At our previous inspection of Anytime Medical Ltd (the provider), in April 2017, the service had been temporarily suspended by the provider as the single employed doctor had resigned and the inspection had therefore been limited in its scope. We found the service had been providing caring and responsive services in accordance with the relevant regulations. However, improvements were required in relation to providing safe, effective and well-led care and treatment. We served requirement notices under Regulations 12 and 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us a plan of the action it intended to take to meet the requirements of the regulations. The service started operating again in late May 2017, following the appointment of a new employed doctor.

We carried out this announced comprehensive inspection of the service on 7 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led? At this inspection we found that the provider had taken appropriate action to address the concerns we identified last year, but we found further issues, relating to safe prescribing. The service was providing effective, caring and responsive services. However, in some areas it was not providing safe or well-led services.

Our findings in relation to the key questions were as follows:

Are services safe? – We found some areas where the service was not providing a safe service in accordance with the relevant regulations. Specifically:

• We found three examples of prescriptions being issued to patients without the appropriate tests being done in accordance with established guidelines. The provider immediately suspended the relevant services and took remedial action, including revising patient questionnaires and arranging for relevant tests to be available to patients. The provider assured us that services would not be reinstated until the issues were fully reviewed by an external clinical assessor.
• Patients were given detailed information about any prescribed medicines, including any risks involved.
• Arrangements were in place to safeguard people, including arrangements to check patient identity. Appropriate safeguarding training had been provided since our last inspection.
• Suitable numbers of staff were employed and appropriately recruited.
• The provider had introduced systems to act upon relevant guidance and safety alerts.

Are services effective? - We found the service was providing an effective service in accordance with the relevant regulations. Specifically:

• We saw evidence of clinical discussions, including reviews of prescribing practice and relevant clinical guidelines.
• Quality improvement activity, including clinical audit had been introduced, but there was scope for this to be improved.
• Staff received the appropriate training to carry out their roles.

Are services caring? – We found the service was providing a caring service in accordance with the relevant regulations. Specifically:

• The provider carried out checks to ensure consultations by GPs met the expected service standards.
• Patient feedback reflected that they found the service treated them with dignity and respect.
• Patients had access to information about clinicians working at the service.

Are services responsive? - We found the service was providing a responsive service in accordance with the relevant regulations. Specifically:

• Information about how to access the service was clear.
• The provider did not discriminate against any client group.
• Information about how to complain was available and complaints were handled appropriately.
• Where the need for improvement had been identified, the provider was taking steps to address the concerns.

Are services well-led? - We found some areas where the service was not providing a well-led service in accordance with the relevant regulations. Specifically:

• Although a system of clinical auditing had been introduced since our previous inspection, we found examples of prescribing without appropriate tests being carried out beforehand. The provider immediately instigated an action plan to address this, which included increasing the frequency and scope of the auditing.
• The service had clear leadership and governance structures.
• Patient information was held securely.

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

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

The areas where the provider should make improvements are:

• Review the frequency and scope of clinical audits.
• Review the arrangements for providing appropriate healthcare advice to female patients.

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

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 Anytime Medical Limited on 25 April 2017.

Anytime Medical Limited operates under the trading name of Anytime Doctor which provides on-line medical services from one website: www.anytimedoctor.co.uk. The website offers prescribing services for several treatment areas and testing kits for sexually transmitted diseases.

The inspection was carried out through discussion with the provider only as no staff were employed by the company at that time. The sole clinical member of staff employed had decided to stop working for the service the day prior to our inspection. This meant the provider was not actively operating on the day of our inspection.

We found this service was providing caring and responsive services in accordance with the relevant regulations. However, improvements were required in relation to providing safe, effective and well led care and treatment.

Our key findings across all the areas we inspected were:

• There was a system in place to check the patient’s identity but this did not include photographic identity checks.
• There were systems in place to mitigate safety risks arising from incidents and complaints, including analysis and learning.
• A safeguarding policy was available but there was no appropriately trained safeguarding lead identified.
• The recruitment procedure included appropriate recruitment checks for clinical staff employed by the service. However, from the records we viewed of previously contracted staff we saw insufficient evidence that checks had been undertaken to ensure they had adequate training and qualifications to carry out their role or that that they had received appropriate appraisal for their on-line prescribing activities.
• There was insufficient monitoring of prescribing to prevent patients accessing inappropriate or unsafe treatment or to ensure clinicians were prescribing appropriately.
• There were some systems to ensure staff had the information they needed to deliver safe care and treatment to patients. However, these systems did not ensure actions were identified, implemented and recorded following best practice updates such as those provided by the National Institute for Health and Care Excellence (NICE) and safety alerts such as those provided by the Medicines and Healthcare Products Regulatory Agency (MHRA).
• 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 not always prescribed treatment in line with best practice guidance. We saw evidence of prescribing for asthma which was not in line with current guidelines.
• Medical records we reviewed were maintained to an appropriate standard.
• The service did not have a programme of ongoing quality improvement activity embedded in their clinical governance system.
• The provider had an induction procedure in place to be carried out prior to the doctor treating patients.
• The provider informed us that staff had access to all policies.
• The service offered the option of sharing information about their treatment with the patient’s own GP but the provider had not made this a mandatory requirement even when treating long-term conditions which required monitoring. However, the provider took appropriate action to address this following the inspection.
• Survey information we reviewed showed that patients were satisfied with the service they received.
• Information about how to complain was available and improvements were made to the service as a result of complaints.
• There was a clear business strategy and plans in place.
• There were insufficient clinical governance systems and processes in place to ensure the quality of service provision.
• The service encouraged and acted on feedback from both patients and staff.
• Systems were in place to protect personal information about patients. The company was registered with the Information Commissioner’s Office.

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

Care and treatment was not being provided in a safe way for service users.

• The provider did not have an effective procedure to ensure safety alerts, such as those provided by the Medicines and Healthcare Products Regulatory Agency (MHRA), were reviewed by a clinician; acted on if necessary and records kept of actions taken.

• The provider did not have a safeguarding lead in place with appropriate training.

Systems and processes were not established and operated effectively to ensure compliance.

• The provider did not have an effective clinical quality improvement programme in place which included clinical audit and monitoring of prescribing against current prescribing guidance and evidence based practice.
• The provider had not ensured that staff management procedures included confirmation that clinical staff had adequate training and qualifications to carry out their role and that appropriate appraisal of their on-line prescribing activities had been undertaken.

The areas where the provider should make improvements are:

• The provider should ensure there are arrangements in place to retain and access medical records for the required period of time following the cessation of trading.
• The provider should consider implementing contingency plans to cover the absence of the Registered Manager or prescribing doctor.
• The provider should consider implementing a follow-up procedure when informing patients of positive results following Sexually Transmitted Disease testing to ensure results are accessed by patients.

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

Summary of any enforcement action already taken

Following our inspection on 25 April 2017. We identified significant risks related to a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (1) Safe care and treatment. We therefore took urgent enforcement action to impose conditions under s31 of Health and Social Care Act. The urgent condition was to ensure that any service user seeking medical attention from Anytime Medical for long term conditions such as asthma, diabetes or hypertension must do so with the express permission to divulge this information to the service users’ GP. Where providers are not meeting required standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use services. When we took this action, our decision was subject to an appeal by the provider.

Anytime Medical confirmed they had implemented the condition to make the service safe. The CQC will follow this up with another inspection to ensure we are satisfied that the provider has taken the necessary action to mitigate CQC’s concerns.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice