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Inspection Summary


Overall summary & rating

Good

Updated 31 October 2018

This service is rated as Good overall. This is the service’s first inspection.

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? – Outstanding

We carried out an announced comprehensive inspection at Fleetwood Same Day Health Centre on 6 September 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At this inspection we found:

  • The service had well established 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. We saw how the provider effectively cascaded learning outcomes to all staff.
  • Patients’ care needs were assessed and delivered in a timely way according to need. The service was meeting the Clinical Commissioning Group’s key performance indicators.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. The provider had systems in place to support staff in updating their clinical knowledge and practice in line with any updates to guidance.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. The service’s management team had a detailed understanding of the training needs of staff.
  • Patient feedback we received was positive about their experiences accessing the service. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was a clear leadership structure and staff felt supported by management.
  • Service leaders had established and embedded comprehensive systems and processes to govern activity and assure themselves that safe and effective care were delivered.
  • We saw the organisation placed high value on, and was responsive to both staff and patient feedback. Feedback received was acted on to make service improvements.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • We saw how the organisation prioritised quality improvement at all levels. This ranged from weekly audits of clinical consultations for all grades of staff, with supportive feedback offered to individuals, to ‘deep dive’ audits being undertaken to review and improve whole processes. The service was proactive in reviewing the effectiveness and appropriateness of the care it provided.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 31 October 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 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. For example, the providers delivering urgent care in the Fylde Coast Integrated Urgent Care System had organised a safeguarding conference in November 2018 with specific focus on the urgent and out of hours’ healthcare sector. The planned conference agenda highlighted a number of current safeguarding themes, including multi-agency working. 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 was an effective system to manage infection prevention and control (IPC). A full IPC audit had been completed in August 2018, with actions identified and completed to make improvements as a result. We also saw that additional room specific monthly IPC checks were completed and documented.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were effective systems for safely managing healthcare waste.

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.
  • There was a comprehensive induction system for temporary staff tailored to their role.
  • 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 or deteriorating conditions, for example sepsis. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need. Systems were in place to manage people who experienced long waits.
  • We did note the service’s reception staff had to work within constraints presented by the building layout. The reception desk was positioned in the centre of a large open foyer area, meaning the service’s staff fielded many queries from the public attempting to present for other services located in the building. The high structure of the reception desk presented a visual barrier, hindering the view receptionists had of patients sitting in the waiting area and also presented a barrier for patients in wheelchairs. The provider was fully aware of these issues, and we saw evidence they had been in consultation with an architect to explore possible options to address them.
  • 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 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. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit 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 we saw all medicines stocked were in date, with staff aware of their responsibilities for monitoring this. However, we did note that a documented log of checks against the medicines stock was not maintained.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • 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.
  • Joint reviews of incidents were carried out with partner organisations, including the local A&E department, NHS 111 service, local GP practices and social services.

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.
  • 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, following an incident involving a patient who required a referral to the safeguarding team, we saw how the provider had reminded staff of relevant safeguarding contact details to ensure referrals were made to the appropriate team. We also saw how an incident had prompted the provider to review its clinical rota system and how it remunerated GP staff to ensure there were no gaps in GP provision during the service’s operational hours. The provider had implemented a ‘lessons learned’ newsletter which was regularly circulated to staff and displayed on noticeboards as a means of effectively disseminating any changes to practice or reminders required as a result of investigations into incidents. This was in addition to discussion in team meetings and information being cascaded via email for permanently employed staff members.

  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 31 October 2018

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. The provider monitored that these guidelines were followed. The provider circulated regular clinical update newsletters to permanent staff and we saw these were also displayed on the premises to ensure locum and agency staff had access to them.
  • In addition, updated NICE guidance was cascaded to the organisation’s training team via the clinical governance lead to prompt exploration of any action needed. For example, when guidance was updated around the National Early Warning Score (NEWS 2) for sepsis (a tool for identifying and responding to patients at risk of deteriorating or sepsis) this prompted the service’s training team to initiate a project on Sepsis NEWS 2 and ensure staff had access to appropriate training.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs. If an urgent referral to secondary care was required, this referral was made by the service and communicated to the patient’s own GP. The patient’s own GP was asked to make any routine referrals required.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. For instance we saw examples where the service liaised closely with the local health visiting team to ensure vulnerable children were appropriately registered with a GP after attending for an appointment at the service.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. There was a system in place to identify frequent attenders and patients with particular needs, for example palliative care patients, and care plans/guidance/protocols were in place to provide the appropriate support. All patient contacts at the service were reported back to the patient’s own GP, ensuring the GP practice would be made aware of any trends of frequent attendance. The service’s quarterly quality submission to the CCG indicated no frequent attenders had been identified during the first quarter of 2018/19. We saw no evidence of discrimination when making care and treatment decisions.
  • Technology and equipment were used to improve treatment and to support patients’ independence.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. We saw an annual programme of clinical audit was in place and outcomes of any completed audits were disseminated to the team through meetings and write-ups in the clinical updates newsletter circulated monthly in order to ensure any required changes to practice were appropriately embedded.

