointment.
  • 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. There were details in the safeguarding policy of local authorities to refer to.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. There were sharps bins and protective equipment available. A risk assessment for infection prevention and control had been completed in February 2019.

  • The provider ensured facilities and equipment were safe and equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them. These risk assessments included fire and health and safety.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
  • There were appropriate emergency medicines in place and the medicines we checked were in date. The clinic had a defibrillator and oxygen in case of an emergency. Medicines and equipment were reviewed on a monthly basis to ensure they were in date and in a suitable condition to use.
  • 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. Staff were knowledgeable about which treatments were covered by their insurance and would refer patients back to their GP if they could not provide treatment.

Information to deliver safe care and treatment

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. For example, the service recorded the patient’s GP details and requested consent for information sharing purposes when required. We saw examples of when the service had referred patients back to their GP for further investigation.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals where required in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

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

  • The systems and arrangements for managing medicines and equipment minimised risks.
  • Staff prescribed medicines to patients and gave advice on medicines in line with legal requirements and current national and international 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.
  • There were effective protocols for verifying the identity of patients including children.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and acted to improve safety in the service. For example, the clinic changed phone line provider after receiving inadequate service when their phone lines were not working for 10 days. There was also an example of when the incorrect information was entered into a patient record. An investigation took place and found no data breach that required reporting, however staff were advised to only have one patient record open at a time.
  • During the last inspection, some out of date items were found on the emergency trolley. This was recorded as a significant event and the items were added to the monthly checklist for emergency medicines and equipment. We found no out of date items during this inspection.
  • 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 gave affected people reasonable support, truthful information and a verbal and written apology where there were unexpected or unintended safety incidents.
  • The service received safety alerts, including medicines safety alerts. Due to the limited scope of the service, many did not apply to the prescribing carried out. The GP told us they reviewed them all but did not document this. The GP told us they would record all actions in the future.

Effective

Good

Updated 24 June 2019

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 national and international evidence-based guidance and standards. Staff attended updates for thyroid treatment and were knowledgeable about the requirements.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • The service would refer patients back to their GP where required. The service also completed food intolerance and allergy testing, as well as a review of stress levels and sleeping patterns to fully investigate and treat thyroid issues.
  • 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 actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. For example, an audit had been completed to ensure reports were issued in a timely manner. The first audit showed out of seven patients, one had not received a report in a timely manner. Actions from this included a review of the report by the patient coordinator and the doctor. The second cycle showed three reports took longer than expected. This was due to a change in the laboratory used and a delay in result reporting. Actions included raising a significant event, discussing the outcomes with the laboratory, updating the blood sampling policy and putting a task on each patient record to ensure it was received on time. The audit was due to be repeated in three months.
  • The clinic had also audited the effectiveness of the medicines and therapies used to treat thyroid conditions. It demonstrated that all patients over time achieved optimal results of their laboratory tests.

  • The patient satisfaction audit completed showed that most of the 27 patients who had responded had attended the clinic for thyroid health related issues (follow up appointments, initial consultations, blood sampling). All patients reported they felt the doctor was good or very good at assessing their condition and providing or arranging care and treatment. All patients were confident in the doctor’s ability to provide care. Comments included “it was a relief to find a doctor who understood” and how “confident they felt in the doctor’s knowledge”.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical 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. Staff were encouraged and given opportunities to develop. There was a training matrix in place to give the manager an overview of when training was due.
  • There was an appraisal system in place and all staff had an annual appraisal completed. The doctor working at the service had an annual appraisal for revalidation purposes.

Coordinating patient care and information sharing

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

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, the service had referred to counselling services when required.
  • Before providing treatment, the GP at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. This was evident on the new patient form and during the first consultation with a clinician. We saw examples of patients being signposted to more suitable sources of treatment when this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation when required.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Staff had been trained in mental health, dementia and learning disabilities, appropriate to their role, to give them a better understanding of patient needs.
  • 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.

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. For example, the clinic advised on appropriate supplements and dietary requirements.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. For example, the clinic completed allergy and intolerance food testing to ensure they were offering holistic care and treatment and to ensure their treatment for thyroid conditions was as successful as possible.
  • The clinic also reviewed patients stress levels and sleeping patterns as this could have an effect on thyroid health.
  • 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.
  • There was a Gillick competency and Fraser guidelines policy in place that staff could refer to for assessing the capacity of patients aged under 16.
  • Staff supported patients to make decisions.

