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The London Travel Clinic at London Bridge Good

Inspection Summary


Overall summary & rating

Good

Updated 17 March 2020

We carried out an announced focused follow up inspection on 17 February 2020 at London Travel Clinic London Bridge to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 August 2019. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • There were systems in place to assess, address and mitigate the risks associated with fire and legionella.

  • The business continuity plan included contact details of all staff working in the service.

  • All staff knew who the safeguarding lead and fire mashals were in the service.

  • Staff understood their duty to raise concerns, report and record incidents and near misses.

  • There were systems in place to review and update Patient Group Directions (PGDs).

In addition the provider should:

  • Consider ways to better accommodate patients with accessibility needs.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 March 2020

At our previous inspection on 16 August 2019, we rated the practice as requires improvement for providing safe services as we identified that safety risks associated with fire and legionella had not been assessed, staff were unclear who was appointed as the fire marshal and safeguarding lead and there were two expired PGDs.

These arrangements had significantly improved when we undertook a follow up inspection on 17 February 2020. The practice is now rated as good for providing safe services.

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 patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. The site had developed a standard operating procedure which included information on the service’s safeguarding lead and the local safeguarding contacts.
  • There was an effective system to manage infection prevention and control. The provider had oversight of risks managed by third parties, including fire safety and legionella. The provider ensured outstanding actions from the risk assessments were followed up and actioned routinely.
  • The provider ensured facilities and equipment were safe, and equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste and effective systems to manage all other aspects of infection prevention control.

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.
  • 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.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.
  • There was a business continuity plan in place and this included contact details of all staff working at the service.

Information to deliver safe care and treatment

Staff

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • 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. Records were all stored on a virtual private network. Additionally, the service would always provide patients with a copy of their records after each consultation.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines and emergency medicines minimised risks.
  • The service carried out regular reviews of clinical records to ensure administration of medicine was in line with best practice guidelines.
  • Staff administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. All Patient Group Directions (PGDs) were up to date and signed by authorised clinical staff.

Track record on safety and incidents

The service

had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues. There was named fire marshals and all staff were aware of who they were and their roles.
  • 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, report and record incidents and near misses.
  • The service told us that they would learn, and share lessons identified themes and took action to improve safety in the service.
  • The service had systems to ensure staff 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 through their online patient record system.

Effective

Good

Updated 7 October 2019

We rated effective as

Good

because:

The needs of patients were assessed, and treatment delivered in line with guidance, there was a system to review the quality of care and treatment provided and make improvements, staff had the requisite skills and training for the role and arrangements were in place to ensure consent to care and treatment was consistently sought.

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

  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing. The service used medicine information resources as a basis for travel-related advice, vaccination and to inform practice. For example, Green Book, National Travel Health Network and Centre (NaTHNac), TRAVAX and British National Formulary (BNF). We saw that staff used a multi-drug interaction checker Medscape to check for contraindications.
  • The service undertook periodic reviews of staff consultations to ensure that they were delivering care and treatment in accordance with legislation and guidance.

  • Clinicians performed risk assessments for each patient to ensure that it was safe to administer vaccines.
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service was involved in quality improvement activity.

  • The service undertook periodic reviews of 15 patient records every 3 months to ensure that staff were following clinical guidance and best practice. audits would assess whether or not staff were documenting contact information, travel information, medical history and that consent was appropriately recorded. Feedback from these reviews was given which would result in improvement in the quality of clinical care.
  • The practice completed weekly infection control checks and checks of the fire escape routes, monthly hand hygiene audits and checks of the vaccine fridges to ensure that medicines were stored correctly and in date.

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. There was a programme of nurse led mentorship and clinical supervision.
  • Nurses were registered with the Nursing and Midwifery Council and were up to date with revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained.
  • Nursing staff who delivered immunisation had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

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

  • Patients would be provided with a copy of their notes documenting the vaccines that they had received to enable patients to share this with their GP.
  • If the service identified that patients needed to be referred to another service, they would tell the patient to contact their GP.
  • Vaccination costs and consultation fees were displayed on the service’s website. The service’s clinical system allowed for a total overview of costs to be provided to patients prior to commencing treatment. If patients did not wish to have the immunisations; the provider would advise them of other providers and which vaccinations could be provided by the NHS.

  • 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.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs.

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 ticked a box on the medical assessment form during consultation and showed it to patients.
  • Staff supported patients to make decisions. Where appropriate, they told us that they would assess and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 7 October 2019

We rated caring as

Good

because:

Feedback from patients and the observations of staff interacting with patients indicated that patients were treated with kindness compassions and respect, there were systems in place to ensure that patients were involved and fully understood the treatment provided and the setup of the service ensured that privacy and dignity were maintained.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

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

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language. Patients were also told about multi-lingual staff who might be able to support them. However, information leaflets were not available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

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 7 October 2019

We rated responsive as

Good

because:

The service delivered care and treatment which met the needs of their patients, the service was easy to access and there were systems in place to listen and respond to complaints.

