You are here

Inspection Summary


Overall summary & rating

Good

Updated 21 May 2019

This service is rated as Good overall. This service has not been inspected previously.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection of Kingston General Practice Chambers on 14 and 15 March 2019 as part of our inspection programme; this included visiting and inspecting all three of the Chambers’ registered locations. Surbiton Health Centre was visited as part of this inspection on 15 March 2019.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen; however, in some areas closer monitoring for contracted staff was required. When safety incidents did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided; however, arrangements in respect of the monitoring of the vasectomy service required review. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

- Review the arrangements in place for oversight of the activities of sub-contracted services; for example, the monitoring of progress by premises landlords in addressing issues highlighted in risk assessments.

- Review the working arrangements with the contracted nursing service to ensure that staff have received all necessary training and are operating safety processes effectively.

- Review the processes in place for monitoring the effectiveness of vasectomy procedures.

- Review the risk assessment process in respect of pre-employment Disclosure and Barring Service checks.

- Review the arrangements in place for ensuring that medicines are prescribed according to appropriate guidance, in particular, in relation to monitoring antimicrobial prescribing and ensuring a fully documented audit trail of the handling of medicines and safety alerts.

- Review the information provided to staff in respect of reporting significant events to ensure that all staff are aware of the location of the reporting form.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 21 May 2019

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 provider conducted safety risk assessments. It had safety policies, including Control of Substances Hazardous to Health and Health & Safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the provider as part of their induction and refresher training. 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. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • For staff directly employed by the provider, staff checks were carried out 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); however, their DBS policy lacked detailed consideration regarding the level of check required for staff (Basic or Enhanced checks are available), and the circumstances under which they would allow a new member of staff to start work before their DBS check was completed. The DBS policy stated that non-clinical staff would be eligible for a Basic DBS check; however, there was no suggestion in the policy that this approach would be considered on a role by role basis depending on the potential risk posed to patients. We were told that, depending on the role they were being employed to perform, the provider allowed for some (non-clinical) staff to begin work prior to their DBS check being completed; however, this approach was not detailed in their DBS policy. We saw an example of a risk assessment checklist that we were told was used to determine whether a member of staff could begin work without a completed DBS check, but use of this tool was not covered in the DBS policy; in addition, this tool did not appear to be tailored to the service, nor did it contain details of the criteria used to determine the level of risk.

  • 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.
  • The provider was not directly responsible for the carrying-out of premises safety checks (such as fire safety, Legionella, Infection Prevention and Control, Portable Appliance Testing, Calibration) at this location, as they rented space and equipment from another organisation (who in turn were also tenants). The provider required evidence of these checks to be supplied to them annually when they renewed their lease, and we saw evidence of this; however, where action was required on the part of their landlord in response to safety risk assessments, the provider did not have a process in place to monitor that the required action was taken. We noted during the inspection that the most recent fire risk assessment for this site had actions identified, and that the provider was unsure whether these had been addressed; having discussed this during the inspection, the provider subsequently sent us evidence to confirm the required work had been completed.

Risks 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. There was an effective system in place for dealing with surges in demand; for example, the service had promptly put in place additional resources at short notice in response to winter pressures.
  • There was an effective induction system for staff tailored to their role.
  • Overall, staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. Staff we spoke to who worked for the extended hours service knew how to identify and manage patients with severe infections, for example sepsis; however, there was a lack of sepsis awareness amongst nursing staff working for the urology and vasectomy service, who were employed via the local Community Health provider who managed the rooms on the first floor of Surbiton Health Centre.
  • 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.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians working for the specialist services made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. The extended hours service did not make referrals; we saw evidence that extended hours clinicians made clear notes of consultations to enable patients’ regular GPs to make referrals where necessary.

Appropriate and safe use of medicines

Overall, the service had reliable systems for appropriate and safe handling of medicines; however, these required review in respect of the vasectomy service.

  • Overall, the systems and arrangements for managing medicines, including medical gases, emergency medicines and equipment, minimised risks. We saw evidence that the medicines fridge (containing the anaesthetic used for vasectomies) was monitored daily and records were kept of fridge temperatures (the fridge was owned and monitored by an external organisation contracted to provide staff and facilities to Kingston GP Chambers via Kingston CCG); however, we noted six occasions during the two weeks preceding the inspection where the fridge temperature had exceeded the recommended maximum by between 0.1 and 0.6 degrees. We asked the staff responsible for monitoring the fridge about the action they had taken in respect of this and we were informed that they had reported the issue to their manager; however, there was no evidence of action having been taken. The provider had not been made aware of this issue prior to inspectors alerting them during the inspection; they undertook to address this with the contractor.
  • The service kept prescription stationery securely and monitored its use.
  • The service ensured that staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance by means of monthly random sampling of clinical notes for the extended hours service. For the dermatology and urology services, the GPs held monthly joint clinics with hospital consultants, who were also available to provide advice on an ongoing basis.
  • The service had not carried-out focussed prescribing audits and had not audited their antimicrobial prescribing; however, we saw evidence that the service actively encouraged responsible antimicrobial prescribing. For example, they had designed information cards for patients who were diagnosed with conditions which were not suitable for treatment using antibiotics (such as a sore throat or cold); these contained information about why antibiotics were unsuitable, they could be completed by clinicians with details of “over the counter” medicines that could be taken to relieve symptoms, and were given to the patient to assist them in selecting the appropriate treatment.

