The Care Quality Commission
  • Doctor
  • Out of hours GP service

Integrated Care 24 - Norfolk & Waveney

Overall: Good read more about inspection ratings

Reed House, Unit 2b, Peachman Way, Broadland Business Park, Norwich, Norfolk, NR7 0WF (01473) 275973

Provided and run by:
Integrated Care 24

All Inspections

23 February 2022

During an inspection looking at part of the service

A summary of CQC findings on urgent and emergency care services in Norfolk and Waveney.

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 Norfolk and Waveney below:

Provision of urgent and emergency care in Norfolk and Waveney was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area lies across a large, predominantly rural, geographical area with a large proportion of the population aged over 65 years.

Compliance with CQC regulations has historically been challenging across Norfolk and Waveney, particularly in Acute, Mental Health and Adult Social Care services, many of which have been rated Requires Improvement or Inadequate.

We spoke to staff in services across primary care, urgent care, acute, ambulance services, mental health and adult social care. Staff told us of increased pressure across urgent and emergency care pathways, staffing issues and a lack of capacity in key sectors including GP and Dental practices and social care. These issues were resulting in inappropriate calls to 999 and attendances in emergency departments. There were delays in discharge for patients who were medically fit but unable to access appropriate packages of care to enable them to leave hospital.

We previously inspected mental health services in the Norfolk and Waveney area in November and December 2021 and found, due to an increase in referrals and staffing shortages, patients in the community had long waits to be seen. This led, in some cases, to patients deteriorating and requiring urgent and emergency treatment. In addition to this, some inpatient services (such as CAMHS) did not have available beds within the area. Patients were kept in urgent and emergency care settings whilst a bed was found. During inspections of acute services, we found patients unable to access appropriate and timely care to meet their mental health needs.

We inspected a number of GP practices and found some concerns in relation to access for patients trying to see or speak to their GP. We found high levels of staff absence resulting in some staff working long hours and experiencing increased pressure on their services.

To try and alleviate the increasing demand on Emergency Departments, GP streaming services had been introduced in EDs in Norfolk and Waveney. Patients who presented at the ED with problems which were deemed suitable for a primary care appointment could be referred to a co-located primary care service. In some cases, streaming services helped to prevent up to 33% of patients attending the ED.

We inspected urgent care services in the Norfolk and Waveney area and found these to be well-run. However, an on-going shortage of out of hours and urgent care appointments, particularly for urgent dental care, meant patients couldn’t always be appropriately signposted by NHS111. This meant patients often presented to ED for treatment. NHS111 in Norfolk and Waveney had also experienced significant staff shortages, much of which has been due to the COVID-19 pandemic. Leaders in this service had a recovery plan in place; however, staff shortages and increased demand had resulted in significant delays in call answering and call-back times in comparison to the national targets and there was also a very high call abandonment rate, meaning people ended the call before speaking to an advisor. Whilst performance across Norfolk and Waveney did not meet national targets and people experienced significant delays, these delays were, on average, shorter than regional and national averages.

We inspected emergency departments (ED) in Norfolk and Waveney between December 2021 and February 2022 and found lengthy delays for people accessing emergency care. A high number of patients were waiting over 12 hours in ED resulting in overcrowding. This impacted on ambulance handovers and further delays in releasing ambulance crews into the community to respond to 999 calls.

Staff shortages have had a significant impact on social care services across Norfolk and Waveney. In addition, the provision of domiciliary care services is challenging due to the rurality of the area. At the time of our inspections, a care hotel was being utilised in Norfolk and Waveney. We spoke to healthcare professionals who had provided services to people being cared for at the hotel and found them to be safe and generally well cared for. The number of people receiving care in the hotel was small and the aim was for them to only stay for a very short amount of time before going home. This service is commissioned until the 30 April 2022, a formal evaluation will take place before any future plans are agreed.

Some social care and learning disability services in Norfolk and Waveney have struggled to achieve compliance with CQC regulations and a rating of good. Some support has been established across Norfolk and Waveney to help services improve. However, the impact of any support to date has been limited.

Staff shortages and service quality has significantly reduced capacity across social care and learning disability services in Norfolk and Waveney. This has resulted in significant delays in transferring people from hospital to their own home or an appropriate place of care. This in turn meant people who were medically fit for discharge remained in hospital delaying the admission of new patients. These delays and poor flow resulted in overcrowded EDs and an inability to transfer patients from ambulances.

Strategic, system wide workforce planning and increased community provision of health and social care is needed to meet the needs of the local population. This is needed to reduce the pressure on urgent and emergency care services and to reduce the risk of harm to people living in Norfolk and Waveney.

We carried out an announced focused inspection at Integrated Care 24 Limited – Norfolk and Waveney (IC24) on 23 February 2022.

This focused inspection was carried out using our Pressure Resilience methodology which meant that we did not use all the key lines of enquiry and the report has not been rated.

