All inspections: Primary Care 24 (Merseyside) Limited

We undertook an announced comprehensive inspection at Primary Care 24 (Merseyside) Limited on 22 and 23 August 2023. We carried out this inspection to follow up on:

A breach of regulation from a previous inspection in May 2022.
Areas identified where we told the provider they should make improvements.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Primary Care 24 (Merseyside) Limited on our website at www.cqc.org.uk

We have rated this practice as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – not inspected, rating of good carried forward from previous inspection.

Are services responsive? – Good

Are services well-led? – Good

The key questions reviewed during this inspection on 22 and 23 August 2023 included:

Safe
Effective
Responsive
Well Led

We found that:

Action had been taken to address the breaches of regulations identified at the last CQC inspection in May 2022.

At this inspection we found:

The service had clear systems in place to keep people safe and safeguarded from abuse.
The provider had reviewed the staffing arrangements to ensure that patient needs were met. This included increasing the number of clinicians working at the service and improving oversight of risk and performance, particularly during busy periods.
The provider had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.
The service had formalised systems with the NHS 111 service with specific referral protocols for patients referred to the Out of Hours (OOH) service. There were clear and effective arrangements for booking appointments, transfers to other services, and dispatching ambulances for people that required them.
The provider understood the needs of its population and tailored services in response to those needs. To do this the provider engaged with commissioners to secure improvements to services, where these were identified.
The provider monitored the performance of the time disposition which included monitoring clinical and operational staffing levels against planned levels. This was for telephone consultation, face-to-face appointments, and home visits.
Patients with the most urgent needs had their care and treatment prioritised.
The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
The provider had introduced several new leadership roles and new staff had been recruited to these.
Openness, honesty, and transparency was demonstrated when responding to incidents and complaints.
There were clear responsibilities, roles, and systems of accountability to support good governance and management. This included an effective process to identify, understand, monitor, and address current and future risks including risks to patient safety.
The service involved patients, the public, staff, and external partners to support high-quality sustainable services.

Whilst we found no breaches of regulations, the provider should:

Continue to monitor and improve service performance against the locally agreed Integrated Urgent Care key performance indicators.
Further develop and use clinical audits, including two cycle audits as part of the organisations quality improvement processes.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

This service is rated as Requires Improvement overall.

We carried out an announced comprehensive inspection of Primary Care 24 (Merseyside) Limited on 9, 10, 11, 12 and 13 May 2022.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We had an additional focus on the urgent and emergency care pathway and carried out several inspections of services across a few weeks in the Merseyside area. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.

A summary of CQC findings on urgent and emergency care services in Cheshire and Merseyside (Liverpool, Knowsley and South Sefton).

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Liverpool, Knowsley and South Sefton within the Cheshire and Merseyside ICS below:

Cheshire and Merseyside (Liverpool, Knowsley and South Sefton)

Provision of urgent and emergency care in Cheshire and Merseyside was supported by services, stakeholders, commissioners and the local authority.

We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff had continued to work hard under sustained pressure across health and social care services. Services had put systems in place to support staff with their wellbeing, recognising the pressure they continued to work under, in particular for front line ambulance crews and 111 call handlers.

Staff and patients across primary care reported a preference for face to face appointments. Some people reported difficulties when trying to see their GP and preferred not to have telephone appointments. They told us that due to difficulties in making appointments, particularly face to face, they preferred to access urgent care services or go to their nearest Emergency Department. However, appointment availability in Cheshire and Merseyside was in line with national averages. We identified capacity in extended hours GP services which wasn’t being utilised and could be used to reduce the pressure on other services. People and staff also told us of a significant shortage of dental provision, especially for urgent treatment, which resulted in people attending Emergency Departments.

Urgent care services, including walk-in centres were very busy and services struggled to assess people in a timely way. Some people using these services told us they accessed these services as they couldn’t get a same day, face to face GP appointment. We found some services went into escalation. Whilst system partners met with providers to understand service pressures, we did not always see appropriate action taken to alleviate pressure on services already over capacity.

The NHS 111 service, which covered all of the North West area including Cheshire and Merseyside, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours (OOH) provider.

We found some telephone consultation processes were duplicated and could be streamlined. At peak times, people were waiting 24-48 hours for a call back from the clinical assessment and out of hours services. We identified an opportunity to increase the skill mix in clinicians for both the NHS 111 and the clinical assessment service. For example, pharmacists could support people who need advice on medicines. Following our inspections, out of hours and NHS 111 providers have actively engaged and worked collaboratively to find ways of improving people’s experience by providing enhanced triage and signposting.

People who called 999 for an ambulance experienced significant delays. Whilst ambulance crews experienced some long handover delays at the Emergency Departments we inspected, data indicated these departments were performing better than the England average for handovers, although significantly below the national targets. However, crews found it challenging managing different handover arrangements at different hospitals and reported long delays.

Service leaders were working with system partners to identify ways of improving performance and to ensure people could access appropriate care in a timely way. For example, the service worked with mental health services to signpost people directly to receive the right care, as quickly as possible. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.

We saw significant levels of demand on emergency departments which, exacerbated by staffing issues, resulted in long delays for patients. People attending these departments reported being signposted by other services, a lack of confidence in GP telephone appointments and a shortage of dental appointments. We inspected some mental health services in Emergency Departments which worked well with system partners to meet people’s needs.

We found there was poor patient flow across acute services into community and social care services. Discharge planning should be improved to ensure people are discharged in a timely way. Staff working in care homes (services inspected were located in Liverpool and South Sefton) reported poor communication about discharge arrangements which impacted on their ability to meet people’s needs.

