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Inspection Summary


Overall summary & rating

Updated 5 December 2018

We carried out an announced comprehensive inspection of Winchester Travel Health on 16 October 2018, to ask 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 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 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.

Winchester Travel Health is a private clinic providing travel health advice, travel and non-travel vaccines, blood tests for antibody screening and travel medicines such as anti-malarial medicines to children and adults. In addition, the clinic holds a licence to administer yellow fever vaccines, and provides other vaccines (such as chickenpox) that are not part of the UK vaccination program.

The location is registered with CQC in respect of the provision of advice or treatment by, or under the supervision of, a medical practitioner, including the prescribing of medicines for the purposes of travel health.

The clinic is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities:

  • Treatment of disease, disorder or injury.

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. The registered manager has a Diploma in Travel Medicine, and other members of the clinical staff either teach in the field of travel health, or hold a foundation qualification in Travel Medicine.

As part of our inspection we asked for Care Quality Commission comment cards to be completed by service users prior to our inspection. We received 12 completed comment cards which were wholly positive about the standard of care received. Service users reported that staff were kind, knowledgeable, friendly, professional and caring. There were several comments relating to how informative the consultation process was.

Our key findings were:

  • Care and treatment was planned and delivered in a way intended to ensure people's safety and welfare.
  • The treatment room was well-organised and well-equipped.
  • Clinicians regularly assessed clients according to appropriate guidance and standards, such as those issued by the National Travel Health Network and Centre.
  • Staff were up to date with current guidelines.
  • Staff maintained the necessary skills and competence to support the needs of service users.
  • There were effective systems in place to check all equipment had been serviced regularly.
  • The provider was aware of, and complied with, the requirements of the Duty of Candour.
  • The provider had an effective system for ensuring the identity of people who used the service.
  • Risks to service users were well-managed. For example, there were effective systems in place to reduce the risk and spread of infection.
  • Service users were provided with information about their health and received advice and guidance to support them to live healthier lives.
  • Information about how to complain was available and easy to understand.
  • Systems and risk assessments were in place to deal with medical emergencies and staff were trained in basic life support.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Updated 5 December 2018

Safe systems and processes

The service had clear systems to keep service users safe and safeguarded from abuse.

  • The lead nurse is the safeguarding lead for the provider.

  • Not all the nursing team had received training on adult and child safeguarding to level three, with one nurse trained to level two. When we spoke to the service about this, they told us this nursing staff member would receive level three training in December 2018. In the interim, all nursing staff had received safeguarding update training in January 2018, and had reminders of changes in safeguarding policy. Non-clinical staff had received training on adult and child safeguarding to levels one and two. Nurses had received specific training to recognise and report suspected risks related to female genital mutilation and were able to verbally describe how they would log, escalate and manage safeguarding concerns.

  • The project manager, who is employed by the partner organisation, was the corporate Caldicott Guardian. (A Caldicott Guardian is a senior person responsible for protecting the confidentiality of service-user information and enabling appropriate information-sharing).

  • A range of safety risk assessments had been carried out with regards to the premises. These included risk assessments relating to the management of fire safety, health and safety, lone working and Legionella.

  • The provider had a range of safety policies which were regularly reviewed and communicated to staff. All policies and procedures were accessible to all staff.

  • The provider carried out staff checks, including checks of professional registration where relevant, on recruitment and on an ongoing basis. 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).

  • Nurses undertook professional revalidation in order to maintain their registered nurse status.

  • There was a chaperone policy and posters offering a chaperone service were visible in the waiting area. (A chaperone is a person who acts as a safeguard and witness for a service user and health care professional during a medical examination or procedure).

  • There was an effective system to manage infection prevention and control. The lead nurse was the infection control lead. Regular audits were undertaken and the most recent audit identified that alcohol gel dispensers were not on the wall. The issue has now been addressed.

Risks to service users

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

  • There were arrangements in place to ensure clinics were only run when there was a suitably trained nurse available. The clinic had recently employed another nurse to increase the days the clinic could open.

  • Clinical staff had appropriate indemnity insurance in place.

  • There were systems in place to respond to a medical emergency. All staff had received training in basic life support.

  • Emergency equipment was available within the building, which included access to oxygen. Emergency medicines stored by the clinic were appropriate.

  • We saw records to show that emergency medicines and equipment were checked on a regular basis. All the medicines we checked were in date.

