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Inspection Summary


Overall summary & rating

Good

Updated 3 September 2019

We carried out an announced comprehensive inspection at Fast Medica Ltd to follow up on breaches of regulations.

We carried out an announced focused inspection on 24 April 2019. This was to follow-up on two warning notices the Care Quality Commission served following an announced comprehensive inspection on 19 December 2018 when the provider was not providing safe, effective and well-led care in accordance with the relevant regulations. The inspection on 19 December 2018 highlighted several areas where the service had not met the standards of regulations. We checked these areas as part of a focused inspection on 24 April 2019 and this comprehensive inspection on 7 August 2019 and found this had been resolved.

The previous inspection reports can be found by selecting the ‘all reports’ link for Fast Medica Ltd on our website at www.cqc.org.uk.

Fast Medica Ltd is an independent clinic in the London Borough of Ealing and provides private primary medical services. The service offers services for adults and children. Most of the patients seen at the service are from the Polish speaking community. Medical consultations and diagnostic tests are provided by the clinic; however, no surgical procedures are carried out.

One of the directors is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Twenty seven people provided feedback about the service, which was positive about the care and treatment offered by the service. They were satisfied with the standard of care received and thought the doctors were approachable, committed and caring. They said the staff were helpful and treated them with dignity and respect.

Our key findings were:

  • The service had demonstrated improvements in all areas highlighted in the previous inspection in December 2018.
  • The service had appointed a clinical lead to ensure the delivery of safe and effective care.
  • The service had reviewed and improved their clinical governance systems.
  • The service had implemented reliable systems for appropriate and safe handling of medicines and the ultrasound scans.
  • The service was involved in quality improvement activity.
  • The service had implemented systems to undertake quality monitoring of clinicians’ performance including the handling of ultrasound scans.
  • Consultation notes and the scan results were documented in the English language, which included complete, legible and accurate information in an accessible way.
  • The service had developed a clinical risk management template to consider how they would manage the risk when offering the baby scans when consent to share information with the woman’s NHS GP was not given.
  • Service specific policies were reviewed and updated. However, they had not always assured themselves that they were operating as intended. For example, some patients had not received coordinated care, because the service had not followed their own policy to encourage patients to share the details of their consultations with their registered GP or regular physician when required to ensure safe and effective delivery of care. The service had not communicated effectively when patients declined, as they had not recorded in the patient’s records that they had tried to persuade them to permit this, in situations in which this would be important.
  • The service had taken steps to improve recruitment processes.
  • Appointments were available on a pre-bookable basis. The service provided only face to face consultations.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Information about services and how to complain was available.
  • The service was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Carry out calibration of medical equipment according to manufacturers’ instructions.
  • Follow your own complaints policy and register with an appropriate organisation to ensure the complainant’s right to escalate the complaint if required.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 3 September 2019

When we inspected the practice in December 2018, we found that this service was not providing safe care in accordance with the relevant regulations. Specifically, we found:

  • The service did not have reliable systems for appropriate and safe handling of medicines.
  • Prescribing was not audited or reviewed to identify areas for quality improvement.
  • Information needed to deliver safe care and treatment was not always available to the relevant staff in a timely manner.
  • They had not always undertaken appropriate recruitment checks prior to employment.
  • There was no documented fire evacuation plan specific to the service. The provider did not carry out a risk assessment to identify how staff could support patients with mobility problems to vacate the premises.
  • The service did not have any formal monitoring system in place to ensure that regular safety checks had been undertaken by the host who was responsible for managing the premises.

At this inspection in August 2019, we found improvements had been made.

