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Inspection Summary

Overall summary & rating


Updated 2 December 2019

Inspection areas



Updated 2 December 2019

Breaches identified at the last CQC inspection in 2018 had been addressed. During the last inspection it was identified that recruitment procedures were not comprehensive and toilets facilities were not compliant with infection control measures. Since the inspection the provider had introduced more comprehensive recruitment procedures and completed a refurbishment of all toilet facilities.

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

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support clients and protect them from neglect and abuse. Staff took steps to protect clients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. We saw some examples of how staff had escalated safeguarding concerns quickly and effectively.
  • The provider carried out appropriate staff checks at the time of recruitment and on an ongoing basis where necessary. 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). We noted the provider had retained some staff DBS certificates in recruitment files, when they should have been returned to the individual. We discussed this with management and were told they would be returned to staff as soon as possible.
  • 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. We saw some examples of how staff had effectively escalated safeguarding concerns.
  • There was an effective system to manage infection prevention and control. Regular infection control audits were conducted. There were systems for safely managing healthcare waste.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. Equipment and records we inspected confirmed this with portable appliance (PAT) testing and equipment calibration having taken place within the last 12 months.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for any locum staff 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 clients with severe infections, for example sepsis. We saw records of training that confirmed this.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. We noted that one paediatric mask in the emergency oxygen case had been marked as out of date, but had been left in situ, as were some single use equipment that the provider had decided were not appropriate for use. These items were removed on the day of the inspection.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place

Information to deliver safe care and treatment

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

  • 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.
  • Individual care records were written and managed in a way that kept clients safe. Allergies were recorded and there were clear records of the treatments advised and those provided. In addition, the clinicians recorded advice given to promote safety during travel.
  • The service had systems for sharing information with other agencies to enable them to deliver safe care and treatment.
  • We saw records of the medicines that had been administered. These records included appropriate details; for example, the brand name, batch number, expiry date and staff initials.
  • Allergies/ adverse drug reactions were recorded, and clinicians were aware of the reporting process for any adverse reactions to newly marketed medicines.

  • The appropriate length of treatment was recorded (for example; Hepatitis B and the recording of three doses administered).

Safe and appropriate use of medicines

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

  • The service had reliable systems for appropriate and safe handling of medicines. Medicines on the premises were stored securely, in line with legal requirements and manufacturers’ instructions.
  • There were appropriate protocols in place for ensuring the receipt, storage and handling of vaccines, in accordance with Public Health England and Green Book guidance.
  • Vaccines were appropriately secured in fridges and stored in the premises, in line with national guidance.
  • Medicines not requiring refrigeration were secured in the consultation rooms and stored in line with national guidance.
  • We saw that the fridge temperatures were monitored, and excursions managed in accordance with the provider’s policy to ensure safety and efficacy of the vaccines was maintained
  • Appropriate emergency medicines and equipment were available. For example, for anaphylaxis after vaccine administration. We saw that daily checks were completed. The defibrillator was held in offices at the top of the building. The provider had completed a risk assessment and timed access to this resource.
  • Sharps disposal was managed safely with an appropriate contract in place for their collection.
  • Medicines information sources were available to clinicians and we found appropriate use of specialised resources e.g. National Travel Health Network and Centre (NaTHNaC) and TRAVAX, to inform treatment options and to support advice to clients. (TRAVAX is an interactive NHS website providing up to date health information for UK health care professionals who advise the public about avoiding illness and staying healthy when travelling abroad.) 
  • The travel risk assessment used by nurses and management of the patient was in line with best practice (e.g. Appendix 2 of the royal college of nursing (RCN) Travel Health Nursing).
  • The nurses used Patient Group Directions (PGDs) to administer vaccines in line with legal requirements; PGDs had been produced in line with legal requirements and national guidance. We saw evidence that nurses had received appropriate training and were assessed as competent to administer the medicines. We found the PGDs were authorised by a GP and lead pharmacist and they were reviewed every six to 12 months.
  • The service provided intradermal Rabies vaccines to clients. For the rabies vaccine, the intradermal route is "off label use", this was fully explained to clients and informed consent was obtained and recorded appropriately. All staff in the clinic were experienced in the use of the intradermal route and were able to provide this service.
  • Patient Specific Directions (PSDs) were used when using medicines which were "off label use". We saw these were documented in the patient’s medical records and the service held a record of all clients who had been administered medicines under a patient specific direction.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues. We looked at a range of these including those related to health and safety and lone working.
  • 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. We noted there had been seven incidents recorded in the last twelve months, all had been investigated, reviewed and any lessons learned had been implemented. For example, an incorrect vaccine had been administered by a nurse, the mistake was identified quickly, a check on the risk to the patient was undertaken, an apology was offered, and additional training and safeguards were introduced to prevent a re-occurrence.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.



