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Inspection Summary


Overall summary & rating

Updated 16 May 2019

We carried out an announced comprehensive inspection on 12 March 2019 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was not providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

We found that this service was not providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The provider offers face to face consultations for immunisations including childhood, travel vaccinations and travel medical advice, and screening services for medical clearance and post-travel consultations.

We received feedback from seventeen patients who used the service which were wholly positive about the service experienced. Many patients reported that the service provided high quality care.

The lead nurse 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.

Our key findings were:

  • The service had systems to manage risk so that safety incidents were less likely to happen.
  • The service reviewed the appropriateness of the care it provided. However, it did not always ensure that care and treatment is delivered according to evidence based guidelines.
  • Staff treated patients with compassion, kindness, dignity and respect.
  • Services were provided mostly met the needs of patients.
  • Patient feedback for the services offered was consistently positive.
  • Responsibilities, roles and systems of accountability to support governance and management required improvement.

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

  • Ensure care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

  • Review systems in place to assure that an adult accompanying a child had parental authority.
  • Review the policy to identify and verify a patient’s identity prior to consultation.
  • Review service procedures to ensure staff receive training appropriate to their role.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Updated 16 May 2019

We found that this service was not providing safe care in accordance with the relevant regulations.

Safety systems and processes

The service had some 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. 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 regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.
  • The service did not have a system in place to assure that an adult accompanying a child had parental authority to consent to treatment.
  • 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).
  • Safeguarding leads and doctors had completed level 3 child protection training and nurses had completed level 2 child protection training and non-clinical staff had completed level 1 child protection training. They knew how to identify and report concerns. The provider was aware of the recent changes to the intercollegiate guidance on safeguarding children and young people and were in the process of updating staff child protection training accordingly. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was a system to manage infection prevention and control. The service undertook monthly infection prevention and control checks; however, they had not undertaken a comprehensive infection prevention and control audit. The service undertook their own legionella risk assessment and acted on the recommendations.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.

  • There was an effective induction system for staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. However, the service had not risk assessed on how they would manage patients with severe infections, for example sepsis.
  • The service had medical oxygen in situ; however, they did not have a defibrillator and emergency medicines to deal with a range of medical emergencies. The service had risk assessed how they would deal with medical emergencies without a defibrillator in place; however, we found this had not considered all the risks and how they would be mitigated. The service had emergency medicine to deal with anaphylaxis, however, they had not risk assessed the need for other emergency medicines.
  • The provider did not have a clear system in place to monitor referrals made for conditional medical clearance following health screening to ensure patients were safe to travel.
  • The provider did not have a system in place to assure safety of remote medical clearance.
  • 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.

Information to deliver safe care and treatment

Staff did not always have 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.
  • Clinicians made referrals in line with protocols; however, they did not have a clear system in place to check progress with referrals.
  • The service did not check and verify the identity of patients; however, staff confirmed patient details prior to treatment. The service informed us that they would check the name and date of birth of a child with the person accompanying the child. If a patient requests a copy of their medical record they had to complete a form and produce a photo identity.

Safe and appropriate use of medicines

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

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service prescribed medicines on headed paper and informed us that they only prescribed travel medicines; however, we found that the doctors prescribed medicines for other ailments. Their medicines management policy was not clear about the scope of medicines that could be prescribed by the service.
  • The service did not carry out any medicines audits to ensure prescribing was in line with best practice guidelines.
  • Staff prescribed, 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. Where there was a different approach taken from national guidance there was a clear rationale for this that protects patient safety. However, the provider did not have a clear system in place for authorisation of patient specific directions for administering unlicensed vaccines. Following the inspection, the service informed us they had set up a daily reporting process to manage patient specific directions.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety

  • There were risk assessments in relation to safety issues, however, these were not always comprehensive and considering all the risks.
  • The service performed regular audits looking at documentation available for staff and patients, health and safety, vaccine ordering and stock control, client confidentiality, client’s rights, clinic bookings and staff training. However, there was no infection control audit.

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. For example, a box of vaccines was found to be frozen and unsuitable for use. Following this incident, refrigerators were checked for any vaccines touching the sides of the fridges and to find if there are any other frozen items. Boxes were purchased to keep the vaccines from touching the sides in all the provider’s clinics. All frozen vaccines were immediately destroyed in accordance to their local wastage policy.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology.
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. We saw evidence that the service had acted on medicines and safety alerts. For example, the service had acted on recent alerts for zika virus and malaria. However, they did not have an effective system in place to monitor the implementation of medicines and safety alerts.

Effective

Updated 16 May 2019

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

Effective needs assessment, care and treatment

The provider did not have an effective system in place to keep doctors up to date with current evidence based practice.

  • Patients’ had access to pre-travel health assessments.
  • Patients’ needs were fully assessed through a pre-appointment health questionnaire.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if they became unwell whilst travelling and provided bespoke travel health advice to service users.

Monitoring care and treatment

The service was involved in some quality improvement activity. For example, the service undertook regular audits of nurse consultations and audits of medical records to ensure they were in line with national guidelines and service protocol. However, the service did not undertake any clinical audits.

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; they had a detailed training checklist for staff.
  • The service was in the process of finalising a doctors’ medical manual and had shared a draft copy with us. The manual included information about screening services, referrals, medicines management, responsibilities, safeguarding, consent, information governance, incident policy, complaints guidance and recruitment.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ 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; however, clinical staff had not completed Mental Capacity Act training and role specific infection prevention and control training. The provider was aware of this and informed us they had recently signed up with an online training provider and these training will be included as part of their mandatory training.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

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

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, the service communicated with the patients’ NHS GPs on patients’ consent as required.
  • The doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • 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.
  • The provider had not risk assessed the treatments they offered. They had not identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma.
  • There were limited arrangements in place for following up on people who have been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthily while travelling.

  • Where appropriate, staff gave people advice so they could self-care.
  • The service provided bespoke travel advice for patients depending on their destination.
  • The service had a range of information leaflets for patients in relation to travel medicine.

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.
  • The service monitored the process for seeking consent appropriately.

Caring

Updated 16 May 2019

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

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat 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.
  • All the 16 patient Care Quality Commission comment cards we received were wholly positive about the service experienced. This is in line with feedback received by the service.

Involvement in decisions about care and treatment

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

  • The service did not have access to Interpretation services for patients who did not have English as a first language. The provider informed us that for non-English speaking patients they usually ask them to bring someone who can speak English.
  • Information leaflets were 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.
  • The service’s website and other sources provided patients with information about the range of services available including costs.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect. However, the clinic did not have curtains in consulting rooms. Following the inspection, the service informed us they had purchased screens for consulting rooms.
  • Patients’ electronic care records were securely stored and accessed electronically.
  • The service had performed a patient survey in February 2019 and received 16 responses. The service provided results which indicated the patients were positive about the service experienced.

Responsive

Updated 16 May 2019

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

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 could be seen outside of normal working hours and can be seen at any of the provider’s five locations around London.
  • The premises were on the lower ground floor which was accessible to patients with mobility problems and wheelchair users.
  • The clinic did not have a hearing loop to support patients with hearing impairments.
  • The patients had access to information leaflets in other languages including Arabic, French, Spanish and Somali on topics such as female genital mutilation, Japanese encephalitis, hand washing and food hygiene. The provider informed us that they had produced information leaflets for patients going to Hajj and Umrah.
  • The service was a designated yellow fever vaccination centre; patients could receive all their required vaccinations from the same service.

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 care and treatment. The service was open between 9:30am and 6pm Monday to Friday and closed on the weekend. Opening hours were displayed on the service website.
  • The service also offered a walk-in service for patients; the patients were asked to complete a health questionnaire once they attend and they were assisted by the reception staff if needed.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that the appointment system was easy to use.
  • The service also informed patients about vaccines that could be obtained free from the NHS.
  • Patient feedback showed that patients were satisfied with how they could access care and treatment.

Listening and learning from concerns and complaints

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The clinical operations manager was responsible for dealing with complaints.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place.
  • The service had not received a complaint in the last 12 months; however, we were shown examples of complaints received at other locations operated by the provider.

Well-led

Updated 16 May 2019

We found that the service was not providing well-led care in accordance with relevant regulations.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care; however, leadership in relation to the medical services was not adequate.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services.
  • Leaders at all levels were visible and approachable.
  • Staff told us leaders were visible and approachable.

Vision and strategy

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

  • There was a clear vision to deliver high quality care. However, they did not have a strategy and supporting business plans to deliver the vision.

Culture

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

  • Staff felt respected, supported and valued. They were happy to work for the service.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they were able to 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. 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 focus on the safety and well-being of all staff. Staff had access to a health scheme which offered counselling services.
  • The service actively promoted equality and diversity.
  • There were positive relationships between staff and teams.

Governance arrangements

There were roles and responsibilities, systems of accountability to support good governance and management; however, the governance arrangements in relation to the doctor’s service required improvement. Following the inspection, the provider informed us they were in the process of appointing a clinical governance lead for the doctors’ service and were in the process of completing a job description for this role.

  • Structures, processes and systems to support good governance and management required improvement.
  • Staff were clear on their roles and accountabilities
  • Leaders had policies, procedures and activities to ensure safety. However, there were some gaps for example the lack of comprehensive infection control audit and limited consideration of risk assessment dealing with a range of medical emergencies.
  • Recruitment records were held in a central location; the provider had difficulty in accessing the recruitment records of staff during the inspection and sent us evidence of recruitment checks for staff after the inspection.
  • Policies and procedures were accessible to staff.
  • The service informed us they had weekly meetings with nurses and non-clinical staff; monthly lead nurse calls and monthly clinical meetings.

Managing risks, issues and performance

There were processes for managing risks, issues and performance.

  • The service had processes to manage current and future performance. Performance of nursing staff could be demonstrated through audit of their consultations; however, this was not performed for doctors. Leaders had oversight of safety alerts, incidents, and complaints.
  • The service had not completed any clinical audits.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • 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, staff and external partners to support high-quality sustainable services.

  • The patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. For example, the service collected regular feedback from patients through comments cards.
  • Staff were able to describe to us the systems in place to give feedback.

Continuous improvement and innovation

There was a focus on learning and improvement. Following the inspection, the provider had discussed the feedback from the inspection and sent us a detailed action plan of changes they were planning to make across all their clinics in relation to the following:

  • Incidents, significant events and complaints: These will be discussed in staff meetings and all staff would have access to incidents, safeguarding and complaints log.

  • Medicines and safety alerts: A system to monitor the implementation of medicines and safety alerts.

  • Medicines management policy: Information on the process/remit of medicines prescribed by the doctors in the travel clinic would be included.

  • Identity checks for children: A new system where a form should be completed to ascertain whether the child is attending with parent/guardian and a system to ensure identity of patients are checked when attending with a child.

  • Defibrillator and emergency medicines: Purchase or rent a defibrillator and purchase a range of emergency medicines according to need.

  • Infection prevention and control: Improve the infection prevention and control audit.

  • Evidence based practice: Provide appropriate guidance to staff; guidance to be added to doctors’ manual; discuss and agree on two cycle clinical audits.

  • Management of referrals: A system will be put in place to ensure the doctors’ check results and follow ups.

  • Training for staff: The Mental Capacity Act training was added to the mandatory training list for staff to complete.