Safety systems and processes

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

  • The service was renting space in shared premises and the host was responsible for managing the premises. The safety risk assessments were available. It had appropriate safety policies, which were regularly reviewed and communicated to staff. 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. Policies were available and were accessible to all staff. They outlined clearly who to go to for further guidance. The practice manager was the safeguarding lead and had received level three child safeguarding training.
  • All staff had received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.
  • Staff understood their responsibilities to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The service treated children and had a system in place to ensure that children were protected.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • A notice in the waiting room advised patients that chaperones were available if required. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • 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).
  • There was a recruitment policy in place to carry out staff checks, including checks of professional registration where relevant, on recruitment and on an ongoing basis. The service had developed a health questionnaire and a health declaration statement as part of health checks during the recruitment process. The service had not recruited any new staff since the previous inspection. However, they had asked all existing staff to complete relevant health checks to ensure satisfactory information was collected about any physical or mental health conditions. The service assured us they would ask for two recent references when they would recruit any new staff in future to evidence satisfactory conduct in previous employment.
  • There was an effective system to manage infection prevention and control. We observed that appropriate standards of cleanliness and hygiene were followed. They had carried out hand hygiene and infection control audits.
  • The service ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions, with the exception of an adult oximeter. There were systems for safely managing healthcare waste.
  • On registering with the service, a patient identity was verified. The service had a system to ask for a photographic identity during the registration process. They were able to pay by the bank account, debit or credit card and cash.
  • The service had a formal documented business continuity plan in place.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety. However, some improvements were required.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for all 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 patients with severe infections, for example sepsis. The service had a paediatric and an adult pulse oximeter which could be required to enable assessment of a child patient with presumed sepsis. However, we noted that the annual calibration of one of the adult pulse oximeters had not been carried out. However, the service informed us a day after the inspection that they had ordered a new adult pulse oximeter and stopped using the uncalibrated adult pulse oximeter.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.
  • 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.

  • 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. Consultation notes were documented in the English language.
  • The service had systems for sharing information with the NHS GP (for patients who do consent to share information with their GP) to enable them to deliver safe care and treatment. The service had reviewed contents of the registration form to ensure that the patients must actively need to opt out by ticking the box if they did not wish to share information with their GP.
  • Patient records and consultation notes were stored securely using an electronic record system. Staff used their login details to log into the operating system, which was a secure programme. The doctors had access to the patient’s previous records held by the service. Any paper records were scanned and stored securely.
  • 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 in line with protocols and up to date evidence-based guidance.
  • The service was registered with the Information Commissioner’s Office.

Safe and appropriate use of medicines

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

  • The service had taken steps to address the concerns raised during the previous inspection.
  • 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.
  • The service informed us they did not prescribe or store any controlled drugs. The service had updated its medicines policy to reflect this.
  • The service had a policy not to prescribe proactively any high risk medicines which required regular monitoring and advised the patients to contact their NHS GP or other private consultants. The service had implemented regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • The service had a documented antibiotic prescribing protocol to support good antimicrobial stewardship in line with local and national guidance. Processes were in place to check and monitor whether the doctors were following this antibiotic prescribing protocol appropriately.
  • The service had a documented repeat prescribing policy. The provider informed us repeat prescriptions were issued for up to two months. Patients were advised to attend a follow up appointment with the service as required, without which the doctors would not prescribe further medicines.
  • All medicines were prescribed based on the clinical need on an acute basis. The provider informed us they were not responsible for monitoring the care and treatment of patients with a long term condition, with the exception of patients receiving treatment from the psychiatrist.
  • Staff prescribed 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 had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service had up to date fire risk assessment in place and the host was carrying out regular fire safety checks. There was a documented fire evacuation plan specific to the service, which included how staff could support patients with mobility problems to vacate the premises.
  • The service had up to date legionella risk assessment in place and regular water temperature checks had been carried out. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The service was renting space in shared premises and developed a formal monitoring system to ensure that regular safety checks had been undertaken by the host who was responsible for managing the premises. 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.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety in the service. For example, the service had reviewed their stock control arrangements after they ran out of nitrogen gas used for cryotherapy (a treatment to remove skin lesions by freezing).

  • The service 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 records of written correspondence.
  • The service had signed up to receive patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team.

Effective

Requires improvement

Updated 3 September 2019

When we inspected the practice in December 2018, we found that this service was not providing effective services in accordance with the relevant regulations. Specifically, we found:

  • The service was unable to provide evidence that the consultations of all clinicians were undertaken in line with accepted best practice in the UK or had a documented rationale for alternative treatment provided.
  • The service did not have effective systems for appropriate and safe handling of ultrasound scans.
  • The limited information was available in the consultation notes. Most of the scan results were documented in the Polish language or mixed notes were documented in both English and Polish languages.
  • The service was not actively involved in quality improvement activity.

At this inspection in August 2019, we found improvements had been made. However, they were required to make further improvements, because:

  • Some patients had not received coordinated care, because the service had not followed their own policy to encourage patients to share the details of their consultations with their registered GP or regular physician when required to ensure safe and effective delivery of care. The service had not communicated effectively when patients declined, as they had not recorded in the patient’s records that they had tried to persuade them to permit this, in situations in which this would be important.

