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Concierge Medical Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 4 October 2019

This service is rated as Good overall with rated outstanding for providing responsive services.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? – Good

We carried out an announced comprehensive inspection at Concierge Medical Practice on 21 May 2019 as part of our current inspection programme. The practice had been inspected on 11 January 2018 under our previous methodology and no rating had been applied.

This service is registered with CQC under the Health and Social Care Act 2008 to provide independent GP services to individual patients in their locality. Thirteen patients provided feedback directly to the Care Quality Commission (CQC). All comments were extremely positive about the service experienced. Patients commented that doctors were friendly, professional and polite, and that nothing was too much trouble. They felt they were well treated and cared for and that doctors responded to their concerns quickly which gave them the reassurance they needed.

Our key findings were:

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • There was an open and transparent approach to safety and a system in place for recording, reporting and learning from significant events. The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents happened, the practice learned from them and reviewed their processes to ensure improvements were made.
  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse and for identifying and mitigating risks of health and safety.
  • Patients received effective care and treatment that met their needs.
  • The practice organised and delivered services to meet patients’ needs. Patients said that they could access care and treatment in a timely way.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines and best practice.
  • Patients told us that all staff treated them with kindness and respect and that they felt involved in discussions about their treatment options.
  • Doctors had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Policies and procedures had been kept under regular review and updated accordingly. There were clear responsibilities, roles and systems of accountability to support effective governance.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. There was a practice development plan that documented both long and short-term priorities for the service.
  • There was visible practice and managerial leadership with audit arrangements in place to monitor quality.

We saw areas of outstanding practice:

  • There were no set limits to consultations so doctors were are able to make a full assessment of medical needs, particularly for those patients with complex, long-term conditions, co-morbidities and/or general age-related frailty.
  • All patients have a named doctor to oversee their care with buddy arrangements in place to cover absences.
  • We saw examples where doctors had exceeded expectations in treating patients with care and compassion which included for example, treating visiting relatives of patient members (who were non-members) and calling in to see patients if they suspected something was not as it should be with them.
  • In addition to home visits, patients had been visited at work, accompanied to hospital (to support both the patients and their families and act as their advocate), supported them in respite and nursing homes and at schools.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 4 October 2019

We rated safe as Good

because:

Concierge Medical Practice demonstrated that they provided services for patients in a way that ensured patients’ safety was maintained at all times.

Safety systems and processes

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

  • There were systems to safeguard children and vulnerable adults from abuse.
  • All team members were trained in safeguarding to the appropriate level according to their role. For example, doctors had completed appropriate training to level three in safeguarding adults and children.
  • Staff checks were carried out at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken routinely. (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).
  • There was an effective system to manage infection prevention and control. The infection control policy covered the cleaning of re-useable devices, such as stethoscopes and blood pressure cuffs.
  • The practice ensured that equipment was safe and maintained according to manufacturers’ instructions. There were systems to manage healthcare waste and guidance to follow in the event a needlestick injury occurred.
  • There were appropriate safety policies supported by safety risk assessments. These were regularly reviewed and communicated to all staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training.

Risks to patients

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

  • Arrangements ensured that appropriate numbers of doctors were available for patients at all times. The doctors operated geographically as two teams with buddy arrangements to cover absences such as sickness or annual leave.
  • Doctors understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections such as sepsis. An example where sepsis had been successfully identified in a patient demonstrated this knowledge.
  • Appropriate insurance schedules were in place to cover all potential liabilities, including professional indemnity arrangements.