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 service saw both adults and children. Patients could be seen outside normal working hours with morning, evening and weekend appointments.
  • Appointments were often available the same day including by walk in.
  • The premises were not suited to patients with mobility difficulties as the premises had no accessible toilets. However, patients could be directed to one of the other clinics which did have the ability to accommodate patients with mobility difficulties.
  • Interpreter services were available for patients who did not have English as a first language.
  • The service was a designated yellow fever vaccination centre; patients could receive all their required vaccinations from the same service.
  • Patient feedback consistently referred to the amount and quality of the information the service provided.

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 appointments and the service kept waiting times and cancellations to a minimum.
  • Services were available by appointment only between 10 am and 8pm Monday, 8.30 am to 8 pm Tuesday, 9 am to 4.40 pm on Wednesday, 2.40 pm to 8 pm Thursday, 9.40 am to 4 pm on Friday and 10 am to 3.40 pm on Saturday.
  • There was a 24-hour online booking system for patients to book appointments.
  • Patients could contact the service via telephone and appointments would then be booked by the receptionist.
  • The service provided time critical treatments post exposure such as rabies vaccinations. The service also directed patients to other local NHS services providing the treatment for free. Patients could start their post exposure treatment programme with the service and were provided with all the information needed to carry on their treatment elsewhere if required.
  • Patient feedback showed that patients were satisfied with how they could access care and treatment. Patients provided feedback to the service using surveys. The results of the surveys were discussed at service meetings held every two months.
  • Telephone translation services were available but there was a charge for using this service. The provider also could accommodate patients who spoke other languages with online translation software. There were no leaflets or information available for patients in other languages.
  • The service had developed a “smart” ordering system which meant that they could bulk order vaccines if they knew that there would be shortages in supply.
  • The service did not have a hearing loop and staff were unclear on what to do if patients presented with a visual impairment. However the service told us that they had once set up a video consultation with a British Sign Language (BSL)

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 took complaints and concerns seriously and had systems in place to respond to them appropriately and to improve the quality of care. Complaints were logged centrally by the provider. The complaint system was advertised in the waiting area and there was a mechanism to provide feedback online.

  • The Operations Manager was responsible for dealing with complaints and the service had a complaints policy providing guidance for staff on how to handle a complaint.
  • This location had received two complaints in the last 12 months. There was a poster in the reception area with contact information to enable patients to make comments or complaints.
  • The service managed a spreadsheet centrally to record and analyse complaints, concerns and feedback including written and verbal feedback.
  • We saw a record of one complaint related to the cost of treatment provided at the service. In response the provider adapted their patient record system to enable nursing staff to calculate the total cost of treatment on the system, show this to the patient and confirm that the patient consented to the cost prior to treatment being initiated.

Well-led

Good

Updated 7 October 2019

We rated well-led as Good because:

Leadership was visible and approachable, and the provider had a vision to provide a high-quality service. Staff felt supported and there was some evidence of patient engagement. Although there was a governance framework which covered most areas of operation, there was limited oversight of third-party managed risks.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality clinical care to patients; however, there was insufficient oversight of health and safety and risks.

  • Leaders had the experience, capacity and skills to deliver the organisational strategy but had not assessed or addressed all risks associated with the delivery of the service. However, from a strategic perspective management were knowledgeable about issues and priorities relating to services. They were knowledgeable about issues and priorities relating to services.

  • Staff told us leaders were visible, approachable and supportive.

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 set of aims and set of values and the service had realistic objectives to enable them to achieve this.
  • Staff were aware of and understood the aims and objectives 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.
  • Leaders and managers told us that 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 provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. There were meetings between all staff working at the service every two months.
  • There were processes for providing all staff with the development they need. This included appraisals and performance development plans. Staff received regular appraisals and 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 time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the well-being of all staff. The service held events for staff twice annually and provided staff with a degree of flexible working where possible.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training and no staff reported facing any discrimination.
  • There were positive relationships between staff and management.

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 in most areas. However, the service did not have adequate systems to assess or address risks associated with fire and legionella.
  • Staff were not always clear on roles and accountabilities although a site-specific protocol was available for staff for example nnot all staff were clear on the identity of the fire marshall or the safeguarding lead.
  • Leaders had established policies and procedures although these were not always embedded. For instance staff were not clear on the system for reporting significant events and some PGDs had expired.

Managing risks, issues and performance

The service had systems in place for managing risks, issues and performance. However, there was not adequate oversight of risks managed by third parties and that site-specific recommendations were followed up.

  • There was an effective, process to identify, understand, monitor and address some risks to patient safety. However, the provider did not have systems in place to assess risks associated with fire and legionella.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations which would be used to improve the quality of care provided. Leaders had oversight of safety alerts, incidents, and complaints.
  • 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 sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • 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, patients, staff and external partners and acted on them to shape services and culture. The practice undertook patient surveys and the feedback provided was mostly positive.
  • Staff said that they were able to provide feedback and that management were supportive.

Continuous improvement and innovation

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

  • Clinical staff at the service participated in a travel health study day organised by Vaccination UK. Clinical staff who attended the study day heard about updates in world travel health and discussed case studies and best practice. All clinical staff who started working at the service where required to have an assessment of their competency in travel health and their competency using oxygen to respond in an emergency situation. The provider had a comprehensive induction process whereby clinical staff would shadow a clinician for a period of four weeks before being shadowed administering immunisations prior to being allowed to work independently.