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NEMS GP Out of Hours Service Good

Inspection Summary


Overall summary & rating

Good

Updated 14 December 2018

This service is rated as Good overall. (Previous inspection November 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services well-led? – Good

We carried out an unannounced focused inspection at NEMS GP Out of Hours Service 11 October 2018. We carried out this inspection in response to concerns, we looked at safe and well led during our inspection. As part of this inspection, we also inspected the provider’s headquarters (NEMS Community Benefit Services Limited) based in Fanum House, Nottingham on 18 October 2018, this visit was announced. The ratings for safe and well led have not changed since our last inspection in November 2015.

At this inspection we found:

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs. Processes were in place to identify patients that needed more urgent attention.
  • The service was aware of some of the challenges to deliver quality care and was taking action to address them.
  • This was an unannounced inspection therefore, we were unable to receive feedback from patients during the inspection. However, patient feedback received by the service demonstrated that staff involved and treated people with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The provider demonstrated effective joint working arrangements with key partners to develop-coordinated care.

The areas where the provider should make improvements are:

  • Develop the staff induction programme to include site specific induction.
  • Ensure oversight of all safety systems and processes on the site including oversight of infection control documentation, daily vehicle and medical equipment checks and the processes in place for the security of blank prescriptions.
  • Encourage all staff throughout the service to report incidents and significant events when they occur.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Good

Updated 14 December 2018

We rated the service as good for providing safe services

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The service was located in a purpose-built centre in central Nottingham, the premises looked spacious and was visibly clean and tidy, however, staff members on duty were unable to provide evidence of infection control audits or action plans carried out at the time of our visit.
  • The provider conducted some safety risk assessments. During our visit to the headquarters, we observed various policies in place which included safety policies which were in place for NEMS GP Out of Hours service.
  • The service employed drivers for various functions. As part of their role, drives maintained their vehicles by ensuring brake fluids were topped up and we saw COSHH sheets for these were available.
  • We looked at two vehicles used by the service and found these to be visibly clean and contained relevant medical supplies and emergency equipment for use during patient visits. We were informed a service contract was in place for the maintenance of the vehicles. However, we found a minimal amount of medical consumable items in one of the vehicles that were out of date, we informed the provider and we were informed that these items would be replaced immediately. We saw records that checks were carried out on a regular basis of these medical supplies and equipment and records were held in the vehicles.
  • Health & safety policies were available and there was evidence that risks had been considered. However, we observed that daily, observational vehicle checks were not documented. Staff we spoke with during our inspection also confirmed this. Staff received safety information from the provider as part of their induction and refresher training. Staff we spoke with told us about driver training they had been provided with as part of their induction process and spoke positively about this.
  • The provider had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. For example, we saw evidence of special notes and alerts on the system designed to inform staff and forward any concerns to other organisations. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There were effective systems in place to assure the provider all clinicians and nursing staff had current registration with their respective professional body. There was a system to ensure that GPs were unable to book or complete sessions if their professional indemnity was not current.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

Ris

ks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. We looked at various staff rotas during our inspection to assess the level of cover. We were informed that driver cover was shared across three sites, NEMS GP Out of Hours, PC24 at Kings Mill Hospital and a satellite location in Newark to ensure an appropriate level of driver shift cover was always maintained in case of low staff levels at any one of the locations.
  • There was an effective system in place for dealing with surges in demand. Some staff we spoke with during our inspection told us that at times they felt staff cover was low, in particular, in relation to nurse cover however, other staff members we spoke with told us that staff levels were adequate and that if nurse cover was lower than usual, gaps would be filled with a GP rather than a nurse. Other clinicians we spoke with told us that they did not feel that staff levels were unsafe.
  • The provider had reviewed previous demand in peak periods such as Christmas and Easter and extrapolated the future requirements to ensure demand was met. A decision had been made to meet the additional demand solely with GPs to ensure all areas of business were covered.
  • There was an induction system for both employed and temporary staff tailored to their role. However, where GPs worked across different locations there was no assurance that they received an induction for all sites. We highlighted this to the provider when we visited the headquarters who gave assurance that they would put in place a system whereby the clinical team co-ordinator at each site would have responsibility to ensure that staff received site specific induction.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. Staff had received training and posters had been put in place as a result of this training. Staff confirmed that guidance was available and were discussed in clinical meetings. We saw sepsis risk identification tools available on the system.
  • Systems were in place to manage people who experienced long wait times to be seen. There was a triage system in place to prioritise and identify patients that required more urgent attention.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse.
  • When there were changes to services or staff, the service assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way. For example, we saw records where there were special notes and safeguarding alerts in place for relevant patients.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The service could access the patients GP records if there was a clinical reason following consent from the patient. Notes were inputted onto the computer system and were immediately available by the patients GP and secondary care.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including medical gases, emergency medicines and equipment, and controlled drugs and vaccines, minimised risks. However, we observed the process in place for the daily recording of checks carried out of the resuscitation trolley and noted that checks had not always been carried out in line with their own policy.
  • The service kept prescription stationery securely. Although we observed blank prescriptions were secured stored both in the main store and in the consultation rooms prescriptions were allocated too, blank prescriptions were not tracked and recorded when allocated to a consultation room. This included those prescriptions taken off site in the vehicles for home visits and a recording system for medicines which were dispensed during these visits.
  • The vehicles were issued with equipment and medical gas cylinders which were stored appropriately and regularly checked. We saw records of checks carried out during our visit. We observed two drivers carrying out checks at the beginning of their shift.
  • The service carried out regular medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service had audited antimicrobial prescribing. There was evidence of actions taken to support good antimicrobial stewardship.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.
  • Palliative care patients were able to receive prompt access to pain relief and other medication required to control their symptoms.