Track record on safety

The service had a good safety record.

  • There were risk assessments in place in relation to safety issues.
  • The provider had a risk log relating to risks which were specific to them, which was regularly reviewed and updated.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving and acting on safety alerts, and a record was kept of action taken in respect of alerts which were relevant to the service; however, there was no record kept of those alerts which had been reviewed and considered not relevant, and therefore, it would be difficult for them to identify if any relevant alerts had been overlooked.
  • The provider carried-out joint reviews of incidents; for example, where a referral to one of their services made by a member practice was not received, the provider worked with the practice to identify and rectify an error made by the practice in their referral process.

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; however, when we spoke to staff during the inspection, not all were aware of the location of the reporting form.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. For example, the service had recorded an incident where a patient’s regular GP practice had overlooked a request made by a GP working for the extended hours service to make an urgent hospital referral in relation to a suspected cancer. Following this, a new protocol was put in place by the service whereby all requests for urgent suspected cancer referrals were followed-up by a telephone call to the practice concerned to ensure that the request had been received and was being actioned.

Effective

Good

Updated 21 May 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. The provider had criteria in place for the referral of patients to their services. In the case of dermatology, all referrals of patients from member practices were triaged by GPs from the provider’s dermatology service, with around 80% being considered suitable to be seen by them, and the remainder being sent to secondary care. The provider audited this process and reviewed cases where patients were triaged as suitable for the dermatology service based on information from their GP, but subsequently referred onto secondary care following their appointment; this allowed them to identify any learning and where necessary, feed back to referring practices.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The provider had a programme of quality monitoring and improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.

  • The provider had identified areas of potential risk in respect of the service provided, and had devised a programme of daily and monthly checks in order to address these risks. For example, a daily check was in place to ensure that notes made by the extended hours service were successfully transferred into patients’ full medical records held by their registered GP.
  • For the dermatology, dementia and urology services the provider was contracted by the clinical commissioners to provide a designated number of clinics. The provider shared with us the monitoring data supplied to commissioners for the reporting years 2017/18 and 2018/19. Monitoring included:

    • The length of time patients had to wait for their first appointment following referral (with a key performance indicator target of four weeks). The data supplied showed a decrease in the percentage of patients seen within the four week target, and an increase in the overall waiting time; however, the provider explained this was due to the demand for the services exceeding the contracted capacity. The provider was able to give examples of ways in which they were pro-active in taking action when waiting times increased; for example, they monitored the waiting times for appointments in secondary care and diverted patients to secondary care providers depending on which service had the shortest wait at the time. They had also negotiated with commissioners for flexibility in appointment provision; for example, to allow them to convert under-used vasectomy sessions into over-subscribed urology sessions. They had also recruited additional clinical resource, and in the case of the dermatology service, they had introduced additional clinical sessions at their own expense in order to reduce waiting times.
    • Benchmarking against local secondary care services was undertaken, which demonstrated that overall, the wait for an initial appointment with the dermatology service was on average three weeks shorter than for an appointment with any one of the three nearest hospitals, and on average 2 weeks shorter for appointments with the urology and vasectomy service.

The extended hours service submitted a monthly report to commissioners which incorporated areas such as service utilisation, patient feedback and individual practice usage. A full annual report was also produced, which looked at areas such as the age of patients using the service and usage on specific days, which enabled the service to be refined to meet demand.

The dermatology service had processes in place to monitor their activity (such as monitoring the effectiveness of the triage process, receipt of histology results following minor surgery, and post-operative infection rates). They had also carried out a clinical audit of the management of basal cell carcinoma within the service and shared learning with practices across the CCG.

For the vasectomy service, we saw evidence that the provider had some arrangements in place to monitor the effectiveness and post-operative infection rate in relation to vasectomy procedures; however, the data provided showed some gaps where patients had been referred back to their usual GP for semen analysis, but where the outcome of the analysis was unknown.