Caring

Good

Updated 24 June 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. The comment cards we received were positive about the kindness and helpfulness of staff. For example, one comment card stated “all staff are so friendly and really make you feel at ease.” Another stated that it was “very friendly and staff were very professional.”
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients. Some staff were bilingual and this enabled them to liaise with some patients in their first language, if this was not English.
  • The service gave patients timely support and information.
  • The clinic completed audits of patient satisfaction. This was an ongoing process and links to surveys were attached to reports, displayed in the waiting room and sent to patients via email, if they consented to this.
  • Results showed that:

    • The doctor was either good or very good in areas such as being polite, making patients feel at ease and treating the patient with care and concern.
    • The healthcare assistant was good or very good at being polite, making patients feel at ease and treating patients with care and concern.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language, if this was required. We saw evidence where the clinic had ordered information leaflets and booklets for patients on a personalised basis. For example, for dietary needs. This enabled patients to be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. For example, one comment card stated “the doctor takes the time to explain things in depth”.
  • Staff communicated with people in a way they could understand; for example, a comment card told us staff took extra time with them due to their mental health needs. This included talking in a calming way and allowing extra time for them.
  • Survey results showed:

    • The doctor was good or very good at listening, explaining the condition and treatment, involving patients in decisions about care and treatment and giving patients enough time to discuss their concerns.
    • The healthcare assistant was good or very good at listening and giving patients enough time to discuss their concerns.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect. Staff had been trained in privacy and dignity. The reception area was separate from the clinical rooms and the front door was locked, which improved confidentiality and staff safety as the clinic operated across two floors.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Results from a survey showed that all patients agreed the doctor would keep information confidential and that they were honest and trustworthy.

Responsive

Good

Updated 24 June 2019

Responding to and meeting people’s needs

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

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, the clinic employed staff who did not have English as a first language. This enabled them to liaise with patients from differing ethnic backgrounds and reduced the need for translators.

  • The facilities and premises were appropriate for the services delivered. For example, there were two floors used by patients for consultations. There was no lift in the clinic. However, if patients could not use the stairs, or did not feel safe to do so, arrangements were in place to complete their consultation on the ground floor.

  • Reasonable adjustments had been made so people in vulnerable circumstances could access and use services on an equal basis to others. For example, the service had put an icon on the notes of vulnerable patients, so they could be easily identified.

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.

  • A survey showed that 100% of patients (27 responses) found it good or very good booking an appointment at the clinic. 100% of patients also reported reception greeting and arrival was very good.

  • 96% of patients who took the survey would recommend the clinic to friends and family.

  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.

  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.

  • The service had complaint policy and procedures in place. We saw examples of when the service learned lessons from individual concerns and complaints. It acted as a result to improve the quality of care.

Well-led

Good

Updated 24 June 2019

Leadership capacity and capability;

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

  • The lead doctor was knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. The provider had responded positively to the previous inspection and had completed recommendations including improving clinical audit and embedding the system for monitoring expiry date of emergency medicines.
  • The lead doctor was visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. Staff commented positively on the leadership within the clinic and felt their concerns would be acted on.

  • 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 clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • The service told us they had a clear vision and ethos which was:

    • “CountryHealth provides personal, tailored, top quality health screenings to individuals and companies as well as dedicated private doctor services offering functional diagnostics and treatments to help our clients to get well and stay well.”

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

  • The service monitored progress against delivery of the strategy.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service and reported they felt the service treated patients holistically.

  • The service focused on the needs of patients who wished to access their services. The service offered telephone appointments where possible to reduce travel times for patients.

  • The provider acted on behaviour and performance inconsistent with the vision and values. The GP reported it had taken some time to appoint a healthcare assistant due to ensuring they were appointing the right person.

  • Openness, honesty and transparency were demonstrated when responding to incidents. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

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

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations which happened on an annual basis.

  • The service actively promoted equality and diversity. All staff had completed equality and diversity training and the provider was proud to have a diverse staff mix.

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 service had regular meetings to discuss a range of topics relating to clinical care, updates and significant events.

  • The provider had established policies, procedures and activities. They were specific to the service and available for all staff.

Managing risks, issues and performance

There were 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. For example, general health and safety reviews were completed and documented to ensure the premises were safe for use.

  • There was a clear task rota in place which also included review of fire equipment and fire alarms. This was signed off as tasks were completed and was available online for all staff.

  • The service had processes to manage current and future performance.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • There were regular meetings. Staff reported due to the small size of the team, meetings were informal but happened frequently when all staff were available. Staff reported they were able to raise concerns.

  • The clinic used performance information to monitor and manage staff.

  • The clinic had information technology systems. All clinical records were completed on the computer.

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.

  • Patients, staff and external partners’ views and concerns were heard and acted on. For example, there was a survey sent to patients and the link was also in the waiting room.

  • The survey results were important to the service and were used to improve access to online appointments.

  • Staff reported their views were heard and they felt part of the team, involved in decision making and were happy to work at the clinic.

  • The clinic had a very active social media presence and posted health information and updates regarding thyroid health. Patients we spoke with reported this was helpful and enabled them to better understand their condition.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement within the clinic. For example, due to the increased caseload of patients the service had employed a healthcare assistant.

  • We spoke with the manager about plans for future development. The clinic were planning to open a European branch in Estonia.