Practice Plus Group - Devon OOH/CAS

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in their care and treatment.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. The provider had processes for staff to report incidents, near misses and safety events. These included timescales for completing investigations and sharing of learning.

The process for Patient Safety Investigations as a result of significant events included holding a patient safety conference within 48 hours and ensuring people who use the services and other relevant people were included in these conferences. A central team from the wider organisation carried out audits and identified areas of good practice and improvements. This was shared across all the service’s where the provider was registered to provide regulated activities.

Significant events were discussed at monthly and quarterly meetings. There was a system to monitor events this included undertaking an investigation, led by the Patient Safety Manager and the Quality and Patient Experience Manager, into the cause and actions identified to address the concerns. The service had a system for the auditing of systems and processes that included monthly quality assurance meetings to identify themes and trends.

Where significant events were deemed to be patient safety incidents, these were reviewed by a panel consisting of the Deputy National Medical Director, CQC Registered Managers, Medical and Clinical Leads, Patient Safety Manager and Quality and Patient Experience Manager. When needed the provider liaised with external services.

End-to-end reviews of patient experience with these other stakeholders took place so improvements could be made. Managers and relevant staff attended bi-monthly risk meetings to monitor progress on investigations and actions that had been taken. When needed an apology was provided in line with Duty of Candour.

For the period of November 2024 to October 2025 a total of 232 incidents were recorded for the out of hours service. Examples included a person who collapsed on arrival at the out of hours centre and required an emergency ambulance to be called and needed hospital admission. The investigation into the incident highlighted that sepsis had not been considered as a differential diagnosis. As a result of the incident all clinicians were reminded about being aware of the signs and symptoms of sepsis and the need to consider these when assessing a person’s condition. (A differential diagnosis is a systematic, step-by-step process clinicians use to distinguish a specific disease from others that present with similar symptoms. It involves creating a list of potential conditions, then using tests and physical exams to rule them out until the most likely cause is identified.)

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People accessed the out of hours (OOH) service via the NHS 111 service. People were seen by a clinician at one of the primary care centres; or received a home visit; or a telephone or video consultation depending on their assessed needs. There were timeframes for people to be seen or contacted by a clinician which were monitored. If there was a delay to a person receiving contact by telephone/video call or a home visit was delayed, comfort calls were made to check for worsening symptoms, and if necessary, the appointment was re-prioritised so that the person would be seen more quickly. When needed people were signposted to other service such as AE.

There were patient safety calling tabs on the system to show when cases would breach the timeframe for a visit or call back to take place. Patient safety calls would be made to inform people of the delay; to check on their symptoms; and provide advice should their condition become worse. In the event of high demand, a care coordinator would review home visits and undertake patient safety calls. Drivers of the OOH cars would call people ahead of time to inform them of an approximate arrival time and ask if there were any special instructions to get to their home.

People received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for people in vulnerable circumstances was coordinated with other services, for example GPs liaised with the community nursing and urgent community care teams to provide additional support where needed.

Staff communicated promptly with a person’s registered GP, so they were aware of the need for further action. Staff also referred people back to their own GP to ensure continuity of care. An electronic record of all consultations was sent to a person’s own GPs which operation managers checked had been read and actioned by the receiving service.

There were clear and effective arrangements for booking appointments and transfers to other services. The service maintained safe pathways by promptly identifying deteriorating individuals and effectively coordinating with SWAST for urgent ambulance dispatch.

Issues with the Directory of Services (A Devon-wide resource that all staff could use to signpost people to other services, for example pharmacies that were open in the out of hours periods) were resolved in a timely manner.

If there were failures with the telephone system a back-up system was available to ensure calls could still be made.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies set out definitions of abuse; what actions should be taken and what training staff should receive. Policies and procedures were known to staff. Training records showed all staff had received safeguarding training at an appropriate level to their role.

Quarterly meetings were held with the safeguarding leads for the service and the Integrated Care Board (ICB) nurses (ICBs are NHS organisations responsible for planning, commissioning, and managing local NHS budgets and services). When needed additional meetings were set up depending on concerns received.

