Practice Plus Group - NHS 111 Devon

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The NHS 111 Service has been set up to respond to calls received by the provider. Services have been designed to respond to peoples’ needs for a short period and complete any care or treatment needed or refer people to other health and social care services, if needed.

If timeframes for call backs by clinicians were not going to be met, a patient safety call would be carried out. This was to ensure that the person’s condition had not worsened and to advise them of the delay. If their condition had worsened then a reassessment of need was carried out and the person was directed to a different service if needed, for example an appointment made with the out of hours GP.

There was a dedicated route for people contacting the NHS 111 service to access mental health support, which avoided the need to go through the call centre. The option for this was given during the introduction message of the NHS 111 call.

The service had a system that alerted staff to any specific safety or clinical needs of a person using the service. Health advisors and clinicians were able view specific information related to safeguarding and special notes on people's records. Clinicians were also able to access peoples’ summary care records which gave a high-level summary of peoples’ needs and special notes related to particular needs such as end-of-life care, known allergies and medicines they were prescribed.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service had regular meetings with other stakeholders, such as the local ambulance service, to gather information to shape service provision. The service also carried out revalidation of category 3 and 4 ambulance disposition. This was to ensure an ambulance was necessary and had been categorised correctly. If needed the category of the ambulance could be changed if the clinician reviewing the case considered the situation to be more urgent, or a person could be directed to another service who could meet their needs if a clinician deemed an ambulance was not required. In all cases if there was a change of disposition, the person would be contacted to inform them of the changes and worsening advice given.

When needed the service was required to take calls from other NHS 111 services, as part of national contingency arrangements. (NHS 111 national contingency refers to protocols used when NHS 111 providers experience significant service failures or extreme demand allowing calls to be re-routed to other providers to maintain patient safety. This ensures continuous, 24/7 access to urgent care, including clinical assessment, when local systems are overwhelmed.)

The provider was also responsible for providing NHS 111 services in England and was able to divert calls to these services which provided in-house resilience to manage demand. They had experienced issues where systems had failed and they had to activate contingency plans, such as reverting to paper based systems or request support under national or local contingency arrangements.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service had access to interpreter services. If this was required, a flag was placed onto the record to inform the clinician or anyone else accessing the record that a translator is required.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the service’s policy. Learning from complaints was evident and staff were able to identify changes made as a result of feedback, including complaints.

Themes were identified through a monthly review of all complaints. These reviews were undertaken by the Patient Safety Manager and the Quality and Patient Experience Manager. Identified themes were discussed at weekly Quality meetings and the monthly Quality Assurance Meeting, where actions were agreed and discussed as to whether the theme posed potential risk. For example, staff attitude and/or complaints about staff being rude.

The service experience callers who could be abusive towards staff. This resulted in the service establishing a ‘Challenging callers’ element to be added to the abusive caller project, to address how staff could be supported while handling calls where the caller is rude, or verbally aggressive.

Results from the national Family and Friend test (FFT) collated by the service showed:

October 2025

• Good experience increased by 0.7% since September, reaching 84.4%.
• Poor experience decreased by 1.3% since September, to 9.4%.
• Total surveys sent: 5613; surveys received: 614 (11% response rate).

September 2025

• Good experience increased by 0.1% since August, reaching 83.7%.
• Poor experience decreased by 1% since August, now at 6%.
• Total surveys sent: 4156; surveys received: 516 (12.4% response rate).

August 2025

• Good experience decreased by 4% since July, now at 67.7%.
• Poor experience increased by 3.1% since July, now at 16%.
• Total surveys sent: 5333; surveys received: 501 (9.4% response rate).

The provider had taken the action to address concerns identified from the FFT and share positive feedback with the teams. Themes identified included delays in call backs and wait times for appointments, actions taken to address these included the introduction of clinical productivity reviews at the monthly performance meeting; the introduction of clinical assessment service (CAS) hubs, to enable NHS 111 staff to book cases in directly for a time slot to call back. These cases were assigned to clinicians allocated to the CAS hubs for them to call within the disposition timeframe.

Regular rota meetings at a local level were undertaken to identify pinch points and target resource planning, monthly planning meetings with the workforce planning teams and the service effectiveness plan which is working towards improvements in CAS lower disposition cases.

Positive comments received by the service from the FFT included: helpful, quick, efficient and reassuring service. The service had also received 30 compliments for the period November 2024 to October 2025. These included comments such as impressed, friendly and thorough assessment.

The service made sure that people could access the care, support and treatment they needed when they needed it.

People could access the service to suit their needs either online or by telephone. The service engaged with people who are in vulnerable circumstances and took actions to remove barriers when people found it hard to access or use services. Referrals and transfers to other services were undertaken in a timely way when a disposition had been reached.

There was a priority option within the initial message heard when people called the service for all Devon patients on an end-of-life care pathway to use, reducing waiting times.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff treated people equally and without discrimination. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

We did not assess this quality statement as this was not relevant for this type of service.