Information to deliver safe care and treatment

  • Staff had the information they needed to deliver safe care and treatment to service users. On registering with the service, and at each consultation, service user identity was verified and recorded in their records. There was a clear policy and system in place to ensure that any children attending the clinic for vaccines were accompanied by a parent. Adults gave verbal consent for treatment and there was a signed parental responsibility and consent form for children. When we spoke to staff, they told us they encouraged parents to bring a Personal Child Health Record, to identify themselves as a child’s legal guardian (A Personal Health Record, also known as the PCHR or '', is a national standard health and development record given to parents/carers at a birth).

  • Individual service user records were written and managed in a way that kept them safe. The records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.

Safe and appropriate use of medicines

The provider had reliable systems for appropriate and safe handling of medicines.

  • There were service user group directives (PGDs) in place to support safe administration of vaccines and medicines. (PGDs are written instructions for the supply or administration of medicines to groups of service users who may not be individually identified before presentation for treatment). All PGDs were signed by the clinical director, who was employed by the partner organisation. Staff were not able to sign the document until they had read it through.

  • A programme of audit was undertaken in relation to medicines, to ensure that administration and prescribing were carried out in line with best practice guidance. There was evidence of clear recording on service user records when a vaccine or medicine had been administered.

  • The provider used an accredited company to deliver vaccines and these were only delivered on the days when the clinic was open. There was a clear policy in place for the management of medicines and how they were stored.

  • We found that medicines were stored securely and were only accessible to authorised staff.

  • Nurses carried out regular audits to ensure storage and administration was in line with best practice guidelines for safe prescribing, such as fridge temperature monitoring and safe security of medicines. Guidance was in place and staff were aware of actions to take if fridge temperatures were outside of the recommended range.

  • The provider had an electronic fridge temperature recording system as an additional safety mechanism. This alerted the Clinical Director and management staff immediately if fridge temperatures were out of range and allowed a more prompt response from staff in order to safely manage vaccines.

  • Arrangements for dispensing medicines such as anti-malarial treatment kept service users safe. The clinic provided complete medicine courses with appropriate directions and information leaflets.

Track record on safety

  • The clinic had a good safety record.

  • Written risk assessments had been completed in relation to safety issues. These included fire safety, the management of Legionella and health and safety. Identified actions had been completed; for example, a window had been fixed to ensure it complied with fire safety standards.

  • Staff were aware of how to alert colleagues to an emergency. Emergency equipment and medicines were available which were accessible and within date.

  • Additional security measures were in place when staff were lone working. Staff we spoke to were able to give examples of safety measures in place to support lone working.

Lessons learned and improvements made

The provider learned and made improvements when things went wrong. They continually monitored and reviewed risks.

  • Significant events and complaints were investigated at monthly meetings and shared at corporate and staff level. There was analysis of themes, trends and numbers of incidents to support any identified changes in processes or service delivery. This helped staff to understand risks and gave a clear, accurate and current picture that led to safety improvements.

  • The service had recorded one serious incidents in the past year, although there were four incidents with ongoing investigations. We saw documentary evidence that all had been reported to the administration manager for review with ongoing action as necessary. An incident occurred when a staff member noted the vaccine fridge temperature logger was displaying the same low temperature reading repeatedly over the course of several weeks. The service notified the Chief Executive Officer, who reviewed the issue and advised staff appropriately. Since the incident, there has been a new management team in place and the service has improved its monitoring processes.

  • Safety measures from other clinics associated with a partner organisation were shared and implemented. The provider had noted that staff had fed back that the incident reporting form was too long and in response the provider had simplified the form.

  • The provider was aware of and complied with the requirements of the Duty of Candour.

  • The service received safety alerts and these were reviewed by the lead nurse of the partner organisation, and disseminated via the IT system. Any required action was undertaken by the lead nurse at the service. Alerts were received by nurses as soon as they logged on to their computer and directed them to the appropriate action which was recorded once completed.

  • All nurses were signed up to receive foreign office alerts. This allowed them to keep abreast of changes in other countries which may affect the service and its work.

Effective

Updated 5 December 2018

Effective needs assessment, care and treatment

The service had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols. For example, NaTHNac (National Travel Health Network and Centre), a service commissioned by Public Health England.

