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LiveSmart U.K. Limited Headquarters Good

This service was previously registered at a different address - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 11 October 2019

We carried out an announced comprehensive inspection at LiveSmart U.K. Limited Headquarters on 19 August 2019 as part of our current inspection programme. We previously inspected this service on 5 September 2018 using our previous methodology, when we found the service was compliant with the relevant regulations. At that inspection, we did not apply ratings.

LiveSmart U.K. Ltd offers online health assessments and provides healthcare plans to people aged over-18 years. The health assessment reports and healthcare plans are produced following a review of laboratory tests of blood samples and of service users’ completed health and lifestyle questionnaires. The reviews are conducted either by a doctor or a dietitian. The service offers higher grade packages, providing a series of monthly telephone health coaching sessions with dietitians for either three or six months. The service does not include prescribing or dispensing any medicines or supplements. It does not routinely provide diagnoses of health conditions, other than in relation to Vitamin D deficiency, but service users are informed of any issues or abnormalities from the test results and advised to contact their own GPs. Details are available on the provider’s website –

www.getlivesmart.com

At this inspection we found:

  • The provider had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the provider learned from them and improved its processes.
  • The provider routinely reviewed the effectiveness of the service and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Service users were encouraged to provide feedback, which was monitored by the provider together with any complaints and used to make improvements to the service.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue with planned training for the clinical team regarding communicating bodyweight issues to service users and their options for managing weight-related risks.
  • Continue with efforts to recruit male dietitians so that service users have an element of choice regarding their health coaching.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 11 October 2019

Keeping people safe and safeguarded from abuse

Staff employed had received training in safeguarding and knew the signs of abuse. The doctors working in the service were all on the relevant NHS Performers Lists. We noted the provider’s safeguarding policy did not record the provider’s safeguarding lead but were told this was the Clinical Operations Lead. Further, the policy did not contain details of the process for raising safeguarding alerts. We discussed this with the provider and were sent a suitably revised policy shortly after the inspection. All staff had access to the policy and were provided with guidance on identifying the relevant safeguarding authority to report any safeguarding concern. All the clinicians had received adult and level 3 child safeguarding training. It was a requirement for the clinicians registering with the service to provide evidence of up-to-date safeguarding training certification.

The service was provided mostly under corporate arrangements with service users’ employers; it was not provided to children under 18 years. Secure online accounts were set up for service users upon initial registration. Direct-access service users, i.e. those who were not participating under arrangements with their employers, paid for the service by valid credit or debit card, which were subject to detailed fraud and identity checks. The provider had assessed the risk of applications being made under false names and concluded, given the nature of the service, that additional checks were unwarranted. When the provider’s staff carried out blood sampling for service users, photographic identification was checked and at each health coaching consultation the service user’s identity was verified.

Monitoring health & safety and responding to risks

The provider’s headquarters office housed its managerial and administrative staff. Service users did not attend the premises. We saw evidence that all staff based in the premises had received training in health and safety including fire safety. Work station risk assessments had been carried out and electrical equipment had been PAT tested in May 2019. The building landlord was responsible for facilities management. A fire risk assessment and a general health and safety risk assessment had been carried out in November 2018. Firefighting equipment had been inspected in May 2019; the fire alarm was tested weekly and drills were carried out on a regular basis.

The provider had an up-to-date policy on infection prevention and control covering, for example, blood sampling done by phlebotomists, including specimen handling, spillages and sharps disposal, and carried out related risk assessments.

The provider expected that all health coaching consultations be conducted in private and that the service users’ confidentiality would be maintained. Staff used a two-factor authentication access code to log into the operating system, which was a secure programme. Staff working remotely were required to complete a risk assessment to ensure their working environment was safe.

The service was not intended for use by people with long term health conditions, or as an emergency service, and did not provide any diagnoses, other than in relation to Vitamin D deficiency. There were processes in place for managing test results, which involved staff contacting service users straight away if their results raised concerns. In that event, they were advised to contact their own GPs.

