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Archived: i-HEART 365 Service - Extended Hours Good

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 17 January 2019

This service is rated as Good overall. (Previous inspection February 2018 - Inadequate)

The key questions now 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 i-Heart 365 Service - Extended Hours service on 14, 16 and 17 November 2018 to follow up on breaches of regulations and inspect a service in special measures. 

We previously carried out an announced comprehensive inspection of the service on 13 and 14 February 2018. Our overall rating for the service was inadequate and inadequate for providing safe, effective, responsive and well-led services, it was rated as good for caring. We served warning notices for breaches in relation to Regulation 16: Receiving and acting on complaints and Regulation 18: Staffing. 

At this inspection we found:

  • The service had reviewed the 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 had introduced systems to review the effectiveness and appropriateness of the care it provided. It had 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.

We observed one area of outstanding practice:

  • The provider had reviewed the identification and management of sepsis across all its services and routinely recorded patient observations in the face to face settings to calculate early warning scores. They had been proactive by sharing and promoting this work with other organisations across healthcare pathways and had contributed to the review of external incidents relating to sepsis led by other organisations.

The areas where the provider should make improvements are: 

  • Review checking of emergency medicines and equipment in line with the Resuscitation Council UK guidelines.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 January 2019

At the previous inspection we rated the service inadequate for providing safe services. This was because systems processes and services were not adequate and did not keep patients safe at all times.

We rated the service as good for providing safe services.

Safety systems and processes

The service had reviewed the 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 accessible to all staff  andthey 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.
  • 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.
  • The system to manage infection prevention and control had been recently reviewed and the provider was liaising with the landlords of the premises in relation to the areas they occupied.  Audits had been undertaken and action plans drafted to identify areas for review.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were 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. The provider also delivered the out-of-hours service and could direct patients to this service, if required. Patients were booked into planned appointments slots to manage the demand for the service.

  • There was an effective 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. For example, all call taking staff referred to a protocol to rule out emergency symptoms and to refer the patient to the most appropriate care. For patients who were seen at the service, clinicians took and recorded the patients observations to calculate the early warning score to identify potential sepsis cases. 

  • 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, the patients own GP practice 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 to minimise risks. The service kept prescription stationery securely and monitored its use. However, we noted gaps in the historical monitoring of the emergency equipment at both the Chapelfield and Woodlands sites and some medicines were checked daily whilst others, such as the oxygen, were checked monthly.
  • Staff prescribed medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service planned to audit antimicrobial prescribing in the near future.

Track record on safety

The service had a reviewed the safety elements of the service.

  • There were now 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 patient's own GP practice, the out-of-hours service, NHS 111 and urgent care services.

Lessons learned and improvements made

The service reviewed the way it 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, we reviewed a breach of infection, prevention and control procedure. The incident record captured the investigations undertaken and the learning from the incident.  All staff were reminded to ensure infection prevention and control procedures were followed when performing tests.
  • 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 17 January 2019

At our last inspection we rated the service inadequate for providing effective services. This was because care provided to patients was not reviewed in a systematic way.

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

The provider had reviewed the 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) via the patient record system and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed through review of documented patient records.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. For example, patients could be referred onto other services such as the mental health team or back to their own GP for continuation of care.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Every attendance at the service is routinely notified to the patient’s own GP. The provider told us they planned to set up a system to notify patients’ GPs when a patient had attended the department on more than three occasions over a four week period.There was a system in place to identify patients with particular needs. Care plans, local guidance and protocols were in place to provide the appropriate support. We saw no evidence of discrimination when making care and treatment decisions.

  • Call taking staff followed protocols to ensure those patients requiring more urgent treatment were directed to the most appropriate service. These were agreed with senior staff and clear explanation was given to the patient or person calling on their behalf.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had introduced a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. A review of all nursing and medical staffs consultation notes with patients had been completed.  Those staff who scored less than 70% were offered supervision and development reviews. A second set of audits completed of those offered supervision demonstrated an average of 27% improvement.

The provider monitored the utilisation of appointments and shared this with the CCG.  Between 61% to 83% of appointments had been used over the last six months.

