Practice Plus Group - NHS 111 Devon

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

The service had a learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were adequate numbers of staff with the right skills, qualifications and experience. The provider was aware that there were shortfalls in clinical advisors and was proactively trying to recruit to these roles. Managers made sure staff received training and regular appraisals.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. The provider had processes for staff to report incidents, near misses and safety events. These included timescales for completing investigations and sharing of learning.

The process for Patient Safety Investigations as a result of significant events included holding a patient safety conference within 48 hours and ensuring people who use the services and other relevant people were included in these conferences. These were in-depth no blame reviews when incidents or near misses occur.

As part of investigations into significant events and complaints, the provider was able to listen back to NHS 111 calls and when needed further training would be provided to health advisors and clinicians to promote good practice.

The service had a system for the auditing of systems and processes. A central team from the wider organisation carried out audits and identified areas of good practice and improvements needed. These were shared across all services where the provider was registered.

There was a system to monitor incidents and complaints. This included undertaking an investigation led by a patient safety review group into the cause and identify actions to address the concerns. When needed the provider liaised with external services to make changes to the NHS Pathways (NHS Pathways telephone triage system is a clinical decision support system (CDSS) supporting the remote assessment of callers to urgent and emergency services.) to improve navigation through the system and improve outcomes for people. For example, an incident happened where an ambulance was needed but had not been sent. The service identified there was a stage in the NHS Pathways which had options to choose from. This meant the incorrect disposition was generated. (A disposition is the final clinical recommendation or outcome determined after a person completes a symptom assessment.) The service reviewed the calls and requested that a change was made to NHS Pathways when it was updated to prevent this occurring again, this was due to be put in place.

Managers and relevant staff attended Devon Integrated Urgent Care Service Quality catch-ups and monthly quality assurancemeetings to monitor progress on investigations and actions that had been taken. When appropriate we saw apologies were provided in line with Duty of Candour.

End-to-end reviews of people’s experience took place with stakeholders, such as the ambulance service, ensuring improvements could be made. For example, they had established a process to re-direct people to the most appropriate service, regardless of where the initial contact was received, online or by telephone, providing a consistent response and a more efficient use of resources.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The system used was an interlinked series of algorithms, or pathways, which link clinical questions and care advice, leading to clinical endpoints. Non-clinical Health Advisors were presented with a series of questions. Based on the answers given, the most appropriate clinical response with a specific level of care and the timeframe was reached. Questions were asked in a clinical hierarchy, so life-threatening questions were asked early in the call, progressing through to questions about less urgent symptoms.

Requests came into the service either by telephone or online. Online requests were placed automatically into the queue for review and were tagged to show that these had originated from the NHS 111 online national system. If the service needed to go into national contingency due to high demand, the link to the NHS 111 national online system would be turned off manually.

NHS 111 National Contingency refers to plans for ensuring the 111 urgent care service remains operational during extreme pressure, allowing providers to reroute calls to other services or regions for support, often triggered by high demand (like winter pressures) to manage patient flow and prevent system collapse, ensuring people get directed to the right care even when local capacity is overwhelmed. It is a strategic plan for NHS 111 providers to share call volumes and capacity when local services are overloaded.

When calls were received into the service, health advisors would complete the NHS Pathways which would provide a disposition, such as a callback by a clinician, an appointment with an out-of-hours GP or in-hours GP. If an out-of-hours GP appointment was needed information would be sent to the provider of this service and the person would be contacted by them with a time to attend.

Each type of disposition had a timeframe in which a person should be either contacted or seen. This information was monitored with the aim of ensuring that the timeframe was not breached. If needed the service would make a patient safety call to explain why there was a delay. Worsening advice was given at the end of each initial contact. If a safety call had to be made, this provided information on what a person would do if their condition got worse, they would be advised to either call the NHS 111 service back or seek help from their local AE if needed.

We reviewed data related to disposition outcomes and key performance indicators (KPI) for September 2025. During this period a total of 35,935 calls were received, the service was contracted for 33,508 calls, with 32,892 answered and found:

Proportion of calls abandoned (KPI 1 is a target of less than 3%)

• A total of 530 calls were abandoned which was 1.59% of the calls received; and the year-to-date figures were 1653 calls abandoned which was 0.79% of calls received.

Speed to answer calls within 120 seconds (KPI 3)

• The average time to answer calls was 195 seconds; and the year-to-date average was 102 seconds.

