Teledoctor HQ

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Medicines optimisation

This is the first assessment for this service. This key question has been rated Good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and took appropriate action to safeguard people. People were kept safe, with risks reviewed as they waited for assessments, at least every three months. Staff understood and managed risks, and the service employed a cardiologist and GP to focus on physical health needs. Staff had the right skills, qualifications and experience. Managers made sure staff received training and regular supervision and appraisals to maintain high-quality care. Following some previous concerns raised about delays in receiving prescriptions, we found that staff managed and titrated medicine prescriptions well and involved people in planning any changes.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and managers could provide examples of learning from incidents and actions being put in place to prevent recurrence. Staff we spoke with were aware of incidents that had taken place in the last year, including patients not disclosing comorbid mental health conditions, and incidents of self-harm.

Staff knew which incidents to report and how to report them. The quality team monitored and triaged all reported incidents daily. Managers reviewed incident reports using the Patient Safety Incident Response Framework (PSIRF). Periodic deep dives on specific areas were undertaken as indicated by thematic analysis. Incidents were discussed in team meetings and supervision sessions, with details provided on the governance channel and in newsletters. Staff gave examples of learning from incidents including improving information provided to patients about rare side effects of medicines such as psychosis, and ensuring contact details for the prescribing team were easily accessible to the client and family members.

Duty of candour is a legal requirement, which means providers must be open and transparent with patients about their care and treatment. This includes a duty to be honest with patients when something goes wrong. Staff were aware of the need to be open and transparent, including after an incident.

The provider had established and maintained safe systems, ensuring continuity of care, including when people moved between different parts of the service. There was a dedicated team to assess referrals and separate teams for autism and ADHD assessments, prescribing medicines, education navigation, psychoeducation and talk therapies. There were clear systems in place for processing information relating to patients promptly at different stages of their journey through the service.

Staff were trained in safeguarding, knew how to make a safeguarding alert and said that they did so when it was appropriate. Staff discussed safeguarding concerns in supervision sessions when relevant.

Current safeguarding children and adults’ policies were easily available to staff. Staff knew how to identify adults and children at risk of, or suffering, significant harm. They could give examples of safeguarding alerts they had made. For example, if a patient was assessed to be at immediate risk, they would discuss this with their team lead, and make an appropriate referral, seeking consent from the patient/parents, but going ahead without consent when appropriate. The team would follow up any concerns with the patient’s GP following any referral.

Staff discussed concerns at daily zoning meetings, with risks escalated as needed, and a debrief provided to them for each case. Staff had the appropriate safeguarding training level for their role, with all clinicians trained to level 3 for children and adults and the safeguarding lead trained to level 5. All non-clinical staff were trained to level 2 for both safeguarding adults and children. Twelve staff were completing training in safeguarding at level 4. The safeguarding lead was involved in interagency meetings as needed, for example including schools when needed.

In the 4 months before the inspection, 35 safeguarding referrals had been made by the service. We reviewed three safeguarding cases and found that they detailed appropriate interventions.

Managers undertook a monthly safeguarding audit where they looked for themes and patterns. They presented this information at the clinical effective and safeguarding committee, which in turn fed into the integrated governance and risk committee.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although staff used a stratified system to record patients’ risks by severity, this was accompanied by a more detailed narrative with plans agreed with patients/parents to address these. The intake team consisted of 13 clinicians, providing universal screening, The risk screen for each patient was reviewed at least every 12 weeks, with patients completing details of any changes, which could result in a full screen if needed.

Staff verified patients’ identity, by checking photo identity documents before consultations. The service was looking into using an advanced identity verification system in the future.

Clinical risk training was delivered internally, tailored for risk assessment in an online environment.
If risks to a patient escalated during a session, staff stopped completing the assessment and started completing a risk assessment. They had an escalation protocol to use, including contacting a team leader for support, and there were times when they had called emergency services. They would also contact the GP to ensure the patient was seen face to face if needed. When staff identified risks for a patient these were flagged on the patient records.

Patients were advised on risks related to their conditions or diagnoses and actions to take if their condition deteriorated.

As this service took place remotely, both for staff and patients, there were no concerns about potential risks within the provider’s environment. The provider made sure IT equipment, facilities and technology supported the delivery of safe care. Staff did speak to patients about their home environment when relevant, for example for the storage of prescribed medicines. The service had appropriate indemnity insurance for its activities.

Patient verification checks took place on all calls, sessions and assessments. Proof of identity and address were also undertaken with all clients.
 

Calls made to and from Client Support teams were audited to ensure bestpractice around the General Data Protection Regulation.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of the inspection the service had 376 employees, of which 85 were contracted members of staff. The biggest staff team was made of clinical staff, followed by operational staff. Managers noted that the service had grown swiftly but had now reached a time of more stable growth. They noted that there had been some turnover of staff in the last year, which had slightly decreased in recent months. The service was actively recruiting to new posts. Faced with reduced funding in the education navigation area, the service took steps to restructure staffing levels, focusing resources where they were most needed to continue delivering effective support to service users. The team had moved to a more efficient term time only model, with several staff relocated to other posts within the organisation.

Most vacancies were for autism and ADHD assessors, who were employed at least 2 years after their registration. There had been some staff sickness approximately 9 months ago, but this had improved more recently.

There were rigorous recruitment practices, with all potential staff asked to fill out detailed forms, and provide disclosure and barring screens, identity documents, proof of qualifications, written references, and proof of right to work. These steps were checked by a compliance team before being signed off as appropriate to proceed. We looked at a selection of recruitment documents for staff and found that appropriate checks had been carried out in each case.

All new staff undertook induction training specific to their role, held every three weeks, and had time to complete their mandatory training, and for shadowing other staff. There were annual checks to make sure staff were registered with their appropriate body, which were more frequent if there were conditions of registration.

Mandatory training compliance was monitored for all staff and reported monthly to the audit committee. Overall, the service had 89% compliance with staff mandatory training.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.Medicine management plans were clearly documented in a treatment planning letter shared with the patient and their GP. Any change to the plan was discussed and agreed with the patient and the GP was updated. The service worked directly with GPs to move clients to Shared Care arrangements, wherever possible, once on a stable dose of medication.

The service followed current and relevant best practice and guidance, including requiring physical health observations to be provided ahead of online appointments. Where this has not been provided, prescribers allowed patients to take a reading during the appointment so that their prescription was not delayed. The team held regular prescribing forums to discuss and share knowledge of current best practice.

Staff received appropriate training, were competency assessed on medicines optimisation, and said they felt confident managing the prescribing of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

There were detailed policies on prescribing, with prescribers keeping paper script stationary in a safe, and a clear system for recording each prescription on the patient record system before generating an electronic prescription. The pharmacies would not release the medication (controlled drugs) until they receive both the electronic and paper copies. The operations team carried out regular audits to check if the prescription numbers the prescriber has written match the number of prescriptions given. Prescribers were seeing up to 8 patients a day.

They had a cardiac meeting weekly with a consultant cardiologist, to check patients’ electrocardiograms prior to commencing medication. Staff said they could resolve issues quickly if patients were running out of medicines. However, some patients fed back that they had experienced a gap in their medicines due to administrative issues. Improvements had been made to automate the process for repeat prescriptions, a duty team had been established to support patients directly and quickly with queries regarding their prescriptions and the service had successfully trialled e-prescribing and was planning to roll this out across the whole service.