i-HEART 365 Service - Extended Hours

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care.

At our last assessment, we rated this key question as requires improvement and the service was in breach of legal regulations. Since the last assessment, the service has made significant improvements and was no longer in breach of regulation. At this assessment, the rating for this key question has changed to good. We found improved management oversight of governance processes across the service. Leaders had strengthened monitoring arrangements to provide assurance that systems were effective, risks were identified and managed, and regulatory requirements were being met. This included oversight of environmental and health and safety assurance at the branch site, equipment testing, staff immunisation status oversight, and other key areas of compliance and risk management. Audit findings were reviewed and acted upon to support continuous improvement and provide assurance to leaders that the service was operating safely and effectively.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clearly defined responsibilities, roles, systems of accountability, and now had effective governance arrangements. These were used to support the delivery of high-quality, sustainable care, treatment, and support. Leaders used information relating to risk, performance, and outcomes to monitor the service and drive improvements.

Leaders had strengthened governance and oversight arrangements by implementing systems to review and monitor environmental safety to include the branch site, in line with the established processes at the main site. A clinical equipment assurance tracker had been introduced as had a monitoring log to record the receipt and dissemination of safety alerts. In addition, a formal data protection audit had been completed, and staff had been reminded of the general data protection regulations (GDPR) information message to be used during outbound calls to patients. Compliance with this process was subject to ongoing monitoring through regular monthly random audits, providing leaders with assurance that data protection requirements were being met.

The provider had systems in place to monitor staff training and had clear processes for managing incidents and complaints. All staff had now received an annual appraisal, and a structured annual service specific check-in process had been introduced to support long term locum GPs. Staff had access to all relevant policies and procedures. Managers held regular meetings with staff including quarterly clinical governance meetings where they reviewed clinical concerns and emerging risks. Actions from meetings were clearly documented and shared with staff to support continuous improvement.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.