The urology service had carried out an audit of their service provision, which included a review of whether they offered value for money to the NHS in comparison to patients receiving the same service in secondary care. The audit found that they provided services at a significantly lower cost than secondary care; the cost of a vasectomy procedure would be approximately three times higher in secondary care, and the overall cost of the urology service would be approximately four times higher.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff were provided with ongoing support; this included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation.

Coordinating care and treatment

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way; this included ensuring that staff working for the extended hours service had access to both clinical and relevant non-clinical information via access to the patient’s clinical records (such as alerts to highlight that a child was on the Child Protection Register, or that a patient had a learning disability).
  • Staff communicated promptly with patient's registered GPs so that the GP was aware of the need for further action. In the case of the extended hours service, notes of consultations made on the service’s patient records system were immediately transferred to each patients’ own GP following the consultation. A daily check was made to ensure that all notes had been transferred successfully.
  • The extended hours service did not make referrals to secondary care; patients requiring a secondary care appointment were referred back to their own GP for the referral to be made; this was made clear in the information provided to both the patient and their regular GP. Where a patient was seen in the extended hours service and identified as needing an urgent referral under the “two week rule” for suspected cancer, the service had an appropriate safetynetting process in place, which involved staff phoning the patients’ own GP to check that the consultation notes had been received and that the referral had been made. Patients seen by the dermatology, urology or dementia services and assessed as needing referral to secondary care were referred directly.
  • There were clear and effective arrangements for booking appointments.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Caring

Good

Updated 21 May 2019

We rated the service as good for providing a caring service.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information which was tailored to their needs; for example, the service had specific information available for patients of the dementia clinic which included a pull-out sheet with suggested reading material relating to the condition.
  • Of the 31 Care Quality Commission comment cards we received relating to this location, 29 were wholly positive about the service experienced and two were mixed. This was is in line with the results of the NHS Friends and Family Test and other feedback received by the service.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about their care.

  • Interpretation services were available for patients who did not have English as a first language. Information leaflets and patient feedback forms were available in dementia-friendly formats for patients of the dementia clinic.

  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand; communication aids were available.
  • For patients with dementia, carers or social workers were appropriately involved. The provider arranged for an advisor from the Alzheimer’s Society to provide on-site clinics on the same day as the dementia clinics, which enabled patients and their carers to find further information about support and community services available to them.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff respected confidentiality at all times.
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Responsive

Good

Updated 21 May 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider had introduced its own patient survey for all GP-led specialist services (in the case if the Surbiton Health Centre site, this included the dermatology, urology/vasectomy, and dementia services); The survey reflected the questions asked in the national out-patient survey and  incorporated questions about patients’ views about the quality of care they received and the “Friends and Family Test”.

Data for the dermatology service showed:

- 100% of patients felt that they were treated with dignity and respect.

- 98% of patients felt that they were involved in decisions about their care.

- 99% of patients felt listened to by clinicians.

- 99% of patients felt able to express their views.

- 99% of patients felt they were treated with kindness and respect.

- 97% of patients felt that clinicians did everything they could to help them to control their condition.

- 94% of patients felt better able to manage their condition now.

Data for the urology/vasectomy service showed:

- 100% of patients felt that they were treated with dignity and respect.

- 99% of patients felt that they were involved in decisions about their care.

- 99% of patients felt listened to by clinicians.

- 99% of patients felt able to express their views.

- 100% of patients felt they were treated with kindness and respect.

- 96% of patients felt that clinicians did everything they could to help them to control their condition.

- 93% of patients felt better able to manage their condition now.

The service was in the process of running this survey for patients of the dementia service, using a dementia-friendly version of the feedback form; however, they had only recently begun surveying these patients and therefore no data was available at the time of the inspection.

The provider shared Friends and Family Test data with us, which was broken down by service. Data showed:

- For the extended hours service at the Surbiton Health Centre location, 99% of patients reported that they would be either extremely likely or likely to recommend the service to friends or family members (1603 respondents during the 2018/19 reporting year).

- For the urology and vasectomy service, data for the most recent 12 month period (February 2018 to January 2019) showed that 98% of patients would be either extremely likely or likely to recommend the service to friends or family members (216 respondents).

- For the dermatology service, data for January to December 2018 showed that 98% of patients would be either extremely likely or likely to recommend the service to friends or family members (446 respondents).

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients were able to access care and treatment at a time to suit them. Extended hours GP appointments were available from this site from 5pm to 8pm Monday to Friday, and 8am to 8pm on Saturdays, Sundays and Bank Holidays. GP led dermatology clinics were run on Monday mornings, and all day on Tuesdays and Fridays, with a monthly joint clinic with the supervising consultant. GP led urology clinics were run on Mondays, with a monthly joint clinic with the supervising consultant. Vasectomy clinics and procedures were run approximately three times per month on a Friday. Dementia services were provided weekly on Thursdays.
  • Patients could access the extended hours service via their regular GP practice or via NHS 111. Patients required an appointment, this was not a walk-in service.
  • Reception staff had received training on the identification of sepsis, and staff were aware of the action they should take if they were concerned that a patient was acutely unwell.

  • Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs; for example, where a patient seen by the extended hours service required a referral to secondary care, they were advised to make an appointment with their regular GP for a referral to be made. Patients seen by the dermatology, urology or dementia services and assessed as needing referral to secondary care were referred directly.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available and it was easy to do. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. Five complaints were received in the last year, all of which related to the extended hours service. We reviewed two complaints in detail and found that they were satisfactorily handled in a timely way.
  • The service learned lessons from individual concerns and complaints. There had been no particular trends in the complaints received; however, from the evidence we saw in relation to the arrangements for sharing information about complaints, we were confident that the provider had adequate processes in place to identify and address any trends in complaints received, should they occur.

Well-led

Good

Updated 21 May 2019

We rated the service as good for leadership.

Leadership capacity and capability

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

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it.
  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

  • Senior management was accessible throughout the operational period, with an effective on-call system that staff were able to use.

  • 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 member practices.
  • 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.
  • 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.

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.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. 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. They had confidence that these would be addressed.
  • There were processes for providing all staff who were directly employed by the service, with the development they needed. This included appraisal and career development conversations. All staff who were directly employed by the service received regular annual appraisals in the last year. We were told that staff who worked for the service but were not directly employed by them would have an appraisal via their direct employer; however, there was no process in place for the service to contribute to this process.
  • 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 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; however, in some areas these were still being developed.

  • Structures, processes and systems to support good governance and management had been established, and the provider was in the process of reviewing these arrangements to ensure they were effective, following the recruitment of members of staff to newly created roles to manage key processes, such as human resources.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety; however, in some areas, such as premises safety checks, closer monitoring was required in order for the provider to assure themselves that the processes in place were operating as intended.

Managing risks, issues and performance

There were processes for managing risks, issues and performance; however, in some areas these required further development.

  • For areas where the provider was directly responsible, there was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety. In some areas, the provider relied on external organisations to identify and monitor risks (for example, in respect of premises such as risks relating to infection prevention and control, fire, and Legionella); the provider had a system in place to check annually that these risk assessments had been completed; however, where actions were identified, the provider did not have arrangements in place to assess the impact of these on their own patients, and to monitor whether actions had been completed.

· 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. Leaders had oversight of incidents, and complaints. Leaders also had a good understanding of service performance against local and national benchmarks and contractual 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.

  • Service utilisation audits were used positively in order to monitor service provision, and the programme of safetynetting checks (such as daily checks of the transfer of notes for patients seen by the extended hours service to their regular GP) provided assurance that systems were operating as intended. There was evidence of audits of clinical outcomes in respect of the dermatology service. The extended hours service carried-out monthly reviews for each clinician of randomly selected patient notes, which were used to provide feedback to the clinician concerned about the quality of their note taking and any issues with the care provided (such as prescribing outside of recognised guidance), and to identify any trends in respect of issues with the running of the service; however, they did not undertake any wide-scale audits of care provision; for example, audits of antibiotic prescribing.
  • We saw evidence that safety and medicines alerts were reviewed by clinical leads, and those relevant to the service were acted on and shared with relevant staff. A record was kept of those alerts which had relevance to the service; however, there was no record kept of those which had been reviewed and considered irrelevant, and therefore, the service did not have a comprehensive audit trail in respect of this process. This was discussed during the inspection and the provider undertook to record details and decisions made on all alerts in future.
  • The providers had plans in place for major incidents.
  • The provider implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

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 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.

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.
  • Staff were able to describe to us the systems in place to give feedback; for example, regular meetings were held for groups of staff across all roles and services. Staff who worked remotely were engaged and able to provide feedback; for example, reception staff told us that they were able to attend staff meetings held at other sites, and that where they were unable to attend, they were able to access meeting minutes and were provided with updates via the service manager, who worked across sites.
  • 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.
  • 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. The provider held annual away days for the senior leadership team, in addition to monthly board meetings and monthly reviews of complaints, incidents and risk.
  • There was a strong culture of innovation evidenced by the provider’s approach to developing their service. For example, they had been the first service to enable extended hours appointments to be booked directly by the NHS 111 service. They were also involved in contributing solutions to wider issues facing the NHS, such as the shortage of GPs; for example, via the introduction of a GP retention and support scheme, and contributing to the training of allied health professionals ahead of their integration into the delivery of primary care as part of the new NHS GP contract.