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AlldayDr Group Ltd Requires improvement Also known as Head Office

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 April 2020

We carried out an announced comprehensive inspection at AlldayDr on 12 February 2020 as part of our inspection programme. This was their first inspection.

AlldayDr is an online healthcare provider that offers a consultation service with a GP through a Smart phone app and online web portal. Patients can register via the online web portal or smart phone app and patients are able to pay either a one-off fee or subscribe to the service.

We rated the service as requires improvement overall. We rated the safe domain as requires improvement because on the day of the inspection risk management, quality assurance and prescribing were not failsafe. We rated the well led domain as requires improvement because on the day of the inspection the provider was not aware of the areas where patient safety may be compromised or other potential risks.

At this inspection we found:

  • Not all systems to manage the risks associated with digital patient care and treatment were failsafe. For example, at the time of the inspection the provider did not have an effective system in place to receive and act on medicines and safety alerts, such as those issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
  • The service reviewed the effectiveness and appropriateness of the care it provided. It usually ensured that care and treatment was delivered according to evidence-based guidelines. However, we did see some examples where this was not the case. For example, contemporaneous notes were not written in accordance with current guidelines.
  • Prescribing was carried out by the GP reviewing patients. However, this was not always in accordance with prescribing requirements.
  • We saw items that appeared to be for sale on the service website that on further review were not purchasable. This was misleading to people reviewing the website. When this was pointed out to the provider the items were immediately removed from the website.
  • Consent to share information with a patient’s NHS GP was obtained at the point of sign up. However, no information had ever been shared following any of the consultations.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • Staff met regularly to discuss consultations, incidents, and any learning that could be applied or improvements that could be made.
  • There was no clinical peer review of GP consultations to ensure they were effective and followed appropriate guidelines. For example, although a clinical care audit tool was in place, the audit had been undertaken by a non-clinical manager.
  • All staff had received appropriate training for their role.

The areas where the provider must make improvements are as follows:

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

The areas where the provider should make improvements are as follows:

  • More clarity was required to ensure all clinicians (once the service is scaled) understood the service expectations and importance of sharing information.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Inspection areas

Safe

Requires improvement

Updated 21 April 2020

Effective

Good

Updated 21 April 2020

Assessment and treatment

We reviewed 15 video consultations and clinical records with the provider, as well as other consultations carried out by way of questionnaires. There was one GP assessing/consulting patients at the time of the inspection. We saw that in each case an assessment of need was made in line with relevant and current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice. We were told that each online consultation lasted for ten minutes at which time the system ended the consultation without warning, although this had never occurred. We were told that if a consultation did happen to end without warning, then the patient could be re-contacted, but at the time of the inspection there was no way to override the possibility.

The service used NICE guidelines and BNF as support tools in providing treatments. Questionnaires required reviewing to ensure they were safe. We discussed these concerns during the inspection and the provider reflected and made changes to the system and protocols immediately to resolve this.

The provider of the service was aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely from patients. They worked carefully to maximise the benefits and minimise the risks for patients and accepted any shortcomings. We were told if a patient needed further examination, we were told they were signposted to an appropriate agency, but we did not see any occasions when this had been necessary. If the provider could not deal with the patient’s request, this was explained to the patient which was recorded on video, but not always in the clinical record.

The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes. The provider undertook peer review of consultations with a colleague outside the service.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes. There was a system in place to audit consultations with the consulting GP involved in those audits alongside the service manager.

Staff training

All staff completed induction training which consisted of health and safety, safeguarding and customer service. The service manager had a training matrix which identified when training was due.

There was a policy in place to ensure that GPs registered with the service received specific induction training prior to treating patients. However, at the time of the inspection there was only the provider in place. An induction log was available to be held in each staff file and signed off when completed. Supporting material was available, when other GPs did join the practice, such as a GPs handbook, guidance on how the IT system worked and aims of the consultation process. There was also a newsletter to be sent out when any changes were made. We saw several areas of support for GPs (in the future when the service is scaled) including clinical and technical protocols.

Administration staff received regular performance reviews. The provider GP had received their own appraisal and there was a protocol in place for monitoring the performance of GPs in the future both at the time of recruitment and during employment.

Coordinating patient care and information sharing

At the time of the inspection there had been no referrals to other services. We discussed this during the inspection along with the need to ensure that there were appropriate information sharing protocols.

If a patient needed a face-to-face consultation, they were advised to seek an appointment with their own registered GP. This was not something that had been facilitated yet.

Patients were asked for their consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service. More clarity was required to ensure that patients were advised of the risks of not informing their GP if they decided to opt out of that opportunity. At the time of the inspection there was an understanding that notes would be shared with a patient’s registered GP “when required”. More clarity was required to ensure all clinicians (once the service is scaled) understood the service expectations and importance of sharing information.

The service was able to refer patients for private treatment or the service was able to signpost patients to their NHS GP if they had any concerns, but this was not something that had ever been facilitated at the time of the inspection.

Supporting patients to live healthier lives

The service identified patients who may need extra support and had a range of information available on the Smart phone app such as healthy eating.

Patients treated for STIs (sexually transmitted infections) would be signposted to GUM (Genito-Urinary Medicine) clinics or given advice on STI prevention.