Proportion of call-backs assessed by a clinician in an agreed timeframe (KPI 4- target 50% or above)

• A total of 4489 (38.9%) of calls (were assessed by a clinician within an agreed timeframe. The figure for the year to date was 33475 of calls (45.57%)

Proportion of calls initially given a category of 3 or 4 for ambulance disposition that received remote clinical intervention (KPI 5- target 95% or above)

• A total of 3768 dispositions (81.98%) received clinical intervention. The figure for the year to date was a total of 26361 dispositions (91.26%).

Proportion of callers allocated the first service type offered by directory of services (KPI -target 80% or above) was 17092 (81.04%).

The KPIs indicate how well the service was responding to people’s needs. For example, if there were high percentages of calls being abandoned this means that people may not get the care, treatment or advice that they need in a timely manner. Ambulance dispositions were reviewed to ensure they were appropriate for the person’s needs and clinical intervention enabled the ambulance to re-prioritise to a higher category, and therefore a quicker response time when needed.

One area where the service knew they needed to improve was meeting the target to ensure clinical callbacks were made within the appropriate timeframe. The service was in the process of implementing a project to analyse data to see where gaps were and how improvements could be made. The factor which was affecting this particular KPI was the availability of clinicians to make these calls. The provider was actively recruiting more clinicians and was reviewing rotas to identify where the shortfalls were.

Data provided by the service, showed that 33 clinical roles had been fulfilled within the first 4 months of 2024. This equated to 22 full-time staff. The service had 29 permanent clinical staff at the time of the inspection. An NHS England campaign to recruit clinical advisors into the 111 service had seen a good uptake with 11 clinical advisors recruited up to February 2026.

Additionally, Clinical Advisor (CA) staffing had grown by 80 staff (over 50% more) since January 2024, with over 40 CAs recently recruited to the service and a new advertising campaign was in place for January 2026. The service utilised agency CAs while recruitment campaigns were in progress.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies set out definitions of abuse; what actions should be taken; and what training staff should receive. Policies and procedures were known to staff. Training records showed all staff had received safeguarding training at an appropriate level to their role.

Quarterly meetings were held with the safeguarding leads for the service and the Integrated Care Board (ICB) nurses (ICBs are NHS organisations responsible for planning, commissioning, and managing local NHS budgets and services). When needed additional meetings were set up depending on concerns received.

The service also held internal safeguarding meetings with the wider Practice Plus Group to share learning and review safeguarding cases.

A report was produced for executive leaders, on a quarterly basis which formed part of the executive board report, and this included findings from the safeguarding audits.

Agreements with other services were in place to share information of concern related to children. Alerts were placed on records of children who were vulnerable, which the service could see when providing advice.

Staff were provided with support if they had to make a referral and needed time to de-brief following what may have been a difficult or distressing case to manage.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were advised on risks related to their condition and actions to take if their condition deteriorated. This could be to attend a walk-in centre, an appointment with the out-of-hours doctor, or a clinical call back within a set time frame. People were informed of the outcome and at the end of each assessment through NHS Pathways people were provided with worsening advice. They were advised to either call the NHS 111 service back for further assessment or attend AE.

If the health advisor handling the call had concerns about the person who was calling, they could seek advice from their operations manager or a clinician. If needed a clinician could take over the call; or the call could be transferred to a clinician. This is known as a ‘warm transfer,’ which enabled prompt assessment of a person’s symptoms.

People who were waiting for a clinical callback were placed in a queue which was monitored; if the timeframe was due to elapse, then a patient safety call would be made. This was to inform the person that there was a delay and to check whether their symptoms worsened. If needed the timeframe could be adjusted so they would be contacted by a clinician sooner. A blended model was used for patient safety calling. This consisted of a text message at the point of calling and a further text message based on a set of guidelines for when timeframes were about to be breached. If a person lived alone, they would always receive a callback and not a text message.

The service monitored the number of patient safety calls made and used this information to support planning staff rotas.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises used for service provision were maintained. Health and safety risk assessments and audits had been undertaken and any risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

Arrangements were in place for safe evacuation in the event of a fire. Fire wardens would hang their tabard over the back of their chairs, so other staff could easily identify them. Routine fire alarm testing was carried out weekly. If there was a fire and staff needed to evacuate the building; then calls would be terminated with the person being asked to call NHS 111 again. The person’s assessment would then be undertaken by another NHS 111 service, as part of contingency plans in case of an interruption of the service. Staff said this had occurred and had worked well.

