Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Nationwide Pharmacies LTD on 6 February 2017. We found this service was not providing safe, effective, caring, responsive or well led services in accordance with the relevant regulations. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for Nationwide Pharmacies LTD on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 27 June 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the warning notices issued following our previous inspection on 6 February 2017. This report covers our findings in relation to the enforcement action we took.

We found this service had not met all the requirements as outlined within the warning notices issued specifically;

• The provider was unable to demonstrate that opioids (a potentially highly addictive medicine) was being safely managed as systems were in there infancy.
• The provider was unable to demonstrate how they had shared information with patient’s GPs with their consent.
• The provider and GP were unable to demonstrate quality improvements.

Nationwide Pharmacies LTD provides an online GP consultation and medicines ordering service. Patients register for the service on the provider’s website, select the medicines they require, complete an online consultation form which is reviewed by a GP, and if approved, the affiliated pharmacy (which we do not regulate) sends the medicines to the patient.

Our key findings were:

• The service had systems to keep people safe however these had not yet all been fully embedded.
• The service had systems to keep people safeguarded from abuse.
• There was a comprehensive system in place to check the patient’s identity.
• There were systems in place to mitigate safety risks including taking action as a result of significant events.
• There were appropriate recruitment checks in place for all staff.
• Systems had been introduced to monitor prescribing practices and to prevent any misuse of the service by patients.
• There were some systems in place to ensure staff had the information they needed to deliver safe care and treatment to patients.
• The service learned and made improvements when things went wrong. The provider was aware of and complied with the requirements of the Duty of Candour.
• Patients were treated in line with best practice guidance and appropriate medical records were maintained.
• An induction programme was in place for all staff and staff, including clinicians had access to all policies.
• The service had a policy to share information about treatment with the patient’s own GP, but were unable to evidence where this had been followed.

The areas where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

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 Nationwide Pharmacies Ltd on 6 February 2017.

Nationwide Pharmacies Ltd provides an online GP consultation and medicines ordering service. Patients register for the service on the provider’s website, select the medicines they require, complete an online consultation form which is reviewed by a GP, and if approved, the affiliated pharmacy (which we do not regulate) sends the medicines to the patient by secure post.

We found this service was not providing safe, effective, caring, responsive and well-led services in accordance with the relevant regulations.

Our key findings were:

• Staff we spoke with were aware of the organisational ethos and philosophy and told us they felt well supported and that they could raise any concerns.
• There was a clear business strategy and plan.
• Prescribing was not routinely monitored to prevent any misuse of the service by patients and to ensure GPs were prescribing appropriately. We found patients being prescribed large quantities of medicines for erectile dysfunction and painkillers but there was a lack of monitoring or follow up for these patients.
• When prescribing was found to be inappropriate, there was no evidence that actions were taken to prevent re-occurrence or that learning was disseminated.
• There were no systems to mitigate safety risks including analysing and learning from significant events.
• Medical records were maintained, however recording was not always adequate. For example, medical records did not show any evidence of clinical diagnoses being made or how care and treatment had been determined.
• There were no systems to ensure that emergency services could be directed to the patient in the event of a medical emergency during a consultation.
• Appropriate recruitment checks had not been conducted for staff recruited from an agency. There was a lack of systems to ensure that staff recruitment information and relevant checks were maintained.
• There was no formal induction programme for newly employed staff.
• There was a lack of policies and procedures to govern activity such as incident reporting and safeguarding adult and children.
• Staff had not received training in all areas needed to ensure they could carry out their role such as the Mental Capacity Act 2005, health and safety, safeguarding children and adults, information governance and fire safety training.
• Patients were not always treated in line with clinical best practice guidance.
• There were limited systems in order to verify a patient’s identity.
• There was a lack of systems and processes in order to assess, monitor and improve the quality and safety of the services provided.
• The service encouraged and acted on feedback from both patients and staff. However, there was no formal process to record, manage and monitor feedback obtained.
• The provider was aware of the requirements of the duty of candour. However, systems were not established to ensure compliance with the duty of candour.
• Patients were not able to access enough information about the GP available.
• The systems to protect personal information about patients were not always adequate. For example, email accounts were not encrypted in order to ensure security of emails sent and received. The company registered with the Information Commissioner’s Office during our inspection visit.
• Information for patients about services and how to complain was available. However, a formal complaints process for staff had not been adequately established.