  • A service user’s first consultation appointment was a minimum of 25 minutes long, during which a comprehensive pre-travel risk assessment was undertaken. This included details of the trip, including any stopovers, any previous medical history, current medicines being taken and previous treatments relating to travel. Nurses showed clear knowledge about the potential concerns of children being taken abroad for a medical procedure such as female genital mutilation. They could demonstrate where they had raised concerns about this and reported it through the appropriate channels.
  • Consultation length was tailored to the service user’s individual needs. If service users shared that they were apprehensive about injections or prone to fainting, extra time was factored into their consultation appointment.

  • Service users received a tailored health assessment. The clinic provided them with a booklet of what vaccinations they had received and which also contained information relating to vaccines. During consultation, the nurse provided a comprehensive individualised travel risk assessment, health information related to their destinations and an immunisation plan tailored to their specific travel needs. They also provided advice on how to manage potential health hazards and some illnesses that were not covered by vaccinations.
  • Latest travel health alerts such as outbreaks of infectious diseases were available.
  • We saw no evidence of discrimination when making care and treatment decisions in the records we viewed.

Monitoring care and treatment

  • Batch numbers of all vaccinations given were recorded in service user notes. The clinic had implemented a system of emailing outcomes of consultations to the service users GP, with their consent. A printed copy could also be supplied to the service user, should they want this.
  • The service had a programme of clinical audits. Audit results, recommendations and learning was shared and monitored to completion.
  • The clinic regularly carried out vaccinations in corporate business settings and schools. There were several audits relating to this work, including a records audit and a school immunisation procedure audit.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Nurses who worked at the clinic had the skills, knowledge and experience to carry out their roles. They had received specific training appropriate to their roles and could demonstrate how they stayed up to date.
  • 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. Staff were encouraged and given opportunities to develop such as attendance at national conferences and study days.
  • The service provided staff with ongoing support. This included an induction process, one-to-one meetings, appraisals, clinical supervision and support for revalidation.
  • New nurses received a tailored induction pack. This included regular meetings to discuss progress, core competencies which had to be completed prior to signing off induction, and clinical practice assessments.
  • We saw up to date records of skills, qualifications and training were maintained and held.
  • Learning needs were identified through a system of meetings and discussions which were linked to organisational development needs.
  • The travel health specialist was also a registered nurse and had recently completed their nurse revalidation. (Revalidation is a process that all nurses and midwives in the UK need to follow to maintain their registration with the Nursing and Midwifery Council to practise safely and effectively).

Coordinating service user care and information sharing

The travel health specialist worked together and with other health and social care professionals to deliver effective care and treatment.

  • The service worked with other travel and health organisations to ensure they had the most up to date information.
  • Before providing treatment, nurses at the service ensured they had adequate knowledge of the service user’s health, any relevant test results and their medicines history. We saw examples of service users being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • The service directly informed service users’ GPs of their treatment with the service users’ consent. However, if service users did not consent to this, they provided service users with a printed copy of their vaccinations, including blood test results to share with their GP or practice nurse.
  • The service clearly displayed consultation and vaccine fees in the waiting area and also on their website.

Supporting service users to live healthier lives

Staff were consistent and proactive in helping service users to live healthier lives whilst travelling.

  • The consultation with the nurse provided service users with advice to prevent and manage travel health related diseases. For example, precautions to prevent Malaria and advice about food and water safety. The consultation also provided information about how to avoid and manage other illnesses not covered by vaccinations which were relevant to the destinations being visited.

Consent to care and treatment

  • Staff understood the relevant consent and decision-making requirements, including the Mental Capacity Act 2005.
  • All service users were asked for consent prior to any treatment being given. Consent to share information was recorded.
  • When providing care and treatment for children and young people, parental attendance was required. Identification was sought in line with their policy and next of kin details recorded.
  • We were informed that treatment was not undertaken without service user consent. For service users with additional needs, the nurse ensured that a carer or advocate was present at the appointment and sometimes a second appointment was made to ensure appropriate time was taken to access mental capacity where required.

Caring

Updated 5 December 2018

Kindness, respect and compassion

  • We observed that staff were respectful and courteous to service users and treated them with dignity and respect. We noted that the consultation room door was closed during the consultation and conversations could not be overheard.
  • All of the 12 service user comment cards we obtained were positive about the service they had experienced. Staff were described as being friendly, caring and professional. We also spoke to two service users who used the service. Both were happy with the quality of care received.
  • The clinic had completed service user surveys. The most recent, completed between September and October (2018) showed that all 12 respondents were satisfied with their consultation.
  • The service ensured that people’s religious and social needs were fully understood and used to inform decision making. There was a sign in the waiting area informing service users that the service aimed to respect service user’s religious needs.