Information to deliver safe care and treatment

Staff

had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

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

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • Medicines were prescribed, administered or supplied to patients by doctors who gave advice on medicines in line with legal requirements and current national guidance.
  • Doctors carried a range of medicines and equipment, which they could dispense whilst visiting patients as required which enabled patients to commence treatment promptly.
  • Processes were in place for checking medicines and accurate records of medicines were kept. Arrangements were in place to monitor the stock levels and expiry dates. Monthly reviews of these were carried out by the practice manager.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Doctors and management staff understood their duty to raise concerns and report incidents and near misses. Support was provided when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. This included ensuring that lessons were learned with potential themes identified. A log of all events was maintained and showed there had been 18 events during the past 12 months. We saw that action had been taken to improve safety in the service. For example, the provider had reviewed receipt of blood test results from the laboratory to assess whether all patients had received details of the results. The findings showed that some improvement was needed and amendments were made to handling blood test results. Learning was shared with the teams and monitoring established to ensure improvements were made.
  • The provider was aware of and complied with the requirements of the duty of candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.
  • The practice acted on and learned from patient and medicine safety alerts. There was an effective system in place to respond to all relevant alerts. Doctors checked patient records to determine whether there were any potential risks to patients when alerts concerned medicines.

Effective

Good

Updated 4 October 2019

We rated effective as

Good

because:

Concierge Medical Practice provided effective care that met with current evidence based guidance and standards. There was a system for completing audits, collecting feedback and evidence of accurate, safe recording of information.

Effective needs assessment, care and treatment

The provider had systems to keep doctors up to date with current evidence based practice. We saw evidence that doctors assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • Guidelines were available from the National Institute of Health and Care Excellence (NICE) electronically to the doctors. They confirmed that this information was used to deliver care and treatment appropriate to patients’ needs. Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.

  • The service ensured patients were given information to help them make a decision about their treatment options.

  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service completed audits to make improvements to the service provided. Audits had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.

  • We viewed three audits which had been carried out by the practice during the past year. Areas for improvement had been identified and action had been taken to address the findings. Follow up audits had been completed or were scheduled to monitor the changes to ensure these improvements had been maintained.

  • One audit determined whether patients were seen on the day that they asked to be seen (93% of these were on the same day that an appointment was requested, the remainder requested an appointment on a different day, which the practice was able to accommodate in 100% of cases). Another audit had been conducted to show whether patients had received a response from their own doctor or the duty doctor within 2 hours (93% of these were within 20 mins). The level of response was by the patient's own doctor (unless urgent or when their doctor was on holiday) which ensured continuity of care.

  • Repeat audits had been completed annually to monitor changes made as a result of initial audits. This included areas such as the management of medicine expiry dates and ensuring that medicines stored in doctors bags did not exceed manufacturers recommended temperatures.

Effective staffing

Doctors and management staff had the skills, knowledge and experience to carry out their roles.

  • All doctors were appropriately qualified. The provider had an induction programme for all newly appointed doctors.

  • The learning needs of doctors were understood and protected time and training was provided to meet them. Up to date records of skills, qualifications and training were maintained.

  • There was a system of appraisals, meetings and review of practice development needs.

  • The service was registered with the General Medical Council (GMC) as a registered body that accepted responsibility for the ongoing learning, training and appraisal of their doctors.

Coordinating patient care and information sharing

Doctors worked well to deliver effective care and treatment.

  • Patients received coordinated and person-centred care.

  • Before providing treatment doctors ensured they had adequate knowledge of the patient’s health and their medicines history.

  • There were three forms of membership of the practice: those patients who received additional access over and above the NHS, but whose primary GP was at an NHS surgery;those patients where Concierge Medical Practice looked after all of their medical needs; and those patients where care was shared between Concierge Medical Practice and the NHS jointly. In all aspects doctors worked well with other health care professionals in order to deliver effective care and treatment. Work had been ongoing to develop a register of preferred consultants for patient referrals. We saw that relationships had become more established with improved access for patients since our last inspection.

  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

  • Patients who were registered with an NHS GP were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service. The practice told us that in some instances patients had requested that information was only shared with NHS services in an emergency. These requests were respected.

  • Concierge Medical Practice provided a service to a residential school for international delegates which supported their health needs while enabling them to complete their studies. They held clinics with prescribing and dispensing on-site. The majority of delegates required translation services which was supported through the use of technology.

