We carried out an announced comprehensive inspection on 8 December 2017 of the face to face private medical service at Freedomhealth Limited. We also followed up the inspection of the online service at Freedomhealth Limited, which we previously inspected on 23 August 2017. The report of the 23 August 2017 inspection can be found by selecting the ‘all services’ link for Freedomhealth Limited on our website at www.cqc.org.uk

At our previous inspection of the online service on 23 August 2017 we found the provider had not ensured that care and treatment was delivered in accordance with evidence based guidelines and the provider had not ensured that patient records were complete and accurate. We issued a requirement notice under the following regulations:

Regulation 12: Safe care and treatment

Regulation 17: Good governance.

At this announced comprehensive inspection, combined with the follow up inspection of the online services, on 8 December 2017 we found the service had addressed the issues identified at the last inspection. We asked the service 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.

Background

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.

Freedomhealth Limited provides private GP services from its location at 60 Harley Street, London, W1G 7HA, as well as an online service providing patients with prescriptions for medicines that they can obtain from the affiliated registered pharmacy. The online service is provided by a separate company Midcounties Co-operative. The GP working for the online service also works in the service as the director. The GP provides private general practice, specialist sexual health services and cosmetic treatments which are available to any fee paying patient. The service is operated by one GP supported by a service manager and reception staff.

The private GP service is open Monday to Thursday from 8.30am until 6.30pm and Friday 8.30am to 5.30pm. The service is not open on the weekend and does not offer out of hours services.

Freedomhealth Limited was originally established in 1997, and has evolved to provide an online service (since 2011) that allows patients to request prescriptions through a website (the online service). Patients are able to register with the website, select a condition they would like treatment for and complete a consultation form which is then reviewed by a GP and a prescription is issued if appropriate. Once the consultation form has been reviewed and approved, a private prescription for the appropriate medicine is issued. This is sent to the affiliated pharmacy before being dispensed, packed and sent to the patient by secure post (the pharmacy is regulated by the General Pharmaceutical Council and does not form part of this inspection).

The service has a registered manager, 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 service is registered with the Care Quality Commission (CQC) to provide the regulated activities treatment of disease, disorder or injury, diagnostic and screening procedures and family planning.

CQC inspected the online service on 23 August 2017, we issued a requirement notice under the following regulations:

Regulation 12: Safe care and treatment

Regulation 17: Good governance

We asked the provider to make improvements regarding; ensuring that care and treatment was delivered in accordance with evidence based guidelines and ensuring that patient records were complete and accurate. We checked these areas as part of this combined follow up online inspection of the online service and comprehensive inspection of the face to face service and found these concerns had been resolved. The online service had redesigned their system including developing patient questionnaires so that they captured all communication between patient and clinician and included an area for clinical notes. The service now required patients’ consent to providing GP details (specifically patients requesting medicine for asthma), failure to provide this information now resulted in prescriptions not being issued.

As part of our inspection we also asked for CQC comment cards to be completed by patients prior to our inspection. We received 49 comment cards which were all positive about the standard of care received.

Our key findings were:

• The provider had a clear vision to deliver high quality care for patients.
• The provider had updated their online website so that it verified patients’ identity.
• The clinical records relating to the online service now had facilities that enabled an audit trail.
• The provider had updated the questionnaire used to obtain patient information for the online service.
• The service shared information about treatment with the patient’s own GP with their consent, for example, the provider’s online service would only prescribe medicines for asthma if the patient had provided their GP details.
• There were systems and processes in place for reporting and recording significant events and sharing lessons to make sure action could be taken to improve safety in the practice.
• The service had clearly defined systems, processes and practices to minimise risks to patient safety.
• Staff had the skills and knowledge to deliver effective care and treatment.
• Staff sought and recorded patients’ consent to care and treatment in line with legislation and guidance.
• The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management.
• The service had systems in place to collect and analyse feedback from patients.

There were areas where the provider could make improvements and should:

• Review how patients with hearing impairments and whose first language is not English are supported.
• Review online patient questionnaires and patient ID checking to ensure they continue to follow best guidance.
• Review quality improvement initiatives which may include completed clinical audits.
• Review the arrangements for treating emergencies following a risk assessment.

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at Freedomhealth Ltd on 23 August 2017. We found this service had made significant improvement however there were some areas where the service was not able to demonstrate it could provide safe and well led services in accordance with the relevant regulations.

Prior to our inspection on 3 May 2017, Freedomhealth Limited offered a digital service that allows patients to obtain a prescription and obtain medicines from an affiliated pharmacy. Freedomhealth Limited also provides private general practice, specialist sexual health services and cosmetic treatments, however, this inspection focused on the digital service.

Following our inspection of the service on 3 May 2017 we imposed a condition on the provider's registration to prevent the provider from providing any Digital and Online Services to patients which fall within the scope of the regulated activity: Treatment of disease, disorder or injury.