Updated 2 December 2019

The service carried out assessments and treatment in line with relevant and current evidence-based guidance and standards.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment. They assessed needs and delivered care in line with current evidence-based guidance.
  • Clients received an individualised travel risk assessment, health information including additional health risks related to their destinations and a written immunisation plan specific to them.
  • Nursing staff understood the requirements of legislation and guidance when considering consent including parental consent.
  • Clinical audits demonstrated quality improvement.

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.

  • Clients’ immediate and ongoing travel health needs were fully assessed. A comprehensive assessment was undertaken which included an up to date medical history.
  • Clients received a NOMAD Travel travel health brief. The brief provided an individualised travel risk assessment, health information including additional health risks related to their destinations and a written immunisation plan specific to them.
  • We saw no evidence of discrimination when making care and treatment decisions. The nursing staff had previously undertaken a study day which included the challenges faced by travellers with disabilities.
  • We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols. For example, National Travel Health Network and Centre (NaTHNac), a service commissioned by Public Health England.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service completed audits and peer review of consultations to ensure care provided was in line with guidance and best practice. We saw evidence of infection control audits, a full clinic audit including consultation notes and a hand hygiene audit.
  • The service used information about care and treatment to make improvements. For example, regular updates were provided to travel health nurses around disease outbreak surveillance which meant clinicians had the most up to date knowledge and health advice for clients visiting those areas.

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 (GMC) and Nursing and Midwifery Council (NMC) 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.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.
  • Staff were provided with ongoing support to maintain their knowledge and competence. This included support for attendance at training events as well as in house per support and mentoring.

Coordinating patient care and information sharing

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

  • Before providing treatment, staff 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 clients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • Details of patient’s GPs were obtained when they consulted with the service. Consent was sought to share information about treatments and contact the GP if any medical history needed clarifying. A letter was sent to the GP following advice and treatments being given to ensure a complete medical history could be maintained.
  • The clinic clearly displayed consultation and vaccine fees. In addition, clients were advised which vaccines were available free from their GP practice.

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.
  • Where clients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Staff were proactive in identifying risks to health for individual service users and providing advice and information on reducing risks. This included preventing travel related illnesses but also extended to other health needs from chronic conditions. We were told of an example where a client living with mental health problems was travelling to a location with poor mental health services provision. The nurse at TMB Manchester took steps to ensure the individual was aware of the associated risks and attempted to identify support that may be available to the client whilst away.
  • Further examples of identifying risks relating to female travellers were discussed, appropriate safeguarding referrals were completed, and staff ensured risks had been communicated to the individual to ensure they were fully informed.

Consent to care and treatment

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

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



Updated 2 December 2019

  • Information for clients about the services available was easy to understand and accessible.
  • We saw staff treated clients with kindness and respect and maintained client and information confidentiality. This was supported by client feedback via CQC comment cards and service surveys.
  • Staff dealt with clients with kindness and respect and involved them in decisions about their care.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care clients received.
  • Feedback from clients was positive about the way staff treat people.
  • Staff understood clients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all clients.
  • The service gave clients timely support and information.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for clients who did not have English as a first language. Clients were also told about information leaflets in different languages that might be able to support them. Information leaflets were available in easy read formats, to help clients be involved in decisions about their care.
  • Clients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • One client we spoke with, who had a fear of injections, told how the staff were particularly caring and gave him lots of time to make decisions and undertake the course of injections required. They told us that they felt no pressure to complete the course in a short period of time and was offered extra appointments if they were required at no extra cost.
  • For clients with learning disabilities or complex social needs family, carers, family or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

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



Updated 2 December 2019

  • The service was responsive to clients’ needs and preferences. Clients could access the service in a timely manner.
  • We found that this service was providing responsive care in accordance with the relevant regulations.
  • The provider understood its client profile and had used this to meet their needs.
  • Clients said they found it easy to make an appointment.
  • Information about how to complain was available and easy to understand. Learning from complaints was shared with staff and other partnership organisations.
  • The clinic was well equipped to treat clients and meet their needs.