Effective needs assessment, care and treatment

The service 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 service 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 service had advised all the doctors to provide a documented rationale for alternative treatment provided when it had not been prescribed in accordance with national UK guidelines.
  • All patients completed a registration questionnaire at their first visit which included information about their past medical history, personal details, date of birth and NHS GP details (plus consent to update NHS GP of all consultations details). This questionnaire was available in both the English and the Polish languages. This questionnaire was scanned and uploaded into the attachments section of the clinical record system.
  • We reviewed 27 examples of medical records which demonstrated that patients’ needs were fully assessed and they received care and treatment supported by clear clinical pathways and protocols. The outcomes of each assessment were clearly recorded, and the clinical notes had included appropriate information in an accessible way. Consultation notes and the scan results were documented in the English language.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.

An ultrasound scan service was offered onsite which included scans for babies carried out by the gynaecologist. In addition, the scans were also carried out by urologist and endocrinologist consultants to help diagnose the causes of pain, swelling and infection in the body's internal organs. (An ultrasound scan is a procedure that used high-frequency sound waves to create an image of the inside of the body).

  • The scans were offered for clinical diagnostic purposes only after the consultation with the doctors. The ultrasound examination was not performed as a result of an external referral.
  • All doctors who conduct the scan were appropriately trained to operate the equipment and analyse the scan results. The provider informed us all the doctors were following the British Medical Ultrasound Society (BMUS) guidelines.
  • The service had reviewed a protocol for safe handling of ultrasound scans and included appropriate information to ensure the effective management and handling of ultrasound scans. The service had carried out a medical notes audit to check the quality of clinical records and assessments to ensure the BMUS guidelines were followed correctly.
  • The baby scans were mostly offered in addition to the NHS maternity pathway. All women were advised to attend their NHS scans as part of their maternity pathway. All women who undertake these scans were given verbal information about the potential risks to the unborn child from additional use of ultrasound during the pregnancy, so they could make an informed decision before proceeding with the scan. The woman’s consent to care and treatment was always obtained and documented. The service shared information with the woman’s NHS GPs with their consent. The service had developed a clinical risk management template to consider how they would manage the risk (when consent to share information was not given) if a significant abnormality was detected during the baby scans.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • We saw the service had implemented an effective system to assess and monitor the quality and appropriateness of the care provided.
  • The service had carried out clinical audits to ensure effective monitoring and assessment of the quality of the service.
  • There was evidence of quality improvement activity to review the effectiveness and appropriateness of the care provided. For example, the service had carried out audits of clinical records to monitor the appropriateness of the care provided which included to ensure treatment options were discussed and decisions documented in the English language. The service had reviewed the template after the initial audit and a follow up audit was planned in the future.
  • The service had carried out prescribing audits to monitor the individual prescribing decisions.
  • The service was not responsible for managing patients with long-term conditions (with the exception of patients receiving treatment from the psychiatrist) and they were referred to their NHS GP or other private consultants with their consent.
  • Patients’ health was monitored to ensure medicines were being used safely and followed up on appropriately. Patients were required to attend a periodic check with the service, without which the doctor would not prescribe further medicines.
  • The doctor advised patients what to do if their condition got worse and where to seek further help and support.
  • We found the service was following up on pathology results and had an effective monitoring system in place to ensure that all abnormal results were managed in a timely manner and saved in the patient’s records.

Effective staffing

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

  • The service was run by two directors. One of the directors was a CQC registered manager. The directors were supported by a practice manager and a head receptionist to deal with telephone, email and face to face queries and book appointments.
  • The doctors were registered with the General Medical Council (GMC) the medical professionals’ regulatory body with a license to practice.
  • The service had kept the evidence of doctors’ professional qualification in their staff files.
  • The doctors had a current responsible officer. (All doctors working in the United Kingdom are required to have a responsible officer in place and required to follow a process of appraisal and revalidation to ensure their fitness to practice). The doctors were following the required appraisal and revalidation processes. All the doctors had received a formal internal appraisal within the last 12 months.
  • All staff were appropriately qualified. The service had an induction programme for all newly appointed staff.
  • The service understood the learning needs of staff and provided protected time and training to meet them. All staff had received training relevant to their role. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The service had a clear approach for supporting and managing clinical staff to assess if their performance was satisfactory or variable.