This follow up visit was carried out to determine if the provider had taken action to address the non-compliance. We found the provider had put systems and processes into place which indicated that in most areas it could provide safe, effective responsive and well led services in accordance with the relevant regulations.

Our key findings were:

• There were improved systems in place to protect patient information and ensure records were stored securely.
• New software was being put into place to improve patient identity checks, however this was not yet operational.
• Patient questionnaires had been expanded and the request for consent to contact the patient’s own GP to inform them of the treatment they were receiving had been strengthened and had been brought into line with GMC guidance.
• There was a complaints policy which provided staff with information about handling formal and informal complaints from patients. Staff told us that all verbal complaints would now be logged in accordance with that policy.
• Systems and processes to govern activity had been reviewed and improved.
• Measures were being put into place to improve the quality of patient records and to deliver care and treatment in accordance with evidenced based national guidelines and standards however these systems were not yet complete.
• A programme of clinical audits was planned.
• Prescribing processes and systems had been reviewed and revised however there remained some discrepancy between the list of medicines sent to us by the provider and those included on the patient questionnaires.
• There was now a business continuity plan in place which considered how the service would continue if there were any adverse events, such as IT failure or building damage.

We identified regulations that were not being met and the provider must:

• Introduce appropriate measures to ensure patient records are complete and accurate and that care and treatment is delivered in accordance with evidence based guidelines.

In addition, the provider should:

• Ensure the new software will provide adequate patient identity checks, and is in line with current guidance.
• Ensure the list of medicines that can be prescribed is in accordance with medicines detailed in the patient questionnaires.

You can see full details of the regulations not being met at the end of this report.

Following the significant improvements the provider has made, we have now removed the condition which we imposed on the provider’s registration following our inspection of the service in May 2017.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Freedom Health Limited on 3 May 2017. Freedom Health Limited offers a digital service that allows patients to obtain a prescription and obtain medicines from an affiliated pharmacy. Freedom Health Limited also provides private general practice, specialist sexual health services and cosmetic treatments, however, this inspection focused on the digital service.

We found this service did not provide safe, effective, responsive and well led services in accordance with the relevant regulations. However, they were providing a caring service.

Our key findings were:

• There were no systems in place to protect patient information and ensure records were stored securely.
• On registering with the service, patient identity checks were limited; other than via a credit/debit card check. The provider could not be sure they were consulting with the person who owned the card.
• There were enough GPs to meet the demand of the service and appropriate recruitment checks for all staff were in place.
• We found that assessments of patient needs and care were not being delivered in line with relevant and current evidence based national guidance and standards.
• The service did not have arrangements in place to coordinate care and share information appropriately for example, when patients were referred to other services.
• There was a complaints policy which provided staff with information about handling formal and informal complaints from patients. Verbal complaints had not been recorded or used to analyse trends and to inform learning.
• The provider told us they had a clear vision to provide an accessible and responsive service. However, our inspection found that systems and processes to govern activity were not always effective.
• There was no business continuity plan to consider how the service would continue if there were any adverse events, such as IT failure or building damage.
• Practice policies were available but not all were followed.
• The provider engaged fully with the inspection process and was keen to implement changes to mitigate the risks highlighted.

We identified regulations that were not being met. The areas where the provider must make improvements are:

• Ensure there are robust governance arrangements in place to identify, assess and monitor risks and the quality of the service.
• Ensure that identity of a patient is confirmed.
• Ensure that information provided by the patient is fully assessed.
• Ensure that care and treatment is delivered in accordance of evidence based guidelines.
• Ensure that practice policies are in place and followed by staff.
• Ensure there is a programme in place of quality improvement.
• Ensure that patient records are complete and accurate and information is shared with a patient’s GP in accordance with General Medical Council (GMC) guidance.
• Ensure all complaints are logged and responded to in accordance with the provider policy.

The areas where the provider should make improvements are:

• Consider documenting team meetings to ensure improved record keeping and evidence learning significant events.

Summary of any enforcement action

We are now taking further action in relation to this provider and will report on this when it is completed.

Following our inspection of the service we imposed a condition on the provider's registration to prevent the provider from providing any Digital and Online Services to patients which fall within the scope of the regulated activity: Treatment of disease, disorder or injury.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During this unannounced, scheduled inspection, we spoke to staff, looked at records, policies and procedures and toured the building.

People were supported to understand the care they received and were able to express their views and choices. On this inspection, we were unable to speak to people who use the service. However, quality assurance and feedback we saw showed that people were happy with their consultations and the quality of care and treatment they received. There were proactive systems in place to protect people’s privacy.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare and everyone had individual treatment plans based on their needs and wishes.

People were kept safe from the risk of abuse through safe practices, policies and procedures. Staff understood the nature and potential for abuse and were trained to report concerns if they had them. There were no safeguarding concerns at the time of our visit and clinical risks were professionally managed.

Staff were properly trained and supported in their roles and the provider had systems in place to monitor the quality of the service.

On this occasion we did not speak to people about this service as there were no patients available to talk to on the day of the inspection.