Involvement in decisions about care and treatment

  • Comprehensive information was given about treatments available and the service user was involved in decisions relating to this. We saw evidence that discussions about health risks, vaccinations and the associated benefits and risks to specific vaccinations were recorded. Written information was provided to describe the different treatment options available.
  • Several of the comment cards commented on how comprehensive and informative the consultations with the nursing staff were.
  • Service users also received individualised comprehensive travel health advice specific to their intended region of travel.
  • Staff told us that although the number of non-English speaking service users was very low, interpreter or translation services could be made available if required.

Privacy and Dignity

The clinic respected and promoted service users’ privacy and dignity.

  • Staff recognised the importance of dignity and respect.
  • The service complied with the Data Protection Act 1998.
  • All service user records were electronic and held securely. Staff complied with information governance and gave medical information to service users only.

Responsive

Updated 5 December 2018

Responding to and meeting people’s needs

The service organised and delivered services to meet service users’ needs. The provider understood the needs of its population and tailored services in response to those needs.

  • Same day appointments were available.

  • Service users were able to book appointments online or via telephone.

  • The clinic offered late weekday and Saturday morning opening times in order to meet service user need and demand.

  • Facilities were appropriate for the services delivered.

  • Information was available on the website, informing prospective service users of the services provided.

  • There were staff available to assist with registration, should the service user encounter any issues.

  • During consultation, service users received personalised travel health information, which detailed any additional health risks of travelling to their destinations as well as the vaccination requirements. This also included general tips and health advice for travellers and identified the prevalence of diseases in areas of the world.

  • In addition to travel vaccines, the service was able to dispense anti-malarial medication through the use of service user group directives (PGDs). (PGDs are written instructions for the supply or administration of medicines to groups of service users who may not be individually identified before presentation for treatment) Other travel related items, such as mosquito sprays, were also available to purchase.

  • There was access to translation services should the need arise. These were available by arrangement.

Timely access to the service

  • Feedback showed service users were able to access care and treatment within an acceptable timescale for their needs. The clinic was receptive to service user requests and sometimes closed later to accommodate service users working patterns and provide care at an opportune time for them.

  • Service users could book appointments via the website. The service was open at a range of different times throughout the week (usually from 9.20am to 12.30pm, with later opening on Tuesday, Wednesday and Thursday. The service was also open every Saturday, from 8.20am to 12.30pm.

  • Consultations and treatment were available to anyone who paid the appropriate charges. This was explained on the website, in the service user information pack and also when contacting the service direct.

  • The service was accessible for people with physical disabilities. There was a disability ramp but the service did not offer bathroom facilities for service users who were wheelchair dependent. Instead, the service provided the option of an off-site visit. This information was available on the service website.

Listening and learning from concerns and complaints

  • The provider took complaints and concerns seriously and responded to them appropriately to improve the quality of care. These were discussed at monthly staff meetings at the clinic and again at provider level.

  • Information about how to make a complaint or raise concerns was available in the waiting area and service users we spoke to said it was easy to follow.

  • The complaint policy and procedures were in line with recognised guidance. The service had received seven complaints in the last year, and learned lessons from individual concerns and complaints. For example, following an incident when a service user became ‘angry and aggressive’ towards a member of staff, the service discussed customer care training and strategies to diffuse challenging situations. A poster regarding zero tolerance of aggression was sited prominently in the reception area, and a mobile alarm hidden from view near the reception desk.

  • The provider took actions from the outcomes of complaints to improve care. All staff received feedback on any complaints and subsequent actions relevant to the service they provided.

