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Durham Dales Health Federation Good

Inspection Summary


Overall summary & rating

Good

Updated 30 August 2019

This service is rated as Good overall.

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 Durham Dales Health Federation, on 30 July 2019 as part of our comprehensive inspection programme.

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 reviewed the effectiveness and appropriateness of the care they provided. They 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.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 30 August 2019

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.

  • All of the locations from where the services were provided, had received a previous CQC inspection which included a review of the systems for managing health and safety, fire safety, infection control and premises. The administrative team leader told us they carried out their own premises audits every month. There were health and safety polices held at each site, we reviewed the policy at the Bishop Auckland Service.
  • 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 provider carried out staff checks at the time of recruitment and on an ongoing basis, where appropriate, for the staff they employed and locums who worked in the service. Disclosure and Barring Service (DBS) checks had been 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). We saw examples of recruitment records all of which complied with the regulations.

  • 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.

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. We saw examples of staffing rotas. There was an effective system in place for dealing with surges in demand. Arrangements were in place to adjust staffing levels across the three sites. The business continuity plan had information on how to deal with any risks associated with the rota.
  • 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 sepsis. 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.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse.

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.
  • 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.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.

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.

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

Effective

Good

Updated 30 August 2019

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. There was a comprehensive document library available to staff with all standard operating procedures, safeguarding information and policies.
  • Telephone assessments were carried out using a defined operating model.
  • Patients’ needs were fully assessed. Where patients need could not be met by the service, staff redirected them to the appropriate service.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Clear referral processes were in place if staff were not able to book an appointment on behalf of the patient during their telephone consultation. These were agreed with senior staff and clear explanation was given to the patient.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had a comprehensive programme of quality improvement activity and routinely received the effectiveness and appropriateness of the care provided.

  • From 1 January 2005, all providers of out-of-hours services were required to comply with the National Quality Requirements (NQR) for out-of-hours providers. The NQRs are used to show the service is safe, clinically effective and responsive. Providers are required to report monthly to their clinical commissioning group (CCG) on their performance against the standards.
  • There were five targets set by the CCG, three NQR and two Local Quality Requirements (LQR). The management team provided us with a yearly report for the financial year 2018/2019, which showed:
  • NQR 2 was to provide electronic discharge summaries detailing all consultations to the patients practice by 8am the next day. The target was 95%, the service had achieved 100% for the whole year.
  • NQR12, for face to face consultations to be carried out within six hours for less urgent cases after clinical assessment. The target was 95%, the service achieved 100% for the whole year.
  • NQR13, for service users to unable communicate effectively in English, an interpretation service would be provided within 15 minutes of booking. The target was 90%, however no service user had needed an interpreter in the given time of the data set.
  • LQR1, frequent service users (who call more than four times per month) were to be highlighted to their registered GP. This target was met.
  • LQR2, the service were to gather data for a year, on patients onwardly referred to A and E and admitted to hospital after a paramedic phone call. This had been recorded by the service.

There was evidence that quality improvements made by the service had a positive impact for patients. For example;

  • The service had carried out an audit on medications which were prescribed by nurses using patient group directions (PGDs), which are specific guidance statements on the administration of medicines authorising nurses to administer them. This highlighted some which were unsigned and others which had been used incorrectly. Improvements were made following this inspection.
  • The service carried out an audit of antibiotic prescribing by all prescribing staff. Over a three-month period in 2018, they audited 259 prescriptions and found that 10 did not meet the prescribing standards and 45 were not coded correctly. Action was taken to correct the errors and learning points discussed with staff.
  • The service had carried out audits of usage. This considered which practice the patients were from, how referrals were received, outcomes of appointments and appropriateness of appointments.
  • There was a programme of audit of case notes to cover all advanced nurse practitioners and GPs who had created a clinical record in the service, however this had not been documented.