All health assessments and health coaching consultations were rated by staff for risk, for example, if there were serious mental or physical issues that required further attention. Those rated at a higher risk were reviewed with appropriate clinical support and recorded on the provider’s clinical escalation log. This was reviewed and discussed at regular clinical meetings, which also considered the serious incident log and any service user complaints.

A range of clinical and non-clinical meetings were held with staff, where standing agenda items included topics such as significant events, complaints and service issues. Clinical meetings also involved case reviews and discussions on clinical updates. We reviewed a number of meeting minutes and saw instances of clinical escalations – where results suggested health concerns and the need for further investigation – and of cases that were referred to service users’ own GPs. We saw that there had been several incidents relating to the test laboratory used by the provider, relating to the collection of blood samples and to test results being sent in error. As a consequence, the provider was in the process of engaging a different laboratory.

Staffing and Recruitment

There were enough staff to meet the demands for the service. There was a rota for the GPs and dietitians, who were currently paid on a mixed basis, either per session or per report, but this was under review for the future and subject to workload demand.

The provider had a selection and recruitment process in place for all staff. We saw the Staff Recruitment and Selection policy which had been reviewed in August 2019. There were a range of checks that were required to be undertaken prior to commencing employment, such as references and Disclosure and Barring service (DBS) checks. 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. The provider also had a policy regarding Fit and Proper Persons, setting out specific requirements for board members, the registered manager and for other staff members.

Doctors employed by the provider were currently working in the NHS. We checked and confirmed they were registered by the GMC and, where appropriate, were on the GP register. They had to provide evidence of having an up-to-date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act. The provider’s dietitians were registered by the HCPC. The provider arranged for appropriate professional indemnity cover.

We saw the provider’s policy that covered staff induction, which had been reviewed in August 2019. Newly recruited staff were supported during their induction period and a plan was in place to ensure all processes had been covered. We reviewed four recruitment files which showed the necessary evidence was maintained and available. Staff could not commence health coaching consultations until induction training had been completed. The provider kept records for all staff and there was a system in place that flagged up when any documentation was due for renewal such as relevant professional registrations. All staff were subject to annual appraisals, which we saw were up to date.

Information to deliver safe care and treatment

Most service users registered under arrangements with their employer. Upon registering and at each health coaching consultation the service user’s identity was verified, initially by credit and fraud checks. When the provider’s staff carried out blood sampling for service users, photographic identification was checked. Staff had access to the service users’ previous records held by the provider. Records could be audited to check which of the provider’s staff had accessed them.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. The provider’s policy had been reviewed in September 2018, with the 2019 review scheduled for shortly after our inspection. We were shown the provider’s serious incident management log, which recorded 16 occurrences treated as serious incidents over the past 12 months. These included instances of patients’ results causing concern over health issues. We reviewed several incidents and found that they had been fully investigated, discussed and led to action to improve the service. For example, the lead clinician had discussed with doctors the quality of their reports and the quality of service provided by the test laboratory had been reviewed. As a result, one doctor was being allocated fewer cases and the provider was investigating alternative laboratory services. In a further case, technical changes had been made to the service’s IT system. Incidents were monitored to identify any trends requiring remedial action and discussed at staff meetings so that learning from them could be shared.

We saw evidence from the incidents log which demonstrated the provider was aware of and complied with the requirements of the duty of candour by explaining to the patient what went wrong, offering an apology and advising them of any action taken. The provider’s duty of candour policy had been reviewed in August 2019.

The provider had a process in place to receive and act on safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA), issued via the NHS Central Alerting System. We were shown examples of these being reviewed and shared.

Effective

Good

Updated 11 October 2019

Assessment and treatment

We reviewed eight sets of medical records that demonstrated that each doctor assessed service users’ needs and delivered care in line with relevant and current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice. The provider used a Q-risk tool to review results and information submitted to assess service users’ risk of having or developing cardiovascular disease.