Caring

Good

Updated 21 April 2020

Compassion, dignity and respect

The provider undertook video consultations in a private room and were not disturbed at any time during their working time. The provider was able to ratify this as they were the GP undertaking consultations at the time of the inspection. In the future when the service was scaled up, and there were more GPs, the provider intimated the expectation that this would be the case for all employees undertaking consultations. A protocol and guidance were already in place.

Patients and staff were aware of preferences and settings within the system to maximise privacy and we saw that staff were given role-based access to patient information.

Patients who had used the service would receive a text message or email from the provider to which feedback could be provided. It was the patient’s choice as to whether they wished to provide that feedback and was not compulsory. Completed feedback forms were then sent to the analytics portal so that the information could be monitored. Positive feedback comments would then be posted on the website. If any negative feedback was received this was reviewed and if required, would be used to improve the service in that specific area.

40% of patients rated the consulting doctor 5 star and 60% rated them 4 star. There was only one consulting doctor at the time of the inspection and this was based on ten responses received.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical issues were available. There was a dedicated team to respond to any enquiries. Patients had access to information about the GP working for the service. At the time of the inspection there was only one GP available for consultation. A female GP was not available for consultation. Information was only available in English.

Patients could have a copy of their video consultation if they requested it.

The survey asked patients who used the service to rate the doctor undertaking the consultation and the service provided between 1 and 5 stars. They were then asked to rate whether they would recommend the service between very likely and very unlikely and provide any feedback in areas that could be done better.

We looked at the feedback that had been received from ten patients who had used the service in 2019 (those were the only results available). 9% rated the service 2 stars, 54% 4 stars and 36% 5 stars.

Overall patients who used the service in 2019 said they would recommend it to others. CQC directly received positive responses about the service from five patients who had used it.

Responsive

Good

Updated 21 April 2020

Responding to and meeting patients’ needs

Consultations were provided seven days a week, 8:00am to 10.00pm. 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 appropriate to contact their own GP or NHS 111.

The digital application allowed people to contact the service from abroad, but all medical practitioners were required to be based within England. Any prescriptions issued could be delivered to the patient’s choice of delivery such as their home or place of work, or collected from a collection point, rather than having to visit a pharmacy.

Patients signed up to receiving this service on a Smart phone app (iPhone or android versions that met the required criteria for using the app). The service offered flexible appointments between 8am and 10pm to meet the needs of their patients.

The provider made it clear to patients what the limitations of the service were. These were discussed during consultations and further information about services was available on the website.

Patients requested an online consultation with a GP and were contacted at the allotted time. Consultations were undertaken in ten-minute slots and more than one slot could be selected. We saw during the inspection that if a patient selected a ten-minute slot, the call ended after ten minutes regardless of whether the consultation was finished or not. However, within the consultation itself, patients were clearly made aware when they were approaching the final minute of the consultation. They had the ability to extend the appointment times which would result in additional cost and this was demonstrated on the clinical system.

Tackling inequity and promoting equality

The provider offered consultations to anyone who requested and paid the appropriate fee. However, there was an element of potential discrimination to ensure that the service was safe and effective.

The provider chose to deliver a service only to English speaking patients. When we asked about this the provider’s response was that it was important for them to be able to provide a safe, effective and responsive service and not to place patients at risk by way of ineffective and dysfunctional consultations which could happen because of language breakdown or poor communications. Immediately following the inspection and to ensure patients were made aware of this, the provider incorporated this information in to their sign-up terms and conditions.

Due to the limitations of their technology and to ensure that services did not place patients at risk, the provider did not support patients with impaired vision, deafness and/or impaired hearing. Immediately following the inspection, and to ensure patients were made aware of this, the provider incorporated this information in to their sign-up terms and conditions.

There was no information about the GPs on the website so that patients could choose who they wished to see. However, at the time of the inspection there was only one GP providing consultations.

Managing complaints

Although there was a comprehensive complaints procedure in place, there was limited signposting for patients and the escalation guidance within the policy was incorrect. Immediately following the inspection, the provider informed us they had updated the policy and removed any reference to the Parliamentary Ombudsmen Service. We saw this had been done.

The policy contained appropriate timescales for dealing with any formal complaint. Formal complaints had to be made in writing and all contact information was available within the policy. The provider was in the process of reviewing other external Independent advocacy services best suited for patient complaints of this type. They also added a complaints section to their website.

At the time of the inspection there had been no complaints received. We saw feedback received where one patient felt they had wasted their money and time for information they could have received easily elsewhere. The issue was because the patient had not provided the appropriate identification. However, we did not see any response or learning documented about this.

Consent to care and treatment

There was clear information on the service’s website with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The app had a set of terms and conditions and details on how the patient could contact them with any enquiries. Information about the cost of the consultation was known in advance and paid for before the consultation appointment commenced. The costs of any resulting prescription or medical certificate were handled by the administration team at the headquarters following the consultation.

Patients automatically provided consent to AlldayDr’s access to their medical records by accepting the terms and conditions. Patients were referred to the Privacy Policy if they wished to withdraw that consent. However, it was not obvious from the consultations that had taken place, that patients correctly understood this.

The consulting GP had received training about the Mental Capacity Act 2005. Staff understood and sought patients’ consent to care and treatment in line with legislation and guidance. Where a patient’s mental capacity to consent to care or treatment was unclear the GP assessed the patient’s capacity and, recorded the outcome of the assessment. The process for seeking consent could be monitored through audits of patient records but we did not see that it had been. Patients under the age of 18 years were not able to use the service.

Well-led

Requires improvement

Updated 21 April 2020