Coordinating patient care and information sharing

Staff did not work 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. The service informed us they would signpost patients 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. They informed us if the patient did not agree to the service sharing information with their registered GP, then in case of an emergency, the service discussed this again with the patient to seek their consent. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Patients received person-centred care. The service informed us if a patient needed further examination they were directed back to their registered GP or regular physician. However, we found some patients had not received coordinated care, because the service had not followed their own policy. The service informed us that patients were encouraged to share the details of their consultations with their registered GP or regular physician when required to ensure safe and effective delivery of care but were free to decline to do so. The service had not communicated effectively when patients declined, as they had not recorded in the patient’s records that they had tried to persuade them to permit this, in situations in which this would be important. For example, the service had not shared the details of a newly diagnosed diabetic patient with their registered GP. In addition, we noted this patient was a lorry driver and the service had not assured themselves that the patient had been advised that the details of this new diagnosis should be shared with the Driver and Vehicle Licensing Agency (DVLA).
  • We also noted that a doctor had changed the medicine (used to treat low functioning thyroid glands) dosage of a patient which was not shared with their registered GP.
  • We saw an evidence where a doctor had started hormone replacement therapy treatment which was not shared with their registered GP.
  • In all the above three examples, we noted the patients did not agree to the service sharing information with their registered GP. However, the service had not followed their own policy because there was no documentary evidence available to demonstrate that the doctors had explained the risks to the patients and encouraged them to share the details of their consultations with their registered GP.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing because they were liable to abuse or misuse, and those for the treatment of long term conditions which required regular monitoring.
  • Patient information was shared appropriately and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • Information shared by email was password protected in order to ensure data security.

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 patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

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

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • Staff demonstrated a clear understanding of the Gillick competency test. (These are used to help assess whether a child under the age of 16 has the maturity to make their own decisions and to understand the implications of those decisions).
  • The service monitored the process for seeking consent appropriately.
  • We were told that any treatment including fees was fully explained to the patient prior to the procedure and that people then made informed decisions about their care.
  • There was information on the service’s website with regards to how the service worked and what costs applied. The website had details on how the patient could contact them with any enquiries.

Caring

Good

Updated 3 September 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service sought feedback on the quality of clinical care patients received.
  • We obtained the views of patients who used the service. We received 25 patient Care Quality Commission (CQC) comment cards. We also spoke with two patients on the day of the inspection. Feedback from patients was positive about the way staff treat people. Patients said the staff was helpful, caring and treated them with dignity and respect. They told us they were satisfied with the care provided by the service and said their dignity and privacy was respected.
  • The service gave patients timely support and information.
  • We saw that staff treated patients respectfully and politely over the telephone.

Involvement in decisions about care and treatment

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

  • The service gave patients clear information to help them make informed choices including details of the scope of services offered and information on fees.
  • Patients told us 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. Feedback suggested that patients felt diagnosis and treatment options were explained clearly to them.
  • 95% of the patients seen at the service were from the Polish community. We found that interpretation services were available for patients who did not have Polish or English as a first language. However, the provider informed us that the patients would be told in advance that they would be paying additional charges for interpretation services. Patients were also told about the multi-lingual staff who might be able to support them.
  • 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 patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 3 September 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.

  • Patients’ individual needs and preferences were central to the planning and delivery of tailored services. Services were flexible, provided choice and ensured continuity of care, for example, late evening and weekend appointments were available for patients who were unable to attend the service during normal working hours.
  • The provider offered services for adults and children. The service ensured that all patients were seen face to face for their consultation.
  • The provider offered consultations to anyone who requested and paid the appropriate fee and did not discriminate against anyone.
  • The facilities and premises were appropriate for the services delivered. The premises were accessible for patients with mobility issues. The services were offered on the second floor. There were a lift and ramp available on the premises. The service had carried out an Access Audit.
  • There was a patients’ leaflet which included arrangements for dealing with complaints, information regarding access to the service, consultation and treatment fees, terms and conditions, and cancellation policy.
  • The service website was well designed, clear and simple to use featuring regularly updated information. The service website included a translation facility.