Service users completed an online form, which recorded their past medical history and that of family members, information regarding their nutritional intake, exercise, smoking and drinking habits, sleep and stress patterns. Service users were also asked to record their health objectives. These were reviewed by a dietitian or doctor (depending on the level of package purchased) together with the results of service users’ blood tests. The eight sets of records we reviewed were generally complete, with adequate notes recorded. Staff had access to all previous notes. A health assessment report was produced within 10 working days. Service users accessed the report securely online or using a dedicated mobile app. The assessment report included test results and a commentary. The service does not routinely provide diagnoses of health conditions, other than in relation to Vitamin D deficiency, but service users are informed of any issues or abnormalities from the test results and advised to contact their own GPs .We saw evidence from the provider’s clinical escalation log of such cases where test results raised cause for concern, service users were contacted by phone and advised, for example, to book appointments with their GP. We saw instances where service users were emailed password-protected reports so that they could refer these to the GPs for further investigation and diagnosis.

Service users who had opted for the basic service package received a 15-minute telephone call to discuss their results. Those who had opted for higher grade packages were then provided with ongoing monthly health coaching by telephone with one of the dietitians. These consisted of either three or six calls, depending on the level of package purchased. The initial health coaching call lasted 50 minutes, the subsequent ones 20 minutes. Basic package service users could subsequently upgrade to receive health coaching calls.

We saw a set of notes for a person with a significantly raised Body Mass Index (BMI) which is used to assess whether a person’s weight is healthy. We could not establish from the initial health report whether the service user had been assessed appropriately and had received suitable coaching. We asked the provider to investigate the case. We were told that from a review of the case notes it had been established that the high BMI had been discussed with the service user during coaching calls. The discussions included weight management strategies and the service user had been encouraged to visit their own GP for support. The provider concluded from the review that the clinical team would benefit from further training around communicating weight, risk and management options as it had not been set out clearly in the health report. The provider told us the training was scheduled for the next monthly clinical meeting and the matter would continue to be reviewed as part of our ongoing auditing of health reports and coaching.

Staff providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely. They worked carefully to maximise the benefits and minimise the risks for people using the service. If a service user needed further examination they were advised to see their GP, within a specified timescale. If a serious and urgent condition was identified, the service user might be advised to attend Accident and Emergency and we saw an example of this happening in the provider’s clinical escalation log.

Quality improvement

The provider had an up to date policy relating to clinical audit procedures and it collected and monitored information on how the service operated to improve outcomes. For example, we saw the results of regular audits of a sample of GPs’ assessments and of dietitians’ cases confirming learning points were highlighted and shared. A clinical escalation log was maintained and monitored, recording instances when service users had been given advice such as relating to concerning test results. Learning from this was also shared with staff. We saw that following one incident the provider’s procedure for clinical escalation had been revised. The provider’s clinical escalation policy had been reviewed in August 2019.

Staff training

Staff had to complete induction training, which included safeguarding, information governance and the General Data Protection Regulation, diversity and equalities, customer care, bullying and harassment, general health and safety and fire safety and basic life support / emergency first aid. Staff also had to complete regular online refresher training and monitoring systems were in place to identify when this was due. In addition, staff were provided with ad hoc group training sessions and we were shown examples relating to blood pressure, sports nutrition and other dietary practices.

Changes to systems and procedures were communicated at team meetings and via email to all staff. The provider used video conferencing facilities allowing remote workers to participate in meetings. Guidance material on the IT system was regularly reviewed and updated when changes were made.

Administrative staff received regular performance reviews. All the doctors had to have received their own appraisals before being considered eligible at the recruitment stage. Their work within the service was included in their appraisals and was part of their revalidation process.

Coordinating patient care and information sharing

Service users were asked to provide full medical histories and their consent was requested to share information with their registered GP. Staff told us that roughly 2,000 patients had provided their GPs’ contact details and 500 had given consent for information to be shared with them. When consent was given, the provider sent a copy of the health assessment report, including test results to the GP electronically and in line with GMC guidance. Staff told us the provider had never had to send a report to a GP without the person’s consent. We discussed with staff the provider’s clinical escalation protocol, regarding instances where a service user withheld their consent to information being shared with their GP, despite significant health concerns being identified. The provider would explain to the service user the benefit of continuity of care being provided by their GP. The provider had a series of screening questions to establish why the service user might not be willing to give consent, which included making an assessment of whether their current mental capacity might be affected.