Supporting patients to live healthier lives

Doctors were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, doctors gave people advice so they could self-care.
  • They were proactive in helping patients to live healthier lives, identifying where patients needed additional support and directed them to appropriate services when necessary.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • We viewed a range of case studies which demonstrated the support given to patients to maintain their health and medical support to enable patients to stay at home for treatment.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Doctors understood the requirements of legislation and guidance when considering consent and decision making.

  • Doctors supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 4 October 2019

We rated caring as Good

because:

Concierge Medical Practice demonstrated that they ensured patients were involved in decisions about their treatment, that their needs were respected, and that services were provided in a way that was caring and supportive.

Kindness, respect and compassion

Doctors and management staff treated patients with kindness, respect and compassion.

  • Feedback from patients was consistently positive about the way doctors treated them. We viewed feedback from a range of sources which included the service website, from patients who completed information forms or emailed CQC directly. All comments were highly complementary about the service. Patients commented that they were happy they had found the service; that they received a quality service in the privacy of their own home. A survey to gather views and experiences of all patients was planned for later this year.
  • Doctors understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • We saw examples where doctors had exceeded expectations in treating patients with care and compassion which included for example, treating visiting relatives of patient members (who were non-members); calling in to see patients if they suspected something was not as it should be with them; and providing alternative, preferred means of communicating directly with doctors to discuss their concerns.
  • The provider told us their service was based upon the strength of the personal relationship between doctors and patients and the building of trust over time. In complex cases, and specifically in end of life care, that relationship also extended to supporting family members and carers.
  • The flexibility of their model, combined with their doctors being aware of the personal circumstances of individual patients, enabled them to pro-actively support their members (not just medically).
  • Doctors always attended funerals and memorial services for their members and provided ongoing continual support to the bereaved.

Involvement in decisions about care and treatment

Doctors and management staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language although the practice told us that requests for an interpreter were very rare.
  • Thirteen patients told us through the feedback comments that they felt listened to and supported by doctors and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Doctors helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients can access and understand the information they are given).
  • A practice newsletter was regularly produced to keep patients informed about practice news and developments.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Doctors recognised the importance of people’s dignity, privacy and respect.
  • Patients commented that doctors were respectful and ensured their dignity was maintained at all times.

Responsive

Outstanding

Updated 4 October 2019

We rated responsive as

Outstanding

because:

Concierge Medical Practice ensured they responded to patients’ needs for treatment and that they were able to deliver those services.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • All patients had a named doctor to oversee their care with known buddy arrangements in place to cover for absences. This ensured that all patients received continuity of care.

  • Patients received services which included face to face and telephone consultations, wound management, management of long term conditions and end of life palliative care.

  • The number of patients was restricted to an appropriate doctor/patient ratio to ensure that there was sufficient capacity at all times to respond to the needs of patients.

  • There were no set limits to consultations so the doctors were are able to make a full assessment of medical needs, particularly for those patients with complex, long-term conditions, co-morbidities and/or general age-related frailty. Diagnostic testing was carried out a patients homes (including blood and urine tests, swabs and ECGs). Results were shared and discussed with the patients immediately they were available (instant with ECG or within 24 hrs for blood tests). Referrals were often made the same day and the doctor has access the their network of consultants whilst they at the patient's home. This enabled three way informal discussions to work collaboratively to agree the best next steps for the patients’ care.

  • We were given several examples of where the service had been able, through its proactive management of the patients’ condition, to avoid hospital admission for some patients where previously there had been a long history of hospital admissions.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Concierge Medical Practice provides a home-visiting service only and are able to support patients who are not mobile, those with c

  • In addition to home visits, patients had been visited at work, accompanied to hospital (to support both the patients and their families and act as their advocate), supported them in respite and nursing homes and at schools.

  • Patients had timely access to initial assessment, diagnosis and treatment.

  • A doctor was contactable 24 hours, every day of the year including weekends and bank holidays.

  • A doctor was always available to advise on urgent concerns and home visits were made as required.

  • Patients reported that the appointment system was easy to use. They could contact the practice through a variety of means such as telephone, email and messaging facilities. This was also helpful for patients who were travelling on business or on holiday to arrange appointments on their return.

