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Archived: Doctor Matt Ltd

Inspection Summary

Overall summary & rating

Updated 6 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Doctor Matt Ltd on 10 January 2017. Dr Matt is an online service providing patients with prescriptions for medicines that they can obtain from the affiliated registered pharmacy

We found this service did not provide safe, effective, responsive and well led services in accordance with the relevant regulations.

Our key findings were:

  • Practice policies were available but staff had no awareness of the policies. For example, the adult safeguarding policy.
  • Risks to patients were not appropriately assessed or managed. For example, we found patients being prescribed large quantities of inhalers for the treatment of respiratory disease but there was a lack of monitoring or follow up for these patients whose condition could put them at serious risk of harm.
  • There service did not follow current evidence based guidelines and standards.
  • There was no formal programme in place for quality improvement, for example clinical audits, to assess the service provision including organisational learning from significant events.
  • The service did not have a business continuity plan in place to deal with disruption to the service or staff absence.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • We found that the service was not following their own recruitment policy which stated that all new employees would receive a Disclosure and Barring Service (DBS) check, but we found that some DBS checks were carried over from previous employment.
  • We found that there was no system in place to monitor training, and some staff had not completed training relevant to their role.
  • Some patients were not treated in line with best practice guidance.
  • Information about services and how to complain was available.
  • The service encouraged and acted on feedback from both patients and staff.
  • Systems were in place to protect personal information about patients. The service was registered with the Information Commissioner’s Office.

The areas where the provider must make improvements are:

  • Ensure there are robust governance arrangements in place that includes a programme of quality improvement and that practice policies, such as the recruitment policy, are followed.
  • Ensure that questionnaires completed by the patient are fully assessed.
  • Ensure there is a system in place for receiving and acting upon medical and patient safety alerts.
  • Ensure that patient records are complete and accurate and that care and treatment is delivered in accordance with evidence based guidelines.
  • Ensure consent and capacity is adequately assessed, and the identity of a patient is confirmed to ensure the people receiving the medicines are over the age of 18.
  • Ensure medical indemnity is in place for clinicians working for the service.
  • The service must have a system in place to manage medical emergencies should they arise while a patient is accessing the service.
  • Ensure all staff have completed safeguarding training.

The areas where the provider should make improvements are:

  • Consider documenting team meetings to ensure learning is disseminated.
  • Only supply unlicensed medicines against valid special clinical needs of an individual patient where there is no suitable licensed medicine available

We have suspended the registration of this provider for six month until 29 June 2017 in order to protect patients.

Inspection areas


Updated 6 April 2017


Updated 6 April 2017


Updated 6 April 2017


Updated 6 April 2017


Updated 6 April 2017