The service also held internal safeguarding meetings with the wider Practice Plus Group to share learning and review safeguarding cases.

A report was produced for executive leaders, on a quarterly basis which formed part of the executive board report, and this included findings from the safeguarding audits.

Agreements with other services were in place to share information of concern related to children. Alerts were placed on records of children who were vulnerable, which the service could see when providing advice.

Staff were provided with support if they had to make a referral and needed time to de-brief following what may have been a difficult or distressing case to manage.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were advised on risks related to their condition and actions to take if their condition deteriorated.

People who were waiting for a clinical callback were placed in a queue which was monitored; if the timeframe was due to elapse, then a patient safety call would be made. This was to inform the person that there was a delay and to check whether their symptoms worsened. If needed the timeframe could be adjusted so they would be contacted by a clinician sooner. A blended model was used for patient safety calling. This consisted of a text message at the point of calling and a further text message based on a set of guidelines for when timeframes were about to be breached. If a person lived alone, they would always receive a callback and not a text message.

The service monitored the number of patient safety calls made and used this information to support planning staff rotas.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We visited 4 bases as part of the inspection. All bases were visibly clean and tidy. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan which was monitored and reviewed.

There were arrangements for safe evacuation in the event of a fire. At the main base, fire wardens would hang their tabard over the back of their chairs, so other staff could easily identify them. Routine fire alarm testing was carried out weekly.

There was a first aid kit and defibrillator on site which were routinely checked to ensure there was sufficient stock and the defibrillator was working.

Staff were provided with adaptations to their workstations if needed.

There was a policy on lone working and the main entrance to the building was locked at night and only accessible by using a keycode. CCTV had been installed to cover the main entrance and car parking areas, which were also lit to promote safety. Access to the main base was by use of a fob at all times and visitors would be greeted by a member of staff.

Bases were accessible for people with mobility needs and hearing loops were available to use. Information on chaperones and providing feedback was seen. When needed, access was controlled with the use of entry systems and reception staff were able to see people who were waiting to be seen and knew what actions to take should someone’s condition deteriorate and they required immediate attention.

All base sites used had emergency equipment which was regularly checked and maintained. Checks we made and records we saw confirmed this.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had a system and process for forecasting staffing needs for the year ahead. This was based on staffing levels and number of calls received the previous year. The system had capacity to identify gaps and build in resilience. For example, when employees left and the loss of their working pattern/rotation might impact the forecast.

The planning team (responsible for the forecast) linked in with the recruitment team, to establish the baseline for recruitment for the year ahead. This included how many staff were already in post and how many would need to be recruited. Forecasting was under constant review, using long line, midline and short line methods (long line forecasts for the year, midline for a 6-8 week period and short line for a 2 week period). Extra hours were added to the forecast to allow for overtime and sickness. For example, if a week needed 100 hours, the service would forecast 125 hours, with the aim of achieving a full rota.

The planning and operation teams worked closely together to monitor demand and staffing. For example, on a daily, weekly, monthly and annual basis.

Safe recruitment practices were followed. We reviewed 5 recruitment files and evidenced that there were effective recruitment systems and processes, and staff had all the appropriate checks prior to being employed by the service. If a Disclosure and Barring Service check indicated concerns about potential new employees a risk assessment was carried out in line with the service’s policy. (Disclosure and Barring Service check enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work.)

Staff worked within their agreed areas of competence and were able to access appropriate learning and development opportunities. The services training team supported and promoted learning and skill development within the service, to ensure staff’s learning needs were met.

There were processes to ensure that staff were appropriately inducted according to their role. For example, pharmacy team, drivers, and reception staff tailored induction plans included topics such as the organisations Vision and Values and local policies / Standard Operating Procedures.

There were systems to routinely check that staff had completed mandatory training with the required timescales.

The system for monitoring the quality of work carried out by staff was effective. Information from the provider showed that all audits had been carried out as required. Audits were carried out on clinical consultations; medicines management; vehicle checks; and performance.

