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Archived: LiveSmart Headquarters Office

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Inspection Summary


Overall summary & rating

Updated 8 November 2018

We carried out an announced comprehensive inspection at LiveSmart Headquarters Office on 5 September 2018, as part of our inspection programme. This service had not been inspected previously.

LiveSmart U.K. Ltd offers online health assessments and provides healthcare plans to people aged over-18 years. The health assessment reports and healthcare plans are produced following a review of laboratory tests of blood samples and of service users’ completed health and lifestyle questionnaires. The reviews are conducted either by a doctor or a dietitiandietitian. The service provides a series of monthly telephone health coaching sessions for either three or six months by a dietician. The service does not include prescribing or dispensing any medicines or supplements and does not provide diagnoses of health conditions, other than in relation to Vitamin D deficiency. Details are available on the provider’s website - www.getlivesmart.com

Our findings in relation to the key questions were as follows:

Are services safe? – we found the service was providing a safe service in accordance with the relevant regulations. Specifically:

  • Arrangements were in place to safeguard people, including arrangements to check service users’ identity.
  • Suitable numbers of staff were employed and appropriately recruited.
  • Risks were assessed and action taken to mitigate any risks identified.

Are services effective? - we found the service was providing an effective service in accordance with the relevant regulations. Specifically:

  • With service users’ consent, information was appropriately shared with their own GP in line with GMC guidance.
  • Quality improvement activity, including clinical audit, took place.
  • Staff received the appropriate training to carry out their role.

Are services caring? – we found the service was providing a caring service in accordance with the relevant regulations. Specifically:

  • The provider carried out checks to ensure reviews and consultations met the expected service standards.
  • Feedback reflected that service users were treated with dignity and respect.

Are services responsive? - we found the service was providing a responsive service in accordance with the relevant regulations. Specifically:

  • Information about how to access the service was clear and the service was available 7 days a week.
  • The provider did not discriminate against any client group.
  • Information about how to complain was available and complaints were handled appropriately.

Are services well-led? - we found the service was providing a well-led service in accordance with the relevant regulations. Specifically:

  • The service had clear leadership and governance structures
  • A range of information was used to monitor and improve the quality and performance of the service.
  • Personal information was held securely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Updated 8 November 2018

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

Keeping people safe and safeguarded from abuse

Staff employed had received training in safeguarding and whistleblowing and knew the signs of abuse. We saw the provider’s safeguarding policy, which had recently been reviewed and updated. All staff had access to the policy and were provided with guidance on identifying the relevant safeguarding authority to report any safeguarding concern. All the clinicians had received adult and level 3 child safeguarding training. It was a requirement for the clinicians registering with the service to provide evidence of up-to-date safeguarding training certification.

The service was provided mostly under corporate arrangements with service users’ employers; it was not provided to children under 18 years. Service users set up secure online accounts, which were subject to fraud and identity checks.

Monitoring health & safety and responding to risks

The provider’s headquarters office housed its managerial and administrative staff. Service users did not attend the premises. All staff based in the premises had received training in health and safety including fire safety. Work station risk assessments had been carried out and electrical equipment had been PAT tested. The building landlord was responsible for facilities management. Assessments of fire and other risks were up to date. Firefighting equipment had been inspected and drills were carried out on a regular basis.

The provider expected that all health coaching consultations be conducted in private and that the service users’ confidentiality would be maintained. Staff used a two-factor authentication access code to log into the operating system, which was a secure programme. Staff working remotely were required to complete a risk assessment to ensure their working environment was safe.

The service was not intended for use by people with long term conditions, or as an emergency service, and did not provide any diagnoses, other than in relation to Vitamin D deficiency. There were processes in place for managing test results, which involved staff contacting service users straight away if their results raised concerns. In that event, they were advised to contact their own GPs.

All health assessments and health coaching consultations were rated by staff for risk, for example, if there were serious mental or physical issues that required further attention. Those rated at a higher risk were reviewed with appropriate clinical support and recorded on the provider’s clinical escalation log. This was reviewed and discussed at regular clinical meetings.

A range of clinical and non-clinical meetings were held with staff, where standing agenda items covered topics such as significant events, complaints and service issues. Clinical meetings also included case reviews and clinical updates.

Staffing and Recruitment

There were enough staff to meet the demands for the service.

The provider had a selection and recruitment process in place for all staff. There were a number of checks that were required to be undertaken prior to commencing employment, such as references and Disclosure and Barring service (DBS) checks. 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.

Doctors employed by the provider were currently working in the NHS as GPs, were registered by the GMC and were on the GP register. They had to provide evidence of having an up-to-date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act. The provider’s dietitians were registered by the HCPC. The provider arranged for appropriate professional indemnity cover.

Newly recruited staff were supported during their induction period and a plan was in place to ensure all processes had been covered. We reviewed four recruitment files which showed the necessary evidence was maintained and available. Staff could not commence health coaching consultations until induction training had been completed. The provider kept records for all staff and there was a system in place that flagged up when any documentation was due for renewal such as relevant professional registrations. All staff were subject to annual appraisals and we saw those for 2018 were programmed for shortly after our inspection.