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, fire procedures and health and safety. The training co-ordinator had recently compiled a leaflet for the different job roles in the service setting out the type of training they required.
  • 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.
  • We saw induction information for staff who were newly working in the service or employed on a locum basis.
  • The provider carried out regular meetings with staff, which included annual appraisals.

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. Care and treatment for patients in vulnerable circumstances was coordinated with other services. Staff communicated promptly with the patient's GP practice so that they were aware of the need for further action and 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.
  • 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. This was helped by almost all of the practices the service covered, having the same clinical system so notes could easily be shared. The service had formalised systems with the NHS 111 service with specific referral protocols for patients referred to the service.
  • The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances.
  • There were clear and effective arrangements for booking appointments, transfers to other services, and dispatching ambulances for people that required them. Staff were empowered to make direct 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.
  • Where appropriate, staff gave people advice, so they could self-care. Systems were available to facilitate this.

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 30 August 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.
  • All of the 80 patient Care Quality Commission comment cards we received were wholly positive about the service experienced. Comments included, very good service, efficient, quick and timely and brilliant staff.
  • The service used the NHS friends and family test to gain feedback from patients. For example, feedback for May 2019 for the Bishop Auckland service showed that 15 of 17 patients (90%) were extremely likely or likely to recommend the service to friends and family.
  • Staff told us that clinical staff often followed up on patients the next day after their appointment if they felt worried about them to ensure they were feeling better or to see if they could be helped further.

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):

  • Information leaflets were available in easy read formats, to help patients be involved in decisions about their care. Interpretation services were available for patients who did not have English as a first language.
  • 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.
  • 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.
  • 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 30 August 2019

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 service had proactively worked with the commissioners of the service to ensure it met the needs of the patients. A public consultation had recently been carried out to ensure the service was appropriate to patient’s needs.
  • 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. The service operated at the following times:

  • Bishop Auckland Primary Care Service – 6pm to 8pm Monday to Friday, weekends and bank holidays 8am to 1pm; these services are GP led. There is an overflow service (if extra capacity is needed) Monday to Friday 12 noon to 5pm, this is advanced nurse practitioner (ANP) led.
  • Barnard Castle Primary Care Service – 6pm to 8pm Monday to Friday, weekends and bank holidays 8am to 1pm; this service is ANP led, with a GP on call.
  • Weardale Primary Care Service (Stanhope Health Centre) – 6pm to 8pm Monday to Friday, weekends and bank holidays 8am to 1pm; this service is ANP led with a GP on call.

Patients could access appointments via the NHS 111 service; they could arrange either face to face appointments or telephone triage appointments (known as warm transfers)

GP practices in the federation can book patients into appointments at the overflow at Bishop Auckland.

The service for patients requiring urgent medical care outside of these and the GP surgery hours is provided by the NHS 111 service.

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.

The complaints policy and procedures were in line with recognised guidance. There had been one complaint since the service opened in 2017. We looked at this in detail and found that it had been handled in a satisfactory and timely way.

Well-led

Good

Updated 30 August 2019

We rated the service as good for leadership.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • The management 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 had 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 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 region. The provider planned the service to meet the needs of the local population.
  • The provider monitored progress against delivery of the strategy.

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.
  • Staff told us they felt that the service was a fast-moving innovative service which focused on the needs of the 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.

  • 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.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. They identified and addressed the causes of any workforce inequality.
  • There were positive relationships between staff.

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.
  • There were a series of meetings held at the service for staff. There were fortnightly management team meetings, performance meetings, clinical and administration team meetings. We saw examples of agendas and minutes for these meetings. Where staff could not attend they had the minutes made available to them.
  • 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.

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 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 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 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.
  • Staff told us the management team listened to suggestions they made; they had changed the colour coding on the booking system for appointments to make it easier for staff and introduced a sign in and out sheet for staff.
  • Staff were aware of the systems in place to give feedback.
  • 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 within the service.
  • The service made use of internal and external reviews of incidents. Learning was shared and used to make improvements.
  • This service worked well with other services such as, the GP practices it served, NHS 111 and urgent care services.