Clinicians work was audited on a regular basis, for someone who had newly started at the service 5 audits were carried out in their first month; then 3 in the following month, before they moved to 1% sampling monthly. A standard template was used and there was a scoring system, expectations were 90% to pass the audit. If an audit had not been passed, then feedback and further support would be provided and a further 3 random audits would be carried out for the next month. Clinicians were able to challenge decisions made on audits, which would be reviewed by the medical lead who was independent of the process. The medical lead would determine whether the audit had failed or not.

National audit meetings were carried out 3 times a year and there were 3 audit team meetings monthly, where cases and concerns were discussed. At the team meetings a telephone or case notes would be randomly audited and discussed.

Information received from the provider on 1% audits showed:

Audits had been completed, and feedback has been provided on those that failed. Themes identified where improvements were needed included obtaining past medical history from a person and discussions around current medicines people were on.

Staff who carried out audits had their work reviewed and compared, to ensure they were auditing cases in line with guidance and scoring was consistent. When needed further training and support was provided.

Out of hours drivers’ work was observed once a year and they were also surveyed on their knowledge, such as knowing who to contact for safeguarding or freedom to speak up.(Freedom to speak up is an initiative within the NHS and independent healthcare sector designed to ensure staff feel safe, supported, and confident to raise concerns about patient care or working conditions without fear of detriment.)

Patient safety calls were reviewed to ensure that information provided to people about delays included all necessary information. Areas for improvement included staff introducing themselves to a person and checking whether the next contact from the service would be from a clinician or not. When needed feedback was given and improvements were monitored through supervision sessions.

Staff told us of how they were supported to achieve career progression. All staff had protected time for professional development. They could use this time for completing mandatory training and build on or develop skills that benefited people’s care. Staff were encouraged to attend courses and share new skills and knowledge with the wider staff team.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks, for example routine checks were maintained on the water systems to ensure there was no sign of Legionella (a bacteria which can cause breathing problems).

All sites visited were visibly clean and tidy and checks on the environment had been made and recorded. There was personal protective equipment available, and arrangements were in place to manage clinical waste.

Medicines including controlled drugs, medical gases and prescriptions were stored securely across the service in buildings and vehicles. Temperature records in rooms indicated medicines were stored within their recommended temperature range and actions taken when temperatures were outside of this range. Emergency medicines and equipment to support deteriorating patients were accessible. Staff told us they were trained to dial 999 or the hospital crash team, when based on hospital sites with an Emergency Department, whilst administering basic life support.

Most medicines were pre-packed by an externally commissioned provider into containers described by the service as cassettes. We saw evidence that the shelf life of a medicine normally stored in a fridge but stored in a cassette at room temperature had been revised in line with the manufacturer’s guidance. Used cassettes with out-of-date medicines were returned to the pre-packing service for restocking on a regular basis. The provider told us the list of medicines and quantities held in each cassette had been determined nationally across the GP out of hours services they were commissioned to provide. Whilst the number of cassettes held was decided within each location based on the historic activity especially over bank holidays and other times of increased demand. A colour coded tagging system was used to identify cassettes that were un-opened, in-use or awaiting return.

Controlled drugs with additional storage, record and disposal requirements were securely stored, with appropriate records, licenses and certificates. At the previous inspection concerns were identified about the accessibility of a controlled drug. Since that inspection processes were revised and the concern resolved. Appropriate processes and records were held to monitor the use of prescriptions.

The service had recently introduced a home visiting service staffed by nurses and paramedics. They used the same vehicles and medicines cassettes as the GPs. These nurses and paramedics were working under Patient Group Directions and other written guidance when administering or supplying medicines from the cassettes to people. (Patient Group Directions are written, legal frameworks allowing registered healthcare professionals to supply or administer specific medicines to pre-defined patient groups without a direct prescription.)

The medical lead shared with us details of the service’s current medicines optimisation update session. The content of the session was based on the learning from complaints, incidents and audits, topics covered included the quality of handwritten prescriptions, appropriate use of anti-microbials and approaches used by people with drug seeking behaviours.