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Inspection Summary


Overall summary & rating

Good

Updated 4 April 2019

This service is rated as Good overall. (Previous inspection January 2018– Requires Improvement).

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, follow up inspection at North Central London (NCL) South Hub on 22 and 24 January 2019. CQC previously inspected the service on 23 and 25 January 2018 and asked the provider to make improvements because although the care being provided was effective, caring and responsive, it was not being provided in accordance with the relevant regulations relating to safe and well led care.

At our previous inspection we found the provider had breached Regulation 12 (1) (Safe care and treatment) and Regulation 17 (1) (Good governance) of the Health and Social Care Act 2008. This was because staff checks were not being undertaken to the appropriate level and because the provider’s decision not to carry oxygen in home visit vehicles had not been sufficiently risk assessed. We also noted the absence of appropriate systems for sharing learning from significant events and for ensuring safety alerts improved patient safety.

The service wrote to us to tell us what they would do to make improvements and we undertook this comprehensive inspection to check the service had followed their plan and to confirm they had met the legal requirements.

At this inspection we found:

•Action had been taken since our last inspection in January 2018, such that when safety incidents happened, systems were in place to ensure learning was shared and processes improved.

•Action had been taken since our last inspection, such that Disclosure and Barring Service (DBS) checks for home visit drivers were now being undertaken to the level stipulated in the provider’s Recruitment Policy. 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.

•The service ensured care and treatment was delivered according to evidence-based guidelines.

•Staff involved and treated people with compassion, kindness, dignity and respect.

•There was a strong focus on continuous learning and improvement at all levels of the organisation.

•The leadership, governance and culture of the service promoted the delivery of high-quality person-centred care.

The areas where the provider should make improvements are:

•Continue to carry out medicines audits to ensure prescribing patterns are in line with best practice guidelines for safe prescribing.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 4 April 2019

•Action had been taken since our last inspection in January 2018, such that systems were in place to ensure learning from safety incidents was shared and processes improved.

•Action had been taken since our last inspection in January 2018 such that appropriate Disclosure and Barring Service (DBS) checks for home visit drivers were now being undertaken.

•Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

•Monitoring and reviewing activity enabled staff to understand risks and gave a clear, accurate and current picture of safety.

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.

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 regularly reviewed and were accessible to all staff. They 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.

When we inspected in January 2018, Disclosure and Barring Service (DBS) checks on home visit drivers were not being carried out to the enhanced level stipulated in the provider’s recruitment policy. At this inspection we confirmed that appropriate DBS checks were in place. 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.

There was an effective system to manage infection prevention and control.

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.

•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. In line with available guidance, 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.

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 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; vaccines and controlled drugs) minimised risks. The service kept prescription stationery securely and monitored its use. Arrangements were also in place to ensure medicines carried in vehicles were stored appropriately. Medicines were not left in vehicles when not in use.

Emergency medicines were available at the base and in home visit vehicles. When we inspected in January 2018, emergency oxygen was not carried in home visit vehicles. This decision had been risk assessed but did not consider home visit situations whereby a patient’s condition might rapidly deteriorate and where therefore, administering oxygen would be beneficial whilst awaiting an ambulance.

At this inspection, the service had conducted a further risk assessment (which included reference to CQC minimum suggested resuscitation equipment) and had concluded that oxygen was not required to be carried on home visit vehicles. However, one clinician with whom we spoke was unaware of the rationale for not carrying oxygen. Also, the risk assessment did not consider home visit situations whereby the GP could be waiting for an ambulance. 

We also noted that the provider’s risk assessment had not considered the latest CQC guidance (August 2018) which includes emergency oxygen in the list of minimum suggested equipment. When we highlighted our concerns, the provider told us that with immediate effect, they would carry oxygen in home visit vehicles.

The service carried out limited medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing. For example, we saw an antibiotic audit which had completed one cycle but actions had yet to be followed up. There were no audits of other prescribing trends.

Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The list of medicines kept had been reviewed, considering local and national guidelines, and reconciled across the service for consistency.

Processes were in place for checking medicines and staff kept accurate records of medicines. This was supported by the supplying pharmacy who supplied medicines in sealed containers which were checked and re-supplied after each period of use. This system had been strengthened following a review of incidents. Defibrillators were checked weekly and this was recorded.

Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Summary Care records were available to all prescribers to allow them to review patients' prescribing records.

Arrangements for dispensing medicines kept patients safe. Medicines were supplied to the service pre-labelled with suitable information and records were made of medicines dispensed or administered to patients.

Palliative care patients could receive prompt access to pain relief and other medication required to control their symptoms. This was supported by the NCL North Hub (Barndoc Out of Hours Service) which held stocks of controlled drugs for this purpose.

Non-medical prescribers (NMPs) were employed by the service and advanced nurse practitioners carried out some home visits. The prescribing by NMPs was not audited to ensure it was within the competency of the individual, however the service had plans to enable this with the increased use of electronic prescribing.