Supporting patients to live healthier lives

The purpose of the service was to support people to live healthier lives. This was done by carrying out an assessment of service users’ health, based on information they submitted and the results of blood tests. A detailed assessment record was provided to service users and an improvement plan drawn up in consultation with a dietitian. This was reviewed at a series of telephone health coaching sessions for three or six months. The provider monitored the effectiveness of the service, using feedback from service users and a clinical outcomes audit, supported by academic reviews. The audit, involving over 400 service users, recorded improvements relating to alcohol consumption, blood pressure, heart rate, exercise, cognitive function and overall health score. We saw feedback from 63 service users, of whom 49 (78%) said they were motivated to make lifestyle changes, with 14 remaining neutral, expressing no opinion.

Caring

Good

Updated 11 October 2019

Compassion, dignity and respect

We were told that the staff undertook telephone health coaching consultations in private, mostly from home, and they were not to be disturbed while making the calls. Private rooms were available at the provider’s premises allowing calls to be made from there. The provider carried out random spot checks to ensure the staff were complying with the expected service standards and communicating appropriately with service users.

We did not speak to service users directly on the day of the inspection. However, we received feedback from three, submitted via our website as part of the inspection process. They were positive regarding their experience of the service, although one person mentioned a delay in receiving their results. We reviewed the record with the provider and saw there was an appropriate explanation for the delay. We also reviewed the provider’s own survey information – feedback was requested in all cases. This related to all aspects of the service and was collated for analysis. It contained feedback from 63 service users. It should be noted that most of them had used the service under arrangements made by their employer. Positive feedback was given regarding compassion dignity and respect. Fifty-five service users (87%) said they were likely to recommend the service, with eight being neutral.

Involvement in decisions about care and treatment

Information guides about how to use the service and technical issues were available. There was a dedicated team to respond to any enquiries.

Service users had access to information about the doctors and dietitians and could book a consultation with a person of their choice. They could also access their records via a secure online account or by using a secure app.

Responsive

Good

Updated 11 October 2019

Responding to and meeting patients’ needs

  • Details of the services offered, together with the costs involved, were set out on the provider’s website.
  • Service users could access the provider’s website and their own online records at all times. A dedicated mobile telephone app was also available to access the records. A customer service team was available for service users to contact by phone.
  • Blood sampling kits could be sent to service users’ homes, they could choose a local clinic, or for an extra fee, a nurse or phlebotomist could attend their home or place of work to take the samples.
  • Telephone health coaching calls could be pre-booked at times convenient to service users. The initial health coaching telephone call was 50 minutes long. Subsequent calls lasted 20 minutes. At the date of the inspection, coaching calls were made between 9.00 am and 6.00 pm, Monday to Friday. Staff told us this could be extended if there was sufficient future demand from service users.
  • The provider made it clear to patients what the limitations of the service were. It did not provide diagnoses, other than in relation to Vitamin D deficiency.
  • When test results or information submitted was of concern, staff contacted service users with appropriate advice for further investigation.

Tackling inequity and promoting equality

The provider offered health coaching consultations to anyone who requested and paid the appropriate fee and did not discriminate against any client group. At the date of the inspection, all but one of the doctors and dietitians were female. The provider had previously identified this as an area for improvement and had sought to recruit male staff so that service users had an element of choice. The recruitment process had not been successful but was continuing. We were told that there might be scope for offering a translation service to people for whom English was a second language, but the need had not so far been identified. We saw evidence that all staff had received Equality and Diversity training.

Managing complaints

The provider had developed a complaints policy and procedure and information about how to make a complaint was available on its website. The policy contained appropriate timescales for dealing with the complaint. There was escalation guidance within the policy. We saw that seven complaints had been made by service users in the past 12 months. These were monitored for trends and discussed at staff meetings. We saw the complaints were handled appropriately and service users had received a satisfactory response. Complaints were among standing agenda items reviewed at monthly clinical governance meetings. There was evidence of learning as a result of complaints, and changes were made to the service as a consequence. For example, following a complaint about bruising after blood sampling, the provider updated its website to warn service users that bruising might occur and added advice on how it could be minimised.