The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. Following an incident relating to sepsis at one of the providers' organisations, the provider had reviewed its approach to identifying and managing sepsis.  Posters alerting patients to the symptoms of sepsis were put up in clinical areas and the sepsis pathway for clinicians in consulting rooms.  All clinical staff attended a training session which included the importance of taking and recording the patients observations to calculate the early warning score. The sepsis protocol on the patient record system was activated across all of the providers services. Between January 2018 to October 2018 the sepsis protocol was triggered 291 times. Following a review of  the medical records, it was identified sepsis was unlikely in 235 cases, in 34 cases sepsis may have been present and 16 red flag cases were identified where the patient received emergency intervention. The provider also trained staff in the importance of communicating the early warning score to the ambulance service and the emergency department.  

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, sepsis and management of infection prevention and control.
  • 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.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable through the review of consultation records.

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. Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example, staff could have access to the patient's record to review existing care plans to contact the other agencies involved. 
  • Staff communicated with patients registered GPs within a specified timeframe 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 callers were referred to other services for support as required. Call taking staff referred to a protocol to rule out emergency symptoms and refer the patient to the most appropriate care.
  • The service had formalised systems with the NHS 111 service to book patients with specific symptoms into appointments with GPs and nurses to be seen. 
  • There were clear and effective arrangements for booking appointments, transfers to other services, and dispatching ambulances for people that require them. 

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. For example, referring tpeople to schemes to help them get fit for any future surgical interventions.

  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given. For example, details of stop smoking services available locally.
  • 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 17 January 2019

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. Call takers gave people who phoned into the service clear information. There were arrangements and systems in place to support staff to respond to people with urgent health care needs. 
  • All of the 65 patient Care Quality Commission comment cards we received were positive about the service experienced. This was is in line with other feedback received by the service.

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. 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 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 patients 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 17 January 2019

At the previous inspection we rated the service requires improvement for providing responsive services. This was because complaints were not consistently investigated and responded to.

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 two sites where the service was delivered from were on opposite sides of Barnsley town centre. The provider met regularly with commissioners to review the service performance. 
  • The provider improved services where possible in response to unmet needs. For example, for those who could not visit their own GP practice during normal working hours.
  • The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. Care pathways were appropriate for patients with specific needs, for example those at the end of their life, babies, children and young people.
  • The facilities and premises were appropriate for the services delivered.

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 on the day they contacted the service either by ringing to make an appointment or booked into an appointment by the NHS 111 service.

The telephone lines to make an appointment were open:

  • Weekdays from 4pm to 6pm.
  • Weekends and bank holidays from 8am to 9.30am

The service was open:

  • Weekdays from 6.30pm to 10.30pm
  • Weekends and bank holidays from 10am to 1pm.

  • Waiting times, delays and cancellations were minimal and managed appropriately, mainly due to patients being booked into an allocated appointment with a GP or advanced nurse practitioner.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Patients reported the appointment system was easy to use.

Listening and learning from concerns and complaints

The service had reviewed the approach to managing complaints and a patient liaison team was established at the provider headquarters for patients to contact and provide feedback. Concerns and complaints were taken seriously and the service 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. Three complaints were received since our last inspection in February 2018. We reviewed the complaints and found that they were satisfactorily handled in a timely way.
  • The service learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. For example, a member of staff reflected on their communication style following feedback from a patient to consider ways of effectively communicating with patients in the future.

Well-led

Good

Updated 17 January 2019

At the previous inspection we rated the service inadequate for providing well-led services. This was because systems and processes were not embedded to manage services safely.

We rated the service as good for being well-led.

Leadership capacity and capability

Following the last inspection the provider implemented a new company structure. Management  roles and responsibilities were reviewed which resulted in new leaders and managers being recruited. Current 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 was in the process of implementing 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 patients, staff and external partners.
  • 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 area. 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. For example, patients and their relatives were invited into the service to be informed of learning following incidents. 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 with the development they need. This included appraisal and career development conversations. All staff had 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 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 and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • 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 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 audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. 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 had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • The provider 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 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. For example, the provider reviewed how patients provided feedback to the service and created a patient advice and liaison department with dedicated staff for patients to contact.  
  • Staff were able to describe to us the systems in place to give feedback directing patients to the advice and liaison department. 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 systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service. The provider had reviewed the identification and management of sepsis across all its services and routinely recorded patient observations in the face to face settings to calculate early warning scores. They had been proactive by sharing and promoting this work with other organisations across healthcare pathways and had contributed to the review of external incidents relating to sepsis led by other organisations.
  • 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.