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.
  • The appointment system was easy to use. Appointments were available on a pre-bookable basis. The service only offered face to face consultations.
  • Consultations were available between 9am to 9pm Monday to Saturday and 9am to 3pm Sunday. The provider was flexible to accommodate consultations if required for working patients who could not attend during normal opening hours.
  • Patients could access the service in a timely way by making their appointment over the telephone, in person or online.
  • This service was not an emergency service. Patients who had a medical emergency were advised to ask for immediate medical help via 999 or if more appropriate to contact their own GP or NHS 111.
  • The patient feedback we received confirmed they had flexibility and choice to arrange appointments in line with other commitments.

Listening and learning from concerns and complaints

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

  • The service had a complaints policy and there were procedures in place for handling complaints. The policy contained appropriate timescales for dealing with the complaint. There was a designated responsible person to handle all complaints.
  • The complaints policy included information of the complainant’s right to escalate the complaint to the Centre for Effective Dispute Resolution (CEDR), the General Medical Council (GMC), and the Care Quality Commission (CQC) if dissatisfied with the response. However, we noted the service was not registered with the Centre for Effective Dispute Resolution (CEDR).
  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • We looked at a complaint received in the last 12 months and found that complaints had been addressed in a professional manner and patients received a timely response. There was evidence that the service had provided an apology when required.
  • 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.

Well-led

Good

Updated 3 September 2019

When we inspected the practice in December 2018, we found that this service was not providing well-led care in accordance with the relevant regulations. Specifically, we found:

  • There was a lack of effective clinical leadership.
  • There was a lack of good governance and limited evidence of quality improvement activity to review the effectiveness and appropriateness of the care provided.
  • There was insufficient quality monitoring of clinicians’ performance.
  • Some policies and protocols did not include sufficient information.

At this inspection in August 2019, we found improvements had been made.

Leadership capacity and capability

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

  • The service had appointed one of the doctors (also the director) the clinical lead (from 4 January 2019) to ensure the delivery of high-quality, sustainable care.
  • The registered manager and the doctors we spoke with 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 service 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.

  • There was a clear vision and set of values. The service had a realistic strategy to achieve priorities. The service did not have a documented business plan.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • 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.
  • The service focused on the needs of patients.
  • The registered manager informed us they would act on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The service 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. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff 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.

  • The service had reviewed and amended its clinical governance systems. At this inspection, we found improvements had been made.
  • Structures, processes and systems to support good governance and management were clearly implemented. For example, the service had carried out audits to ensure safe prescribing guidelines were followed. They had developed a documented repeat prescribing policy. They had carried out prescribing audit to monitor the quality of prescribing.
  • The service had carried out clinical notes audit to monitor that the clinicians had maintained an accurate, complete and contemporaneous record in respect of each service user. This included a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
  • Staff were clear on their roles and accountabilities.
  • The service had reviewed and updated policies and procedures. However, they had not always assured themselves that they were operating as intended. For example, some patients had not received coordinated care, because the service had not followed their own policy and encouraged some patients to share the details of their consultations with their registered GP or regular physician when required to ensure safe and effective delivery of care. The service had not communicated effectively when patients declined, as they had not made a note in the patient’s records that they had tried to persuade them to permit this, in situations in which this would be important.
  • The service held regular clinical governance meetings.

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, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on the quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.
  • There was a peer review system in place.
  • The service held regular staff team meetings.
  • The service had developed a Medical Advisory Committee (MAC) and both the directors and the responsible officer were included in the MAC. They had decided to meet twice a year to review the performance of all practitioners with practising privileges.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • 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 and staff to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the patients and staff. The service had gathered feedback from patients through feedback and in-house patient surveys. The service had carried out patients’ survey from October 2018 to June 2019. This was highly positive about the quality of service patients received.
  • 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 saw an annual staff survey was carried out in October 2018.
  • Staff meetings were held regularly which provided an opportunity for staff to engage with the service.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • There were examples of compliments received by the service. We saw a number of positive comments documented on the online review websites at the time of our inspection.
  • The service had initiated an online networking tool to communicate quickly with staff members. This networking platform was used to share information, staffing matters and monitor the resources.

Continuous improvement and innovation

There were evidence of systems and processes for learning and continuous improvement.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Staff were involved in discussions about how to run and develop the service.
  • The staff we spoke with informed us that they could raise concerns and discuss areas of improvement with the directors as and when required. The staff were encouraged to identify opportunities to improve the service delivered.