Track record on safety

The service had a good safety record.

  • The service monitored and reviewed activity. This helped them to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system in place for receiving and acting on safety alerts.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. The provider met regularly with partner organisations involved in the provision of urgent care services to improve joint working arrangements and the delivery of care. Staff we spoke with during our inspection told us about incidents they had reported and told us about the process and how these had been dealt with by the service. We saw evidence that incidents were discussed across the organisational boundaries.
  • A clinician we spoke with told us about a significant event that had been raised, and explained how this had been discussed in an audit meeting. This clinician also told us how generic emails were often received from the senior management team which detailed learning outcomes from other significant events that that had been raised and investigated.
  • At the time of our inspection, the service primarily used a paper based system to report incidents which were then populated onto a database. Some members of staff we spoke with told us they could email the medical director directly to report an incident and they felt confident in being able to report incidents. This allowed the service to identify themes and trends and share findings with the wider team. Other staff members we spoke with told us they did not always receive information relating to incidents reported however, the service sent out a quarterly report to the managers of the service who were then responsible for sharing any learning with their team.
  • We were told that the service was currently exploring an electronic system called Datix for incident reporting to further improve the process.

Effective

Good

Updated 14 December 2018

Caring

Good

Updated 14 December 2018

Responsive

Good

Updated 14 December 2018

Well-led

Good

Updated 14 December 2018

We rated the service as good for providing a well-led service. Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • During the inspection at NEMS GP Out of Hours Service and the headquarters (NEMS Community Benefit Services Limited, 484 Derby Road, Nottingham), leaders of the service demonstrated that they had the experience, capacity and skills to deliver the service strategy and address risks to it. They discussed some of the challenges they faced in the delivery of out of hours services and were open and transparent and confidently discussed the actions they were taking and the plans they had to further improve services.
  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. During our visit to NEMS GP Out of Hours Service and during our discussions with clinicians, they told us about the development of an effective audit process and told us about examples of various audits carried out by the service.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. We observed good leadership on site at NEMS GP Out of Hours Service during our unannounced visit.
  • Senior staff, including an on-call manager and on-call director were accessible throughout the operational period.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with patients, staff and external partners.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. It met with commissioners to discuss how it could met the needs of the population.
  • The provider monitored progress against delivery of the strategy.
  • The provider ensured that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values. Some staff members we spoke with told us that they did not feel senior management were always visible at NEMS GP Out of Hours Service. We spoke with the senior leaders who told us that they were working to ensure better integration of all sites.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service. Some staff members we spoke with told us they had been employed by the service for a number of years and felt supported by the senior management team.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance consistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We looked at examples of complaints received and responses provided by the service during our announced visit to the headquarters. We saw responses demonstrated openness, honesty and transparency. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. Some staff members we spoke with had confidence that these would be addressed however, some staff members we spoke with told us they did not have confidence that concerns would be addressed but had not always followed the process in place to report incidents.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff we spoke with at NEMS GP Out of Hours Service told us about their appraisal process. Staff were supported to meet the requirements of professional revalidation where necessary. The service acknowledged difficulty in recruiting some staff, however, during our unannounced visit to NEMS GP Out of Hours we observed a nurse was in training to work within the out of hours service and was observing other nurse members.
  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out as standard operating procedures. These were accessible to staff through their intranet system, along with other guidance.
  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • There was a clear leadership structure and staff were aware of who to escalate concerns to.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding. There were local leads who monitored and supported their specialties such as safeguarding and engaged with the local system to ensure a joined-up approach to patient care with local agencies and providers such as GPs and secondary care.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. The provider told us that they were working to improve the service and had employed a quality and governance lead. The quality and governance lead was able to demonstrate their approach to improving quality and governance for the service.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Staff at all levels were clear in relation to their roles in managing safety alerts, incidents and complaints.
  • Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.
  • Governance meetings were held at a provider level, these were attended by the heads of services, governance lead and clinicians. From the minutes seen, issues discussed included an overview of incidents and complaints, patient pathways, safety alerts among other issues.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • The providers had plans in place and had trained staff for major incidents. There was a business continuity plan in place in the event of a major incident such as power failure, telephone loss or building damage.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service used information technology systems to monitor and improve the quality of care. GPs were provided with laptop computers that allowed them to work from home and alleviate pressures in the primary care centres by undertaking telephone triage and call-backs to patients. During our visit to the headquarters, we were informed that the provider intended to purchase additional lap-tops to further enhance their capacity to meet the anticipated additional demands of winter pressures. Staff we spoke with at NEMS GP Out of Hours service also told us this.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. Staff received data protection training.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. The provider had undertaken a staff survey within the last 12 months and had analysed the responses. There were a number of findings and the provider was taking action to respond. For example, better feedback in response to near misses and incidents; more effective communication from senior management. The findings of the survey were fed back to staff.
  • Staff members told us that they had suggested posters to be displayed in the waiting area regarding waiting times and this was actioned.
  • Staff were able to describe to us the systems in place to give feedback. Staff were encouraged to provide feedback through the monthly meetings with their line managers. The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service. Quarterly audits of telephone and face to face consultations were carried out and learning communicated to relevant staff members. The provider was working with the CCG to continually improve the services provided.
  • Staff knew about improvement methods and had the skills to use them.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.