The service was last inspected in June 2018 when it was rated as Good throughout.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen.
  • Call handling performance in the NHS111 service had been sub-optimal for some time due to increased demand coupled with staff shortages. The provider had a credible plan to increase staffing to the desired levels.
  • The service was performing well in meeting the targets for patients to be seen at a primary care centre, but less well for those to be seen in their place of residence.
  • There was an effective system to manage infection prevention and control.
  • There was an effective process of ambulance validations.
  • The service respected and promoted patients' privacy and dignity.
  • The service had an experienced leadership team with the capacity and skills to deliver high-quality, sustainable care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

21/06/2018

During a routine inspection

This service is rated as Good overall. (Previous inspection March 2017 – Good overall, Requires Improvement in Safe)

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 at Integrated Care 24 Limited – Norfolk and Waveney (IC24) on 21 June 2018.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could 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:

  • Consider formal chaperone training for staff performing the role.
  • Consider how the service strategy of matching capacity and demand is communicated to non-clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

23 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Integrated Care 24 (IC24) NHS111 and out-of-hours service in Norfolk on 23 March 2017.

The service was inspected in March 2016. The inspection report was unrated and focussed on Safe and Well Led domains only. Following that inspection we issued several requirement notices to the provider to improve the service. These requirement notices related to Regulations 12 (safe care and treatment), 17 (good governance), 18 (staffing) and 19 (fit and proper persons employed). We followed these notices up during this inspection to see whether sufficient improvements had been made.

Following the inspection on 23 March 2017,overall the service is rated as Good.

Our key findings were as follows:

  • The provider had a clear vision which focussed on quality and safety.
  • There were systems in place to help ensure patient safety through learning from incidents and complaints about the service.
  • The service was consistently meeting National Quality Requirements and locally agreed key performance indicators.The primary care centres where patients were seen had good facilities and were equipped to meet the needs of patients. Vehicles used for home visits were clean and well equipped.
  • We found that the service was well-led and managed by an effective senior management team and board of directors, and their values and behaviours were shared by staff.
  • The service worked with other organisations and with the local community to develop services.
  • NHS 111 staff were supported in the effective use of NHS Pathways. Call review and audit was regular and robust in its application.
  • The service shared experience reports with the clinical commissioning group (CCG) on a regular basis which contained information on complaints, feedback from professionals, feedback from patients, incidents and accolades.

However, there was one area of practice where the provider should make improvements.

  • Record details of recruitment and induction processes for clinical staff effectively in line with Schedule Three of the Health and Social Care Act 2008.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

16 March 2016

During a routine inspection

We carried out a focussed inspection with 48 hours’ notice at Integrated Care 24 (IC24) NHS 111 and Out-of-Hours Service on 16 March 2016.

The inspection focussed on safety and leadership at the service and took place following information of concern that had been highlighted to CQC.

Overall, we found that a number of key improvements needed to be made in order to ensure that people always received a safe effective service. However, action already taken by the new leadership indicated that the service is capable of making these improvements.

We found that:

  • Systems and processes to help prevent patients being put at risk of harm were not always in place. For example, some nurses triaging patients were found to have undertaken tasks without evidence of them having had the appropriate training.
  • There were delays in patients accessing both the 111 and the GP out of hours services.
  • Although staff were clear about reporting incidents, near misses and concerns, scope for ongoing learning and/or improvement as a result of any incident was limited.
  • Systems to record whether recruitment procedures had been followed were ineffective, meaning the service was unable to demonstrate whether staff were appropriately qualified and security checked.
  • Inspectors found medicines that were out of date in some areas of the GP out-of-hours service.

However we also found:

  • The service was able to identify areas for staff development and learning, as appropriate and effective clinical audits were in place.
  • NHS 111 staff followed call procedures, to triage public telephone calls for medical care and emergency medical services, that helped them make safe and effective decisions when speaking to patients needing assistance.
  • Reviews and audits of calls to the service were regular and robust.

CQC has told the provider it must:

  • Ensure all out-of-hours staff who triage patients have been adequately trained to make clinical decisions by telephone and have been assessed as competent to do so. In addition, protocols and guidelines must be implemented to guide staff to make safe and appropriate decisions with regard to how people’s needs are assessed and dealt with.
  • Prioritise ongoing work to investigate and tackle the causes of delays relating to patient care.
  • Ensure medicines held at primary care centres are within the manufacturers’ recommended expiry dates and make sure there is an effective process for managing this.
  • Put systems in place to ensure that staff files and recruitment procedures are effectively recorded.
  • Undertake Disclosure and Barring Service checks for all staff in a timely and orderly manner.
  • Ensure sufficient and appropriately trained staff are present at all primary care centres and that contingency arrangements for staff to follow are agreed for when gaps in GP cover arise.

The provider should make the following improvements:

  • Learning relating to incidents should be shared with all relevant staff to encourage a culture of on-going improvement.
  • Staff should always use the correct prescription pads when prescribing medicines.
  • The provider should ensure all staff receive timely mandatory training and are supported in undertaking this.
  • The provider should take action to ensure all staff are aware of who the safeguarding leads are within the service.
  • All controlled drugs should be ordered from a wholesaler using the correct form, in line with Regulation 14 of the Misuse of Drugs Regulations 2001.
  • Ensure a robust process is in place for monitoring clinical equipment, to make sure that it is fit for purpose.