Well-led

Updated 5 December 2018

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of the service. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The service had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

  • The partner organisation had an overarching governance framework, which supported strategic objectives, performance management and the delivery of quality care. This encompassed all the services provided by the partner organisation and ensured a consistent and corporate approach.
  • Policies, procedures and standard operating procedures were developed and reviewed at organisation level. These were cascaded and implemented as appropriate. Staff had access to these and used them to support service delivery. The lead nurse (who was also the Registered Manager of the service) contributed to the review and implementation of the policies.
  • We saw there were effective arrangements in place for identifying, recording and managing risks; which included risk assessments and significant event recording. These were discussed in monthly meetings for the team, and at a corporate level.
  • There was a comprehensive understanding of both local and organisational performance. A range of regular meetings were held which provided an opportunity for staff to be engaged in the performance of the service.
  • Staff we spoke with demonstrated they had the capacity and skills to deliver high-quality travel services. They were knowledgeable about issues and priorities relating to the quality and future of services, understood the challenges and were addressing them. Challenges included the managing of staff files, which were not always available at the service location because they were transferred to and from the partner organisation's office, and ongoing IT issues. When we spoke to the service about these issues, they told us they recently introduced a new computer system, and were currently uploading all paper file data to the IT system. We saw that service user care was not affected by these ongoing issues.
  • Staff told us the provider was supportive, visible, approachable and supported staff development.

Vision and strategy

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

  • There was a clear vision and set of values. The vision was: ‘to make a significant and valued contribution to the health and well-being of our local communities, by providing high quality independent travel and healthcare vaccination services to individuals and local businesses’. Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service monitored progress against delivery of the strategy.

Culture

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

  • Staff stated they felt respected, supported and valued. They were proud to work for the service.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • The service focused on the needs of service users.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • There was a clear organisational leadership, management and staffing structure. There were a range of departmental staff based at the partner organisation's office, which included the Clinical Director and a senior Operations Manager. The nurses reported to the Clinical Director. Meetings were minuted, held centrally and available for staff to review. We reviewed copies of some of these meetings.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. Staff were aware of their responsibility to comply with the requirements of the Duty of Candour. (This means that people who used services were told when they were affected by something which had gone wrong, were given an apology and informed of any actions taken to prevent any recurrence).

  • There were processes for providing all staff with the training and development they needed. These included appraisal, external courses and the opportunity to undertake a diploma and qualification in travel health. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff. For example, following an incident involving a member of staff and a service user, at the reception desk, staff have been provided with a mobile panic alarm.

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 and understood. The partner organisation had policies, procedures and activities to ensure safety, that were available to all staff. These were tailored and made specific to the location.
  • Staff were clear on their roles and accountabilities.
  • Strategy meetings and operational reporting structures provided assurances that the service was operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • We saw there were effective operational arrangements in place for identifying, recording and managing risks.
  • There was an effective process to identify, understand, monitor and address current and future risks within the clinic. For example, the staff undertook a variety of checks to monitor the safety of the clinic.
  • Leaders had oversight of safety alerts, incidents, and complaints.

  • The provider had recently reviewed and improved the auditing system to ensure that a range of both clinical and non-clinical audits were being completed to give a better overview of the performance of the service.

Appropriate and accurate information

  • The provider was registered with the Information Commissioner’s Office and had its own information governance policies. There were effective arrangements in line with data security standards for the availability, integrity and confidentiality of service user identifiable data, records and data management systems.
  • The provider used information technology systems to monitor and improve the quality of care. For example, each vaccine name and batch number was recorded on to each service user record once administered. The provider had invested in improved fridge monitors which gave live updates of fridge temperatures whenever these were required. They automatically informed staff if the temperature had gone out of range so that this could be quickly acted upon.
  • Data or notifications were submitted to external organisations as required. For example, an annual audit was undertaken as part of the Yellow Fever vaccine licence.

Engagement with service users, the public, staff and external partners

  • The provider involved service users, staff and external partners to support high-quality sustainable services.
  • The clinic proactively sought service users’ feedback via a feedback form which was completed monthly. Sixty-two service user responses had been received in 2018, all of which were positive about the service provided.
  • CQC comment cards showed all 12 service users (100%) were satisfied with their consultation and would recommend the service to a friend. We spoke with two service users who were also satisfied with the service provided.
  • Staff were encouraged to provide feedback at their regular meetings. Changes had been made as a result of staff feedback. For example, signage for products on display in the reception area was clearer.

Continuous improvement and innovation

  • There were systems and processes for learning, continuous improvement and innovation.
  • There was a focus on continuous learning and improvement at all levels. For example, the service had recently conducted a record-keeping audit, to offer support and training for staff. An audit of complaints more closely links team meetings with a complaints summary.
  • The induction system had undergone a review and new systems had been implemented to enhance the induction and provide more comprehensive clinical supervision and feedback.