Consent to care and treatment

There was clear information on the provider’s website regarding how the service worked and costs involved. There was a set of responses to frequently asked questions. The website had a set of terms and conditions and details on how service users could contact the provider with any enquiries.

Consent was sought when service users opened their online accounts, when having blood tests and at the commencement of their coaching calls. Staff had received training on the Mental Capacity Act 2005. They understood and sought service users’ consent in line with legislation and guidance.

Well-led

Good

Updated 11 October 2019

Business Strategy and Governance arrangements

Staff told us there was a clear vision to work together to provide a high-quality responsive service that put caring and patient safety at its heart. There was a detailed business plan in place, setting out how the service was intended to develop over the coming few years.

The provider had a mission statement to improve people's health using science, technology and human support. There was a clear organisational structure, with a management team of six, including a chief executive officer (the registered manager), chief medical officer and chief technical officer. Staff were aware of their own roles and responsibilities. There was a range of service-specific policies which were available to all staff. These were reviewed annually and updated when necessary.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included random spot checks of health coaching consultations and records audits. The information from these checks was reviewed at regular clinical and governance meetings. This ensured a comprehensive understanding of the performance of the service was maintained.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions.

Leadership, values and culture

The provider had an open and transparent culture. We were told that if there were unexpected or unintended safety incidents, the service would give affected patients reasonable support, truthful information and a verbal and written apology. This was supported by the provider’s Privacy and Decency policy.

The provider’s aims and objectives were set out in its statement of purpose and included:

  • To provide high quality, safe, professional services to our service users. This will include focusing on providing high-quality health promotion and clinical support as needed to both our individual users and corporate clients.
  • To focus on prevention of disease by promoting health and wellbeing and offering relevant care and advice.
  • To be a learning organisation that continually improves what we are able to offer.
  • To ensure that we take close account of feedback about the services that we offer.

Safety and Security of Patient Information

Systems were in place to ensure that all patient information was stored and kept confidential.

There were policies and systems in place to protect the storage and use of all patient information. Service data was stored on a secure server, with the system requiring multifactor authentication to access. There was a clear audit trail process to monitor who had accessed any records. Regular penetration tests were conducted by security consultants to ensure data security was maintained. An audit to initiate certification under ISO 27001:2013 – a recognised standard relating to information security - was scheduled for shortly after our inspection. The provider was registered with the Information Commissioner’s Office. There were business contingency plans in place to minimise the risk of losing patient data. We saw evidence that all staff had received training in information governance and relating to the EU’s General Data Protection Regulation.

Seeking and acting on feedback from patients and staff

There were systems in place for service users to provide feedback, some of which was published on the provider’s website. Feedback was requested after every interaction. The provider used a commercially available customer rating system, the results of which indicated a high level of service user satisfaction. Since our last inspection, the provider had redesigned its reports in response to service user feedback. In addition to seeking feedback on existing aspects of the service, the provider sought feedback from a group of service users regarding new features introduced and those planned for the future.

Staff were able to provide feedback to management at their annual appraisals and as part of an annual staff survey.

The provider had a whistleblowing policy in place. A whistle-blower is someone who can raise concerns about practice or staff within an organisation. Under the policy, the registered manager was responsible for dealing with any issues raised under whistleblowing.

Continuous Improvement

The provider consistently sought ways to improve. All staff were involved in discussions about how to run and develop the service and were encouraged to identify opportunities to improve the service delivered.

Staff told us that the team meetings allowed them to raise concerns and discuss areas of improvement. We saw from minutes of staff meetings where audits were reviewed and discussed to identify possible areas of improvement.

There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, through clinical audit of a sample of doctors’ assessments, dietitians’ work and individual service user case studies, together with reviews of service user feedback, complaints and significant incident reports.