  • Between November 2018 and April 2019 audits showed that 100% of all patients were seen on the day that they asked to be seen (93% of these were on the same day that an appointment was requested, the remainder requested an appointment on a different day, which the practice was able to accommodate in 100% of cases).

  • Between November 2018 and April 2019, 100% of all patients who contacted the practice by telephone were responded to by their own doctor or the duty doctor within 2 hours (93% of these were within 20 minutes). The level of response was by the patient's own doctor (unless urgent or when their doctor was on holiday) which ensured continuity of care.

  • An audit of referrals made between June 2018 and December 2018 showed that 100% of referrals were made on the same day as the patient was seen by the doctor, with 82 % of referrals seen within 10 days and discussed with their doctor within 2 days of been seen by the consultant.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • The service had complaint policy and procedures in place.

  • Information about how to make a complaint or raise concerns was available.

  • Doctors were aware of the complaints policy and would inform the practice manager about a complaint when appropriate.

  • The practice had received one complaint during the past year. We reviewed the complaint and found that the complaints procedure had been followed. Although the complaint had not been upheld the practice had reviewed their procedures and amended these to ensure a similar situation would not arise in future.

Well-led

Good

Updated 4 October 2019

We

rated well-led as Good because:

Concierge Medical Practice provided services which were well led and well organised, within a culture that was keen to promote high quality care in keeping with their systems and procedures.

Leadership capacity and capability

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

  • The management team were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • The management team were visible and approachable. They worked closely with all doctors to make sure they prioritised compassionate and inclusive leadership.

  • Responsibilities were shared between the directors which included responsibility for the safety and clinical governance, developing innovative ways to enhance the practice and clinical management.

  • There were effective processes to develop leadership capacity and skills.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • The service developed its vision, values and strategy jointly with doctors and management staff.

  • Doctors were aware of and understood the vision, values and strategy and their role in achieving them.

  • The service monitored progress against delivery of the strategy.
  • Staff meetings were held monthly and included discussions about and reviews of the practice vision and strategy.
  • The service had made a strategic decision to focus their business on the importance of continuity of care and the role it plays in patient safety and outcomes.
  • They had implemented a growth share scheme, granting their doctors shares in the company which aligned them both to their vision, giving them a stake in the future success of the service. The provider told us this scheme both rewarded and motivated their doctors, as well as providing a "lock-in", which helped with managing an ever-present general practice recruitment and resource risk

Culture

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

  • Doctors and management staff we spoke with felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients.

  • The provider acted on behaviour and performance inconsistent with the vision and values.

  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Doctors told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

  • There was a strong emphasis on the safety and well-being of all doctors.

  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training.

  • There were positive relationships between all doctors and management staff.

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, understood and effective.

  • Doctors and management staff were clear on their roles and accountabilities. There were established policies, procedures and activities to ensure safety that assured they were operating as intended. Policies and procedures had been kept under regular review.

Managing risks, issues and performance

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

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of practice staff could be demonstrated through audit of their consultations and prescribing decisions. The provider had oversight of safety alerts, incidents, and complaints.
  • Practice audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of monitoring and changes made to services to improve quality if needed.
  • The provider had plans in place and had trained doctors and management staff for major incidents.
  • All doctors and management staff were annually appraised and monthly one-to-ones were carried out. Doctors were supported to meet the requirements of professional revalidation where necessary.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all doctors and management staff had sufficient access to information.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.

  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients and staff

The service involved patients and doctors to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from their patients and doctors and acted on them to shape services and culture.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. All learning was shared through immediate feedback and at the monthly staff meetings.
  • Doctors and management staff were encouraged to take time out to review individual and team objectives, processes and performance.
  • Concierge Medical Practice had regularly entered and reached the finals in various annual awards including those for best healthcare awards. The practice had reached the finals for business awards and health investors awards scheduled to be held in June 2019.
  • Future service development included provision of nursing and extended services for members of the practice.