Track record on safety

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.

Joint reviews of incidents were carried out with partner organisations including NHS 111 services.

Lessons learned and improvements made

When we inspected in January 2018, we saw evidence that when things went wrong, reviews and investigations were not always sufficiently thorough and did not include all relevant people.

At this inspection, we noted there was an improved system for reviewing and investigating 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.

A new NCL Clinical Governance Group had also been created where significant events were routinely discussed. Staff bulletins had also been introduced to ensure learning and themes from these incidents were shared, along with the actions taken to improve safety.

When we inspected in January 2018, the service did not have a robust system to enable learning from patient safety alerts. At this inspection, we noted new protocols had been introduced. Safety alerts were now routinely disseminated to relevant staff via the service’s clinical system. For example, records showed a recent alert had been disseminated and acted upon regarding the risk of harm from the inappropriate placement of oximeter probes (these are medical devices used to measure patients’ oxygen saturation as part of their vital signs being taken). We also saw evidence safety alerts were regularly discussed at the service’s Clinical Governance Group meetings.

Effective

Good

Updated 4 April 2019

•The service ensured care and treatment was delivered according to evidence-based guidelines.

•Patients had comprehensive assessments of their needs, which included consideration of

clinical needs, mental health, physical health and wellbeing.

•Clinical audits were carried out and all relevant staff were involved. There was also participation in relevant local performance audits.

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 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 people’s needs were met. The provider monitored these guidelines were followed.

Telephone assessments were carried out using a defined operating model. Staff were aware of the operating model which included for example, use of a structured assessment tool.

Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

Care and treatment was delivered in a coordinated way which considered the needs of those whose circumstances may make them vulnerable.

There was a system in place to identify frequent callers and patients with needs, for example palliative care patients, and protocols were in place to provide the appropriate support.

Technology and equipment were used to improve treatment and to support patients’ independence. For example, the service was piloting the use of the Electronic Prescription Service (EPS) out of hours. The pilot was delivered in conjunction with NHS Digital and NCL South Hub staff spoke positively about how the new system reduced the need for paper prescriptions.

Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was meeting its locally agreed targets as set by its commissioner:

Between February 2018 and November 2018, the service met commissioners’ 2 hour average monthly target for undertaking urgent home visits.

Between February 2018 and November 2018, the service met commissioners’ 6 hour average monthly target for undertaking routine home visits.

The service made improvements using 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. We also saw evidence of regular clinical performance audits for all nurses and doctors using the RCGP toolkit. Records showed recent clinical audits had covered sepsis and high risk broad spectrum antibiotics.

We spoke with commissioners before we carried out our inspection. They had recently conducted a quality assurance visit and we noted feedback was positive on how the service monitored quality and the safety of outcomes.

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 which covered topics as safeguarding.

We looked at how the provider ensured all staff worked within their scope of practice and had access to clinical support when required. We noted that non-medical prescribers (NMPs) were employed by the service and advanced nurse practitioners carried out some home visits. However, the prescribing by NMPs was not audited to ensure it was within the competency of the individual. We noted the service had plans to enable this with the increased use of electronic prescribing.

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.

Coordinating care and treatment

Staff worked together, and worked well with other organisations to deliver effective care and treatment.

We saw records that showed 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 patients ‘registered GPs so 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. The service worked with registered GPs to develop special patient notes (where appropriate accessible to all IUC clinical staff) to support continuity of care and consistency of management.

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.

The service ensured care was delivered in a coordinated way and considered 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 require 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.

Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.

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 4 April 2019

•Staff involved and treated people with compassion, kindness, dignity and respect.

•Staff helped people (and those close to them) to cope emotionally with their care and treatment.

•People’s privacy and confidentiality were respected at all times.

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 handlers gave people who phoned into the service clear information. There were arrangements and systems in place to support staff to respond to people with specific health care needs such as end of life care and those who had mental health needs.

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 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. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.

Staff communicated with people in a way 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 4 April 2019

•Patients could access care and treatment from the service within an appropriate timescale for their needs.

•Reasonable adjustments were made and action was taken to remove barriers when people found it hard to use or access services.

•Facilities and premises were appropriate for the services being delivered.

•Improvements were made to the quality of care as a result of complaints and concerns.

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 provider engaged with commissioners to secure improvements to services where these were identified. For example, the service had introduced an Electronic Prescription Service (EPS) which made prescribing and dispensing more efficient and saved time when medication was required urgently.

The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. For example, the service used the national CPIS (child protection information system) to flag up children with care plans. The system generated an alert which was required to be acknowledged by the clinician before they could proceed with clinical note writing.

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.

The service made reasonable adjustments when people found it hard to access the service.