  • The service used key performance indicators (KPIs) that had been agreed with its Clinical Commissioning Group to monitor their performance and improve outcomes for people. The service shared with us the performance data from April 2018 to June 2018 as its first quarterly quality submission, as well as its monthly submission from July 2018 that showed, across all sites operating within the Fylde Coast Integrated Urgent Care system:

    • 99.36% of people who arrived at the services in July 2018 were seen and were subsequently referred on or discharged within 4 hours. This was better than the target of 95%.
    • Between April 2018 and June 2018 the provider reported it had achieved the target of at least 90% of people who attended the urgent care sites being seen within 15 minutes or less.
    • 2.33% of people who attended the urgent care services in July 2018 were advised to attend A&E. This met the target set by the CCG of less than 5%.
    • The provider reported the percentage of ambulance service requests which were responded to by either a GP or a nurse practitioner within 20 minutes for patients with pressing needs. While this was lower than the target of 95%, this indicator included requests made overnight at a neighbouring site providing out of hours care. The provider confirmed that requests made to the service during daytime operation were responded to within the agreed target timescale.

  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. The provider’s clinical governance team had implemented an annual programme of audit. A selection of topics involved a “deep dive” whereby a whole process was reviewed and updated as necessary. One example we saw was a urinary tract infections (UTI) audit. All consultations across all locations and by all clinicians were reviewed over one month. The Public Health England and NICE Guidance was used as reference for good practice. A team of auditors looked at the patient flow, consultations, tests and outcomes, including prescribing. Subgroups of patients were analysed including pregnant women and children. Recommendations were made on many aspects of care including, but not limited to, when to test (urine dipstick testing and hospital microbiology samples) when to repeat samples. Results were cascaded to all clinicians, update sessions were held and clinicians were encouraged to share their learning with colleagues. System changes were put in place including handing repeat samples out to pregnant women. The clinical governance team were keen to embed learning and ensure change of practice was adopted. They reviewed references on embedding learning and included in the updates time for reflection and discussion of how the audit would change individual practice. All staff were asked to submit a piece of reflective work to contribute to their appraisal on how their practice would change.

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. This covered such topics as safeguarding, information governance, health and safety as well as incorporating opportunities to shadow more experienced colleagues to aid familiarity with the role.
  • 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. We saw evidence of comprehensive training and development protocols in place and embedded into practice. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. Clinicians told us during the inspection how they regularly shadowed colleagues in order to develop their skills with presenting cases they were less familiar with.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.
  • The provider could demonstrate how it ensured the competence of all staff, including those employed in advanced roles by audit of their clinical decision making, including non-medical prescribing. Comprehensive systems were in place to audit and feedback around clinical decision making and record keeping to individual clinical staff. The provider utilised an electronic record and auditing tool to achieve this. As standard, 2% of each clinician’s consultations were audited with feedback provided. This percentage was increased if it was identified a member of staff required additional support. Clinicians we spoke with as part of our visit felt the system was a positive and supportive one which facilitated improvements in clinical practice.

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.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Staff communicated promptly with patients’ registered GPs so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary. There were established pathways for staff to follow to ensure patients were referred to other services for support as required.
  • 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.
  • The service had formalised systems with the NHS 111 service with specific referral protocols for patients referred to the service. An electronic record of all consultations was sent to patients’ own GPs.
  • There were clear and effective arrangements for booking appointments and transfers to other services. Staff were empowered to make any direct urgent referrals and/or appointments for patients with other services.

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.

  • The service identified patients who may be in need of extra support, such as those with a learning disability.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.
  • 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.
  • The provider monitored the process for seeking consent appropriately.

Caring

Good

Updated 31 October 2018

We rated the service as good for caring.

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. receptionists gave people who presented at the service clear information. There were arrangements and systems in place to support staff to respond to people with specific health care needs such as end of life care and those who had mental health needs. At the time of our inspection, two members of staff within the integrated urgent care system were undertaking training in a mental health promotion training programme designed to increase the confidence and skills in having effective conversations about mental health and to help people manage their mental health needs.
  • All of the 30 patient Care Quality Commission comment cards we received were positive about the service experienced. As well as making positive comments about the service, one card made reference to a four hour wait to be seen. However, eight of the cards explicitly complimented the service on how quickly patients were seen for treatment. Patients praised staff for being approachable and friendly, describing a manner which put patients at ease. This positive feedback was is in line with the results of the patient survey results gathered by the service, where between April 2018 and June 2018, 96% of 634 patients questioned stated they would recommend the service, with patients on average rating the service 4.8 out of 5.
  • The provider had facilitated staff attending two days of ‘Daisy Training’ in September 2018 to consolidate staff putting dignity and respect at the heart of the service provided. Following completion of this, the provider told us it intended to train a number of ‘dignity champions.’