Responding to and meeting people’s needs

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

It took account of patient needs and preferences.

  • The provider understood the needs of their clients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, other travel clinics within Manchester were available for clients who found access to the clinic limiting and staff provided information to clients about these services.
  • The service made reasonable adjustments when patients found it hard to access the service. We found that the entrance to the service had a small step and consultation rooms were on the lower ground floor making the areas inaccessible for clients who used wheelchairs. We were told of an example of where a client with mobility issues had been carried down to the lower floor by their partner, staff had supported them with this.

  • We heard that nurses ensured their advice to clients remained up to date and took steps to inform clients where advice altered within the time frame of their travel plans.

Timely access to the service

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

  • Clients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • The service was available in the evenings, weekends and on bank holidays if there was sufficient demand.
  • Clients with the most urgent needs had their care and treatment prioritised.
  • Clients reported that the appointment system was easy to use.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available. Staff treated clients who made complaints compassionately.
  • The service informed clients of any further action that may be available to them should they not be satisfied with the response to their complaint, however this information was not documented on the service’s complaints information or in letters to complainants.
  • The service had complaint policy and procedures in place. The service had an appetite to learn lessons from individual concerns, complaints and from analysis of trends. There had been no complaints made in the last twelve months.



Updated 2 December 2019

There were systems in place to ensure good governance.

  • There was a clear leadership and management structure and staff felt supported by management.
  • Staff had received comprehensive inductions and attended staff meetings and training opportunities. There was a strong focus on continuous learning and improvement at all levels.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The provider encouraged a culture of openness and honesty.

Leadership capacity and capability;

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a vision and credible strategy to deliver high quality care

and promote good outcomes for patients.

  • The service had a realistic strategy and supporting business plans to achieve priorities.
  • It was clear from speaking to staff and management that they had a desire to deliver high quality travel healthcare and promote good outcomes for clients. Staff were clear about their responsibilities in relation to it. However, there was no documented mission statement for staff and leaders to refer to. We discussed this with the management team, who told us there were plans in place to articulate the vision and values to underpin their motto of “be Nomad ready.”
  • Staff were aware of and understood the strategy and their role in its achieving aims.
  • The service monitored progress against delivery of the strategy.


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

  • Staff felt respected, supported and valued. They were proud to work for the service. One member of staff told us it was the best job they had ever had and that really looked forward to coming to work.
  • The service focused on the needs of clients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. We looked at the provider’s policy around whistleblowing and saw it was prescriptive and did not provide information or guidance on reporting behaviour or language that fell short of criminality. For example, homophobic or racist language. We were told that the policy would be reviewed and updated.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities.
  • The provider had established policies, procedures and activities to ensure safety which were available to all staff. They assured themselves that they were operating as intended. Regular nurse meetings and operational reporting structures provided assurances that the service was operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

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

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of clients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of client identifiable data, records and data management systems. For example, the provider was registered with the Information Commissioner’s Office and had its own information governance policies. All staff had signed a confidentiality agreement as part of their job contract.
  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • The service encouraged and heard views and concerns from the public, clients, staff and external partners and acted on them to shape services and culture. Comment cards were available for all clients who used the service and a review of these had led to the provider introducing new combined vaccinations. The provider also monitored “Google reviews” to monitor their service and to date there had been 147 reviews, all of which were five stars.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • The provider was proud to support environmental issues and had introduced recyclable non-plastic bags for clients to take their products away in.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

There were systems to support improvement and innovation work. For example, the provider had recently introduced a dental first aid kit for travellers.