Information to deliver safe care and treatment

Upon registering and at each health coaching consultation, the service user’s identity was verified. Most service users did so under arrangements with their employer. When the provider’s staff carried out blood sampling for service users, photographic identification was checked. Staff had access to the service users’ previous records held by the provider. Records could be audited to check which of the provider’s staff had accessed them.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We were shown the provider’s serious incident management log, which recorded 14 incidents over the past 12 months. We reviewed three incidents and found that these had been fully investigated, discussed and as a result action taken in the form of a change in processes. For example, we saw two incidents relating to data processing issues with the various IT systems had been promptly reported to the technical team and addressed. An incident involving a blood sample container being incorrectly labelled by the phlebotomist resulted in staff being reminded of the appropriate procedure. Incidents were monitored to identify any trends requiring remedial action and discussed at staff meetings so that learning from them could be shared.

We saw evidence from two incidents which demonstrated the provider was aware of and complied with the requirements of the duty of candour by explaining to the patient what went wrong, offering an apology and advising them of any action taken.

The provider had processes in place to receive and act on safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA) and we were shown examples of these being reviewed and shared.

Effective

Updated 8 November 2018

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

Assessment and treatment

We reviewed 10 sets of medical records that demonstrated that each GP assessed service users’ needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence based practice. The provider used a Q-risk tool to review results and information submitted to assess service users’ risk of having or developing cardiovascular disease.

Service users completed an online form, which recorded their past medical history and that of family members, information regarding their nutritional intake, exercise, smoking and drinking habits, sleep and stress patterns. Service users were also asked to record their health objectives. These were reviewed by a dietitian or doctor together with the results of service users’ blood tests. The 10 sets of records we reviewed were complete, with adequate notes recorded. Staff had access to all previous notes. A health assessment report was produced within 10 days. Service users accessed the report securely online or using a dedicated mobile app. The assessment report included test results and a commentary. The service did not provide service users with diagnoses, other than in relation to Vitamin D deficiency. We saw evidence from the provider’s clinical escalation log that where test results raised causes for concern, service users were contacted by phone and advised, for example, to book appointments with their GP. We saw instances where service users were emailed password-protected reports so that they could refer these to the GPs for further investigation and diagnosis.

Service users were provided with ongoing monthly health coaching by telephone with one of the dietitians. These consisted of either three or six calls, depending on the level of service package purchased. The initial health coaching call lasted 50 minutes, the subsequent ones 20 minutes.

Staff providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely. They worked carefully to maximise the benefits and minimise the risks for people using the service. If a service user needed further examination they were advised to see their GP, within a specified timescale. If a serious and urgent condition was identified, the service user might be advised to attend Accident and Emergency and we saw an example of this happening in the provider’s clinical escalation log.

Quality improvement

The provider collected and monitored information on how the service operated to improve outcomes. We were shown that quarterly audits of healthcare assessments were conducted, with learning points highlighted and shared. A clinical escalation log was maintained and monitored, recording instances when service users had been given advice, for example, over concerning test results. Learning from this was shared with staff.

Staff training

Staff had to complete induction training, which included safeguarding, information governance and the General Data Protection Regulation, diversity and equalities, customer care, bullying and harassment, general health and safety and fire safety and basic life support / emergency first aid. Staff also had to complete regular online refresher training and systems were in place to identify when this was due. In addition, staff were provided with ad hoc group training sessions; we were shown two training presentations, relating to salt intake and its relation to hypertension (high blood pressure) and another regarding diabetes. Changes to systems and procedures were communicated at team meetings and via email to all staff. The provider used video conferencing facilities allowing remote workers to participate in meetings. Guidance material on the IT system was regularly reviewed and updated when changes were made.

Administrative staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at the recruitment stage.

Coordinating patient care and information sharing

Service users were asked if information could be shared with their registered GP. When consent was given, the provider sent a copy of the health assessment report, including test results to the GP electronically and in line with GMC guidance. Staff told us the provider had never had to send a report to a GP without the person’s consent. We discussed with staff the provider’s clinical escalation protocol, regarding instances where a service user withheld their consent to information being shared with their GP, despite significant health concerns being identified. The provider would explain to the service user the benefit of continuity of care being provided by their GP. The provider had a series of screening questions to establish why the service user might not be willing to give consent, which included making an assessment of whether their current mental capacity might be affected.

Supporting patients to live healthier lives

The purpose of the service was to support people to live healthier lives. This was done by carrying out an assessment of service users’ health, based on information they submitted and the results of blood tests. A detailed assessment record was provided and an improvement plan drawn up in consultation with a dietitian. This was reviewed at a series of telephone health coaching sessions for three or six months. The provider monitored the effectiveness of the service, using feedback from service users, supported by academic review. Service users' feedback included improved sleeping patterns and diet and increased levels of exercise.

Caring

Updated 8 November 2018

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

Compassion, dignity and respect

We were told that the staff undertook telephone health coaching consultations in a private room and were not to be disturbed at any time during their working time. The provider carried out random spot checks to ensure the staff were complying with the expected service standards and communicating appropriately with service users.