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given):

  • Interpretation services were available for patients who did not have English as a first language. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they very much 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.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.

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.
  • The service monitored the process for seeking consent appropriately.

Responsive

Good

Updated 31 October 2018

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 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. Working as part of the wider Fylde Coast Integrated Urgent Care system, clinician resources were able to be moved between sites as necessary, affording flexibility in service delivery to meet patient demand.
  • The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. For example, alert messages were used on electronic patient records. Care pathways were appropriate for patients with specific needs, for example babies, children and young people.
  • The facilities and premises were appropriate for the services delivered.
  • The service made reasonable adjustments when people found it hard to access the service. For example, a hearing loop was available in the reception area to support those patients with hearing difficulties.
  • The service was responsive to the needs of people in vulnerable circumstances. For example, we were told by staff of instances where appropriate support had been put in place to ensure patients with learning disabilities could access appointments easily and therefore receive the necessary treatment.
  • Initially as part of a pilot scheme, the provider had engaged with commissioners to set up a wound care service, which had grown and was well established at the time of our inspection. The provider offered wound care across three separate sites to over 800 patients each month on average.

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. The service operated every day of the week from 8am to 8pm.
  • Patients could access the service as a walk in-patient without booking an appointment, or by pre-booking appointments directly via the NHS 111 service or 0300 telephone services. Patients were generally seen on a first come first served basis, although the service had a system in place to facilitate prioritisation according to clinical need where more serious cases or young children could be prioritised as they arrived. The reception staff had a list of emergency criteria they used to alert the clinical staff if a patient had an urgent need. The criteria included guidance on sepsis and the deteriorating patient, and the symptoms that would prompt an urgent response. The receptionists informed patients about anticipated waiting times.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment. The service used key performance indicators (KPIs) that had been agreed with its clinical commissioning group to monitor their performance and improve outcomes for people. The service shared with us the performance data from April 2018 to June 2018 as its first quarterly quality submission, as well as its monthly submission from July 2018 that showed, across all sites operating within the Fylde Coast Integrated Urgent Care system:

    • 99.36% of people who arrived at the services in July 2018 were seen and were subsequently referred on or discharged within 4 hours. This was better than the target of 95%.
    • Between April 2018 and June 2018 the provider reported it had achieved the target of at least 90% of people who attended the urgent care sites being seen within 15 minutes or less.
    • 72.39% of ambulance service requests were responded to by either a GP or a nurse practitioner within 20 minutes for patients with pressing needs, which was lower than the target of 95%. We discussed this with the provider, who confirmed this indicator included requests made overnight at a neighbouring site providing out of hours care. The provider confirmed that requests made to the service during daytime operation were responded to within the agreed target timescale.
    • 96.7% of ambulance service referrals seen in July 2018 received a face-to-face assessment within 4 hours of the referral being received if appropriate. This was better than the target of 95%.

  • Waiting times, delays and cancellations were minimal and managed appropriately. Where people were waiting a long time for an assessment or treatment there were arrangements in place to manage the waiting list and to support people while they waited.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Referrals and transfers to other services were undertaken in a timely way.

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. The service had logged 17 complaints received in the last year. We saw the service logged both verbal and written complaints in order to maximise learning and improvements. We reviewed two complaints and found that they were satisfactorily handled in a timely way.
  • Issues were investigated across relevant providers, and staff were able to feedback to other parts of the patient pathway where relevant.
  • The service learned lessons from individual concerns and complaints and also from analysis of trends. Complaints and associated learning were discussed at the provider’s regular governance meetings. It acted as a result to improve the quality of care. For example, we saw a case where a complaint had been received via the CCG regarding a patient unable to get an appointment with the wound care service. The provider contacted the patient to apologise, and meetings were arranged with other stakeholders to discuss and troubleshoot the issues which had led to the complaint in order to put measures in place to mitigate a repeat.

Well-led

Outstanding

Updated 31 October 2018

We rated the service as outstanding 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 extremely knowledgeable about issues and priorities relating to the quality and future of services. They demonstrated a comprehensive understanding of the challenges and were addressing them.
  • Leaders were established at all levels and were visible and approachable. They worked closely with staff and other providers within the system 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. The provider had established a succession planning training group which met on a six -weekly basis in order to provide support for staff as they stepped into leadership roles within the organisation. The provider was also developing an overarching ‘talent management’ strategy to ensure the most appropriate and effective support was in place for staff progression within the organisation.
  • Established clinical leaders within the organisation were supported through a clinical leadership group which met bi-monthly and was led by the organisation’s clinical director. The focus of the group was to support development of leadership skills and empowering staff to contribute to the development of the organisation’s strategic vision.

