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Care UK – Wycombe Minor Injuries and Illness Unit Requires improvement

We are carrying out checks at Care UK – Wycombe Minor Injuries and Illness Unit using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Care UK-Bucks Out of Hours (OOH) service and the Minor Injuries and Illness Unit (MIIU) at Wycombe General Hospital on 13 December 2016. The out of hours service operates from a single call centre and headquarters in Aylesbury. The MIIU operates from the Wycombe General Hospital. Overall the service is rated as requires improvement.

Specifically, we found the service to require improvement for the provision of safe and well led services. The service is rated good for providing effective, caring and responsive services.

Our key findings across all the areas we inspected were as follows:

  • There was an effective system for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • The provider had systems in place to identify, assess and manage risk but the systems were operated inconsistently. Some risks associated with the process of initial assessment (of walk-in patients) carried out by a reception staff at the MIIU had not been managed effectively. The patient who was assessed as a ‘routine’ by a reception staff could wait up to four hours before a first contact with a clinician.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. The National Quality Requirements (NQRs) standards for the OOH service and the Key Performance Indicators for the MIIU service were monitored and reviewed to ensure that if any improvements were required they would be identified and implemented’

  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, the provider did not have a systematic approach to assure themselves that all GPs not directly employed by the Care UK had completed training relevant to their role and that sub-contracted staff covering the minor injuries service had completed mandatory training and had regular appraisals.
  • There were safeguarding systems in place for both children and adults at risk of harm or abuse as well as palliative care (care for the terminally ill and their families) patients who accessed the service.
  • There was a system in place that enabled staff at the out of hours service to access patient records, for example the local GP and hospital, with information following contact with patients as was appropriate.
  • The service proactively sought feedback from staff and patients, which it acted on.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The service worked proactively with other organisations and providers to develop services that supported alternatives to hospital admission where appropriate and improved the patient experience.
  • The service had good facilities and was well equipped to treat patients and meet their needs. The vehicles used for home visits were clean and well equipped.
  • The service managed patients’ care and treatment in a timely way.
  • Information about services and how to complain was available at the out of hours centres. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was a clear leadership structure. Communication channels were open and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Respond to and mitigate the risk associated with the process of initial assessment, carried out by a receptionist and first patient contact with clinicians to ensure that patients are accessing the appropriate service, transferred in a timely fashion to alternative services and to mitigate unnecessary risk associated with waiting times.
  • The provider must review, assess and monitor the governance arrangements in place to ensure and improve the quality and safety of the services provided.
  • Ensure all GPs not directly employed by the Care UK had completed training relevant to their role and that sub-contracted staff covering the minor injuries service had completed mandatory training and had regular appraisals.

The areas where the service should make improvements are:

  • The provider should make sure that prescribers follow the prescribing policies for recording the supply of medicines.
  • Review and improve the national quality standards relevant to the face to face consultations both at an out of hours base and at patients place of residence within two hours of assessment for those patients classified as ‘urgent’.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 20 April 2017

The provider is rated as requires improvement for providing safe services.

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not always effectively implemented to ensure patients were kept safe. For example, in the Minor Injuries and Illness Unit the provider had not fully reviewed the risks associated with the process of initial assessment and first patient contact with clinicians to ensure that patients are accessing the appropriate service, transferred in a timely fashion to alternative services and to mitigate unnecessary risk associated with waiting times.
  • The prescribers did not always follow their own prescribing policies in relation to high risk medicines.
  • The provider had a comprehensive process for checking out of hours vehicles and medicines and equipment were checked and we saw evidence of this. Emergency equipment on site was managed by the NHS trust and the service could report when they had used anything.
  • There was an effective system in place for recording, reporting and learning from significant events and lessons were shared to make sure action was taken to improve safety in the service.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The service had clearly defined processes and practices in place to keep people safe and safeguarded from abuse.
  • When patients could not be contacted at the time of their home visit or if they did not attend for their appointment, there were processes in place to follow up patients who were potentially vulnerable.
  • There were systems in place to support staff undertaking home visits.

Effective

Good

Updated 20 April 2017

The provider is rated as good for providing effective services.

  • Data showed the National Quality Requirements (performance standards) for GP out of hours services and Key Performance Indicators for the Minor Injuries and Illness Unit were monitored and reviewed and improvements implemented to ensure patient needs were met in a timely way. For example, data from November 2015 to October 2016 showed that 100% of patients defined as in need of ‘urgent’ face to face assessment had been assessed within 20 minutes.
  • However, the provider was required to further review and improve face to face consultations within two hours after the definitive clinical assessment for those patients classified as ‘urgent’.
  • The minor injuries and illness unit data showed that they were performing above targets. For example 99% of patients classified as routine were seen within four hours.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. There was a consistent focus on ensuring staff had completed mandatory training. There were appraisals and personal development plans for staff.
  • There was an effective system to ensure timely sharing of patient information with the relevant support service identified for the patient and their GP.

Caring

Good

Updated 20 April 2017

The provider is rated as good for providing caring services.

  • Feedback from patients about their care and treatment through our comment cards and collected by the provider was very positive. Patients were positive about their experience and said they found the staff friendly, caring and responded to their needs. Some patients felt that the wait to be seen at the Minor Injuries and Illness Unit was too long, however, there was no evidence that the wait was over the recommended four hours.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • Patients were kept informed with regard to their care and treatment throughout their visit to the service.
  • The provider was mindful and respectful of the needs of patients, and their carers, receiving end of life care and, where necessary, provided them with a direct telephone number so that they were able to access clinician’s out-of-hours directly.

Responsive

Good

Updated 20 April 2017

The provider is rated as good for providing responsive services.

  • The service engaged with the NHS England Area Team and local clinical commissioning groups to secure improvements to services where these were identified.
  • The service had systems in place to ensure patients received care and treatment in a timely way and according to the urgency of need. However, the pathways used to assess patients who attended the Minor Injuries and Illness Unit were not always fit for purpose. The reception staff using the pathways had not had clinical training in how to use them and they were not always used appropriately.
  • The service had good facilities and mobile vehicles were well equipped to treat patients and meet their needs.
  • Information about how to complain was available at High Wycombe hospital base and easy to understand. Evidence showed the service responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Requires improvement

Updated 20 April 2017

The provider is rated as requires improvement for providing well led services.

  • There was a governance framework which supported the delivery of the strategy and good quality care. However, monitoring processes were ineffective. The provider failed to identify the areas of concern we found during this inspection. For example, the lack of training for staff undertaking initial triage and prescribers did not always follow the organisations prescribing policy.
  • Governance procedures did not ensure that reception staff were offered appropriate training and monitoring of their work in order for them to safely and appropriately carry out assessments of need. Reception staff were not given any formal clinical training in using the assessment pathway and there was no evidence of an audit of their work being undertaken, to ensure that they were performing to the correct level.
  • The provider had not assured that all GPs not directly employed by the Care UK had completed training relevant to their role including safeguarding children, safeguarding adults and basic life support. They had not ensured that a system was in place to identify when sub-contracted staff at the minor injuries unit had undertaken regular mandatory training and had a regular appraisal.
  • The service had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. This was evident at local level and senior level. Staff were always able to contact senior managers and who were visible across the service.
  • The service proactively sought feedback from staff and patients, which it acted on.
  • The service complied with the requirements of the duty of candour and encouraged a culture of openness and honesty.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. The service was seeking innovative approaches to accessing relevant patient information in conjunction with other providers, through the use of a system called the Medical Interoperability Gateway (MIG) which provided wider access to records.
  • The service was involved with and developing services to improve health outcomes in Buckinghamshire and to relive the pressure on other health services.