The provision of primary care to social care, including GP and dental services, should be improved to support people to stay in their own homes. Training was being rolled out to support care home staff in managing deteriorating patients to avoid the need to access emergency services. We found some examples of effective community nursing services, but these were not consistently embedded across social care. Staffing across social care services remains a significant challenge and we found a high use of agency staff. For example, in one nursing home, concerns about staff competencies and training impacted on the service’s ability to accept and provide care for people who had increased needs.

We found some care homes felt pressure to admit people from hospital. Ongoing engagement between healthcare leaders and Local Authorities would be beneficial to improve transfers of care between hospitals and social care services. In addition, increased collaborative working is needed between service leaders. We found senior leaders from different services sometimes only communicated during times of escalation.

This report covers the inspection of Primary Care 24 (Merseyside) Limited. The reports of previous inspections can be found by selecting the ‘all reports’ link for Primary Care 24 (Merseyside) Limited on our website at www.cqc.org.uk.

This report comprises information from a combination of:

What we found when we inspected the service.
Information from our ongoing monitoring of data about the provider and information from the provider, patients, staff, the public and other organisations.

At this inspection we found:

The service had systems in place to report significant events and incidents.
Staff involved and treated people with compassion, kindness, dignity and respect.
Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

The service is rated as requires improvement for being safe because:

Not all staff had received up-to-date safeguarding training for their role.
There were periods of understaffing which were not addressed in a way that ensured peoples safety was always protected. For example, there were shortfalls in clinicians available on some weekends and bank holidays.

The service is rated as requires improvement for being effective because:

The provider continually did not meet some of the integrated urgent care indicators due to the demand for the service and the way it was delivered.
There were missed opportunities for working with other services to improve the patient journey and feed back to commissioners. For example, working with NHS 111 to identify those patient pathways who could be booked into a face to face appointment with a clinician rather than receive a telephone consultation prior to an appointment.

The service is rated as requires improvement for being responsive because:

Patients were not always able to access care and treatment from the service within an appropriate timescale for their needs.

The service is rated as requires improvement for being well-led because:

Staff satisfaction about working at the service was mixed. Staff did not always feel actively engaged with or empowered by the leadership team.
The approach to service delivery and improvement was reactive and focused on short-term issues. For example, providing clinical resources on Monday mornings to contact patients who contacted the service over the weekend.

The areas where the provider must make improvements as they are in breach of regulations are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The areas where the provider should make improvements are:

The organisation should continue to work closely with all system partners to tackle the capacity pressures on urgent and emergency care in the health and social care system in Liverpool.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This service is rated as Good overall.

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 inspection at Urgent Care 24 Limited (an out of hours provider) on the 19 and 20 March 2018. This was carried out as part of our inspection process and a comprehensive inspection was completed. During the inspection we visited four of the provider's out of hours locations.

At this inspection we found:

The service had a good safety record. They had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from these and improved their processes.
The service had clear systems to keep people safe and safeguarded from abuse.
There was an effective system to manage infection prevention and control, at the time of inspection infection audits were taking place at each of the locations used by the provider.
The service had reliable systems for appropriate and safe handling of medicines, which included regular audit and external scrutiny.
The service routinely reviewed the effectiveness and appropriateness of the care it provided. The provider had systems to keep clinicians up to date with current evidence based practice. They ensured that care and treatment was delivered according to evidence- based guidelines.
The service was actively involved in quality improvement activity, including working closely with external agencies and commissioners to meet patient’s needs.
Staff had the skills, knowledge and experience to carry out their roles. They 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. Staff worked together, and worked well with other organisations to deliver effective care and treatment.
Patient feedback we reviewed including the NHS Friends and Family Test, internal service surveys and other feedback collected by the service was positive about the care and service patients received.
The provider understood the needs of its population and tailored services in response to those needs. The provider engaged with commissioners to secure improvements to services where these were identified.
There was a strong focus on continuous learning and improvement at all levels of the organisation. For example, the service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
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.
There were clear responsibilities, roles and systems of accountability to support good governance and management.
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.
There was a focus on continuous learning and improvement at all levels within the service.

We saw a number of areas of outstanding practice:

There was evidence that incident reporting was widely promoted across the organisation. Staff had received risk management and root cause analysis training and there were high numbers of incidents reported through the Datix system. This suggests there was good awareness of the importance of reporting patient safety incidents and near misses across the service. When significant events had occurred there were good systems for reviewing and investigating, learning and sharing lessons to improve safety in the service.
The provider improved services where possible in response to unmet needs. For example, prior to December 2017 an electronic Escalation Management System (EMS) was introduced into the service. This information system was in operation across a number of service providers across the Clinical Commissioning Group (CCG). The aim of the new system was to ensure that all staff in each organisation were kept aware of service pressures and activities across the healthcare providers, so that patients could be diverted to services that were less busy. All service and shift managers provided support for this along with members of the executive team.

There was a strong emphasis on the safety and well-being of all staff. As a team they supported each other and we saw that events and training were organised to build a strong team ethic. We saw that a food bank for staff had been set up by the provider, so food could be left anonymously for staff members if they were struggling financially at home.
The service provided a free taxi service to patients who were unable to pay for their journey to the outreach clinics.

The areas where the provider should make improvements are:

Review and develop an overarching management system to ensure that all the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located. This should include annual assurance that health and safety and infection control risk assessments required have been completed and any issues identified have been addressed.
Review the Datix system and risk register to ensure that all reported significant events are closed off the system when investigations and actions have been taken.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Primary Care 24 (Merseyside) Limited

All Inspections

22 and 23 August 2023

During a routine inspection

09/11/12/13 May 2022

During a routine inspection

19 & 20 March 2018

During a routine inspection