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. As part of the provider’s programme of mandatory training, all staff completed a session around the provider’s company culture and values annually.
  • 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 model of integrated working had removed inequalities in the provision of urgent care across the region and established a more consistent delivery of service by aligning care pathways across sites.
  • The provider closely monitored progress against delivery of the strategy.
  • The provider had ensured that staff who worked across all sites in the integrated urgent care system felt engaged in the delivery of the provider’s vision and values.

Culture

The service had a well established and embedded culture of high-quality sustainable care.

  • In the process of aligning the service to become part of the Fylde Coast Integrated Urgent Care Service, the provider had needed to implement changes to the staffing structure which it was aware had placed much anxiety on the workforce. However, despite this staff told us they felt extremely respected, well supported and valued. They told us they were proud to work for the service. Staff acknowledged the service had been through a turbulent transition period, but felt the provider had managed this well and stability had swiftly been restored. We saw how the provider had facilitated a staff training day focussing on developing resilience skills in an effort to support the team through the period of transition.
  • 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. We saw examples where patients received a prompt apology when something had gone wrong, with a comprehensive explanation of measures put in place to minimise the chances of the issue being repeated.

  • 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 comprehensive 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 were supported to meet the requirements of professional revalidation where necessary.
  • 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 organisation had successfully applied to participate in NHS Innovation’s Coaching for Culture Change programme. This was a nine month project examining organisational and team culture and its relationship to patient safety and improvement. This project was underway at the time of our inspection, with 125 members of staff across the integrated urgent care service having completed a survey which had led to a report detailing the cultural profile of each site. Meetings were being held to identify opportunities for improvement. The provider told us how the process was allowing them to engender a culture of psychological safety.
  • 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, understood, effective and well embedded. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. Meeting structures were in place at senior management level to ensure comprehensive oversight of service delivery across all sites within the system.
  • There was a clear staffing structure. Staff understood 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 and assured themselves that they were operating as intended.

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 regular audit of their consultations, prescribing and referral decisions. Weekly audit meetings were held at senior management level and we saw how this helped to drive the provider’s strategy around improving quality. Leaders had oversight of MHRA alerts, incidents, and complaints, and had considered and implemented appropriate mechanisms to cascade learning from these to most effectively embed any necessary changes. 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.
  • Clinical audit was undertaken in a methodical manner and in such a way to maximise the positive impact it had on quality of care and outcomes for patients. Audit topic selection was facilitated by the provider’s comprehensive clinical governance structures, which allowed for any issues to be swiftly identified and addressed. There was clear evidence of action to resolve concerns and improve quality. Quality improvement work was prioritised by the provider.
  • The providers had plans in place and had trained staff for major incidents.
  • The provider implemented service developments and where efficiency changes were made this was with input from clinicians and stakeholders to understand their impact on the quality of care.

Appropriate and accurate information

The service ensured it maintained and 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 regularly and frequently 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, allowing the provider to maintain high standards of unscheduled healthcare provision.
  • The service used information technology systems to monitor and improve the quality of care.
  • 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. For example, staff told us how they had fed back to the provider regarding the volume of emails circulated which were not necessarily relevant to all staff, and that may go unread for some time for some staff to due irregular working patterns. We saw minutes from meetings where these concerns were discussed with staff, with an action plan formulated to address them, including new email distribution lists being created to help filter email circulation appropriately, and a morning ‘huddle’ introduced as means of supporting effective communication of any changes.


    We saw how the provider had formulated a comprehensive action plan in response to patient feedback received. This facilitated effective monitoring of the timely actions taken as a result. For example, patients had previously fed back regarding limited access to drinking water while waiting to be seen by the clinician, and that there was limited space to sit in the waiting area during times of high demand. As a result, the service had purchased and installed a water dispenser and additional seating for the patient waiting area.

  • Staff were able to describe to us the systems in place to give feedback, such as team meetings and staff surveys. We saw evidence of the most recent staff survey and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement at all levels within the service. We saw the organisation’s training and development team were proactive in supporting and facilitating the development of staff at all levels.
  • Staff knew about improvement methods and had the skills to use them. We saw they were being implemented effectively across the organisation.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared effectively and used to make improvements. Methods of information cascade took into account the service’s use of locum or agency staff.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. For example, the provider’s involvement in NHS innovation’s coaching for culture change programme. There were systems to support improvement and innovation work.
  • The provider was proactive in contributing to the local and national healthcare economy. For example, in November 2018 it was hosting a national safeguarding in urgent and emergency care conference in Blackpool in conjunction with NHS England. The aim of this conference was planned to educate and highlight pertinent issues regarding safeguarding in the urgent and emergency care sector to delegates from a wide range of healthcare providers and other stakeholders.