Where it was not safe to end a call, the national Operational Delivery Team (ODT) would be informed, and calls could be reconnected to other locations.

There was a first aid kit and defibrillator on-site which were routinely checked to ensure there was sufficient stock and the defibrillator was working.

Staff were provided with adaptations to their workstations if needed, although some staff said there had been delays in getting the equipment they needed, such as ergonomic chairs.

A policy on lone working was in place and the main entrance to the building was locked at night and only accessible by using a keycode. CCTV had been installed to cover the main entrance and car parking areas, which were also lit to promote safety. Access to the main office was by use of a fob at all times and visitors would be greeted by a member of staff.

If a team manager identified a health advisor would be lone working, the Central Operational Delivery Team would be informed, the health advisor would be stood down from their shift and asked to leave the building. If a team manager was lone working, they could remain on site, and the Central Operational Delivery Team would complete 60-minute check ins.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had a system and process for forecast planning the year ahead. This was based on staffing levels and number of calls received the previous year. The system had capacity to identify gaps and build in resilience. For example, when employees leave and the loss of their working pattern/rotation may impact the forecast plan. The planning team (responsible for the forecast) linked in with recruitment, to establish the baseline for recruitment for the year ahead, which included how many staff were already in post and how many would need to be recruited. Forecast planning was under constant review, using long line, midline and short line methods (long line forecasts for the year, midline for a 6–8-week period and short line for a 2-week period). Extra hours were added to the forecast to allow for overtime and sickness. For example, if a week needed 100 hours, the service would forecast 125 hours.

The planning and operation teams worked closely together to monitor demand and staffing. For example, on a daily, weekly, monthly and annual basis.

At times of peak demand, the service used the on-call structure for bronze, silver and gold command when required, as well as Sterile Service Delivery Period (SSDP), a way of managing peak demands and when escalation is required), whereby every employee trained in call handling is placed on the telephones.

Safe recruitment practices were followed. We reviewed 5 recruitment files and evidenced that there were effective recruitment systems and processes, and staff had all the appropriate checks prior to being employed by the service. If a Disclosure and Barring Service (DBS) check indicated concerns about potential new employees a risk assessment was carried out in line with the service’s policy. (DBS is a check which enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work).

Staff worked within their agreed areas of competence and were able to access appropriate learning and development opportunities. The services training team supported and promoted learning and skill development within the service, to ensure staff’s learning needs were met.

All staff had received an induction training programme, which required 2 assessments to be completed and passed, before they were able to commence their role. There were systems to routinely check that staff had completed mandatory training with the required timescales.

Audits were carried out on call handling in accordance with the NHS Pathways licence. Timeframes for audits were different depending on how long a member of staff had been working for the service. For example, an employee who had completed induction, had 5 calls per month monitored for a 3 to 4 month period, which once signed off after this time, changed to 3 per calls per month. Email feedback was provided to staff from these audits, which could also be accessed on the services learning management system (LMS).

The service aimed to carry out audits in the month that the member of staff was working and were structured to review areas of good practice and provide areas for reflection or learning. Feedback was provided over the telephone or in person. Feedback was provided every 3 months as routine, even when the member of staff was passing their audits. When staff had passed audits, even if there were no areas for learning feedback was still routinely given. When needed audit frequencies were increased if areas for improvement had been identified and further support was required.

There was a process for an independent review to be carried out if the member of staff did not agree with the outcome of an audit. Auditors meet regularly to discuss scoring and ‘benchmarking’ to ensure they were consistent in how they audited calls. When needed NHS Pathways was contacted to clarify points.

Information from the provider showed all audits had been carried out as required.

Staff told us of how they were supported to achieve career progression. All staff had protected time for professional development. They could use this time for completing mandatory training and build on or develop skills that benefited people’s care. Staff were encouraged to attend courses and share new skills and knowledge with the wider staff team.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks, for example routine checks were maintained on the water systems to ensure there was no sign of Legionella (a bacteria which can cause breathing problems).

The service did not store any medicines on the premises. When people needed medicines to be prescribed as part of their care and treatment, people were referred to the relevant service, such as Pharmacy First. If there were no pharmacies open then people were directed to other services for care and treatment, such as the out-of-hours doctors who kept small supplies of commonly used medicines at their bases.