We did not speak to service users directly on the day of the inspection. However, we received positive feedback from two, submitted via our website. We also reviewed the provider’s own survey information – feedback was requested in all cases. This related to all aspects of the service and was collated for analysis. It contained feedback from 124 service users. Where feedback was given regarding compassion dignity and respect, it was consistently positive.

Responsive

Updated 8 November 2018

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

Responding to and meeting patients’ needs

  • Details of the services offered, together with the costs involved, were set out on the provider’s website.
  • Service users could access the provider’s website and their online records at all times. A dedicated mobile telephone app was available.
  • Blood sampling kits could be sent to service users’ homes, they could choose a local clinic, or for an extra fee, a nurse or phlebotomist could attend their home or place of work to take the samples.
  • Telephone health coaching calls could be pre-booked at times convenient to service users. The initial health coaching telephone call was 50 minutes long. Subsequent calls lasted 20 minutes. At the date of the inspection, coaching calls were made between 9.00 am and 5.30 pm, Monday to Friday. However, the provider had plans to extend this into the evening.
  • The provider made it clear to patients what the limitations of the service were. It did not provide diagnoses, other than in relation to Vitamin D deficiency.

  • When test results or information submitted was of concern, staff contacted service users with appropriate advice for further investigation.

Tackling inequity and promoting equality

The provider offered health coaching consultations to anyone who requested and paid the appropriate fee, and did not discriminate against any client group. At the date of the inspection, all the GPs and dietitians were female. The provider had identified this as an area for improvement and had plans to recruit male staff so that service users had an element of choice. It also intended offering a translation service to people for whom English was a second language.

Managing complaints

The provider had developed a complaints policy and procedure and information about how to make a complaint was available on its website. The policy contained appropriate timescales for dealing with the complaint. There was escalation guidance within the policy. We saw that seven complaints had been made by service users in the past 12 months. These were monitored for trends and discussed at staff meetings. We saw the complaints were handled appropriately and service users had received a satisfactory response. There was evidence of learning as a result of complaints, and changes were made to the service as a consequence. For example, nurses and phlebotomists had been instructed to arrive five minutes early for private blood sessions and half an hour early for corporate sessions.

Consent to care and treatment

There was clear information on the provider’s website regarding how the service worked and costs involved. There was a set of responses to frequently asked questions. The website had a set of terms and conditions and details on how service users could contact the provider with any enquiries.

Consent was sought when service users opened their online accounts, when having blood tests and at the commencement of their coaching calls. Staff had received training about the Mental Capacity Act 2005. They understood and sought service users’ consent in line with legislation and guidance.

Well-led

Updated 8 November 2018

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

Business Strategy and Governance arrangements

Staff told us there was a clear vision to work together to provide a high quality responsive service that put caring and patient safety at its heart. There was a detailed business plan in place, setting out how the service was intended to develop over the coming few years.

The provider had a mission statement to improve people's health using science, technology and human support. There was a clear organisational structure and staff were aware of their own roles and responsibilities. There was a range of service-specific policies which were available to all staff. These were reviewed annually and updated when necessary.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included random spot checks of health coaching consultations and records audits. The information from these checks was reviewed at regular clinical and governance meetings. This ensured a comprehensive understanding of the performance of the service was maintained. There were established plans to introduce structured quarterly learning sessions to support GPs and dietitians.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions.

Leadership, values and culture

The provider had an open and transparent culture. We were told that if there were unexpected or unintended safety incidents, the service would give affected patients reasonable support, truthful information and a verbal and written apology. This was supported by an operational policy.

Safety and Security of Patient Information

Systems were in place to ensure that all patient information was stored and kept confidential.

There were policies and IT systems in place to protect the storage and use of all patient information. The provider had a system to show a clear audit trail of who had access to records. Regular penetration tests were conducted by security consultants to ensure data security was maintained. The provider was registered with the Information Commissioner’s Office. There were business contingency plans in place to minimise the risk of losing patient data.

Seeking and acting on feedback from patients and staff

There were systems in place for service users to provide feedback, some of which was published on the provider’s website. Feedback was requested after every interaction. The provider had plans to use web-based surveys in future, using established commercial services. In addition to seeking feedback on existing aspects of the service, the provider sought feedback from a group of service users regarding new features introduced and those planned for the future. For example, following feedback the provider was redesigning and simplifying how some data was presented in its health assessment reports.

Staff were able to provide feedback about the quality of the operating system and any change requests were logged, discussed and decisions made for the improvements to be implemented.

The provider had a whistleblowing policy in place. A whistle-blower is someone who can raise concerns about practice or staff within an organisation. There was a named person responsible for dealing with any issues raised under whistleblowing.

Continuous Improvement

The provider consistently sought ways to improve. All staff were involved in discussions about how to run and develop the service, and were encouraged to identify opportunities to improve the service delivered. For example, the provider had arranged for quiet waiting areas at corporate clinics to allow service users to relax before and after blood sampling and to have an assistant on hand to deal with any concerns.

Staff told us that the team meetings allowed them to raise concerns and discuss areas of improvement. We saw from minutes of staff meetings where previous interactions and health coaching consultations were discussed and reviewed to identify possible areas of improvement.

There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, through clinical audit.