The areas where the provider must make improvements are:

• Ensure that information about safety is used to promote learning and improvement by introducing formal arrangements for monitoring safety, significant events, incidents and concerns.
• Ensure the safe and proper use management of medicines in line with evidence based and national guidance and/or best practice.
• Ensure systems and processes are established and implemented in order that care and treatment is provided in a safe way.
• Ensure patient records relating to care and treatment are accurate, complete and contemporaneous, and include a record of the care, treatment and decisions taken.
• Ensure systems and processes are implemented in order to take appropriate action if there is a clinical or medical emergency.
• Ensure care and treatment is provided with the consent of the relevant person and that policies and procedures implemented reflect current legislation and guidance.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure that staff employed by the service receive appropriate support, training, professional development, supervision and appraisals; as are necessary to enable them to carry out the duties.
• Ensure that systems and processes are implemented for the purpose of identifying, receiving recording, handling and responding to complaints.
• Ensure that processes and procedures are implemented in order to assess, monitor and improve the quality and safety of services provided.
• Ensure that processes and procedures are implemented in order to assess, monitor and mitigate the risks relating to the health, safety and welfare of staff and service users.
• Ensure that systems and processes are implemented in order to promote a culture that encourages candour, openness and honesty at all levels.

We have issued Warning Notices requiring the provider to take action to improve its services by 28 March 2017. Further details are shown in the table at the end of this report.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Nationwide Pharmacies provides an online treatment service for a variety conditions such as erectile dysfunction, weight loss and anti-malaria treatment. Due to the nature of the service and the desire for most patients to remain anonymous it was not possible to speak to people about their experiences.

The service had policies and procedures for safeguarding children but not adults. Staff said they had received training in safeguarding children only.

The service obtained expert professional advice from a doctor and a pharmacist. Staff said they were well supported in their roles.

Letter from the Chief Inspector of General Practice

We rated this provider as Good overall. 

There had been three previous inspections of this provider in February 2017, June 2017 and April 2018. The inspection in April 2018 highlighted the provider was working in accordance with the relevant regulations.

The inspection reports for the previous inspections can be found by selecting the ‘all services’ link for Nationwide Pharmacies LTD on our website at .

The key questions are rated as:

• Are providers safe? – Requires improvement
• Are providers effective? – Good
• Are providers caring? – Good
• Are providers responsive? – Good
• Are providers well-led? – Good

We carried out an announced comprehensive inspection at Nationwide Pharmacies LTD, an online GP consultation and prescribing provider located in Buckinghamshire on 30 April 2019. This inspection was part of the digital and online providers inspection programme to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Patients register for the provider on the provider’s website, select the medicines they require, complete an online consultation form which is reviewed by a GP, and if approved, the affiliated pharmacy (which we do not regulate) sends the medicines to the patient.

At this inspection we found:

• The provider had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the provider learned from them and improved their processes.

• Patient identity checks were not fully effective in particular for patients being prescribed medicines liable to abuse, overuse or misuse or medicines that require ongoing monitoring or management.

• The provider reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

• The provider prescribed medicines to treat asthma and Class 4 and 5 controlled opiate medicines such as codeine and dihydrocodeine. The records we reviewed did not detail a rationale for prescribing these medicines without consent to contact and share information with the patient’s GP.

• All patient data was encrypted and securely stored.

• Staff involved and treated people with compassion, kindness, dignity and respect. Patient feedback from a variety of different sources highlighted high levels of satisfaction.

• Patients could access care and treatment from the provider within an appropriate timescale for their needs.

• Information about the provider and how to raise concerns and complaints was available.

• There was a strong focus on innovation, continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report).

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Providers and Integrated Care