The service was responsive to the needs of people in vulnerable circumstances. For example, the service had developed a specialist referral pathway which aimed to ensure that callers experiencing poor mental health received a specialist intervention from mental health crisis services rather than being signposted to a hospital emergency department where they might have to wait a long time for further assessment or might not attend.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

Patients are able to access care and treatment at a time to suit them. The service operating hours are seven days a week from 6:30pm to 8am and 24 hours at weekends and bank holidays.

Patients could access the out of hours service via NHS 111.

The service did not generally see walk-in patients and a ‘Walk-in’ policy was in place which clearly outlined what approach should be taken when patients arrived without having first made an appointment, for example patients were told to call NHS 111 or referred onwards if they needed urgent care. All staff were aware of the policy and understood their role with regards to it, including ensuring patient safety was a priority.

Patients had timely access to initial clinical assessment, diagnosis and treatment.

We saw the most recent local performance results for the service (February 2018- November 2018) which showed:

oBetween February 2018 and September 2018, the service met commissioners’ 6-hour average monthly target for undertaking routine base appointments.

oBetween February 2018 and September 2018, apart from February 2018 and March 2018, the service met commissioners’ 2 hour average monthly target for undertaking urgent base appointments.

We noted the provider had acted to improve performance. For example, in October 2018, the provider secured additional commissioner funding for its clinical staffing rota. We noted the immediate impact on performance against the 2 hour average monthly target for undertaking urgent base appointments, with performance improving from 1hr:45mins (September 2018) to 1hr:24mins (October 2018).

Waiting times, delays and cancellations were minimal and managed appropriately.

Patients with the most urgent needs had their care and treatment prioritised.

Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Referrals and transfers to other services were undertaken in a timely way.

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 and it was easy to do. Staff treated patients who made complaints compassionately.

The complaint policy and procedures were in line with recognised guidance. Thirteen complaints were received in the last year and we saw evidence these had been satisfactorily handled in a timely way.

Issues were investigated across relevant providers, and staff could feedback to other parts of the patient pathway where relevant.

The service learned lessons from individual concerns and complaints and from analysis of trends. This was supported by the service’s Clinical Governance Group meetings which routinely reviewed complaints and ensured these resulted in improvements in the quality of care.

Well-led

Good

Updated 4 April 2019

•Action had been taken since our last inspection in January 2018, such that the leadership, governance and culture of the service promoted the delivery of high-quality person-centred care.

•There was an effective governance framework, which focused on delivering good quality care.

•Structures, processes and systems of accountability were clearly set out, understood and effective.

•There was an effective and comprehensive process in place to identify, understand, monitor and address current and future risks.

•Clinical and internal audit processes had a positive impact in relation to quality governance, with clear evidence of action to resolve concerns.

We rated the service as good for leadership.

Leadership capacity and capability

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 staff could 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 to deliver urgent & unscheduled patient care that was timely, consistent, safe and seamless.

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 region. 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 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. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

Staff told us they could raise concerns and were encouraged to do so. They had confidence these would be addressed.

There were processes for providing all staff with the development they need. This included appraisal and career development conversations. 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 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. Staff had received equality and diversity training. Staff felt they were treated equally.

There were positive relationships between staff and teams.

Governance arrangements

When we inspected in January 2018, although there were designated roles and responsibilities

to support good governance, the arrangements for governance and performance management were not always reliable or appropriate to keep people safe.

At this inspection we noted the introduction of a range of new governance processes and protocols. For example:

A monthly NCL Clinical Governance Group had been established to ensure clear responsibilities, roles and systems of accountability and to support good governance and management.

A new dedicated team had been established to receive and disseminate patient safety alerts.

Existing protocols had been  reviewed and updated to ensure learning from significant events was shared amongst all relevant staff.

We noted structures, processes and systems were clearly set out, understood and effective. The governance and management of pilot projects, partnerships and joint working arrangements 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 they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

There was evidence that the service’s risk register was discussed at monthly NCL Clinical Governance Group meetings; to help staff identify, understand, monitor and address current and future risks including risks to patient safety.

Performance of some employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions.

Leaders had oversight of patient safety alerts, incidents, and complaints. Leaders also had a good understanding of service performance against 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 service had plans in place and had trained staff for major incidents; and we noted these had been implemented during the Grenfell Tower fire and the Westminster Bridge terror attack.

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. The service’s Clinical Governance Group received regular updates on performance and used this information to identify and address any 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. Patient representatives told us they had been involved in shaping the service from the onset; having sat on the initial contract procurement panels and subsequently on various service improvements fora.

Staff were able to describe to us the systems in place to give feedback such as “Ask the medical director” question and answer meetings.

Staff who worked remotely were engaged and able to provide feedback through email and clinical bulletins.

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.

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.

There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in and commissioners spoke positively about how the provider routinely participated in London wide and national integrated urgent care work streams and was a regular participant in service development pilots.

For example, the provider was piloting a project which allowed video calls to be taken directly from health care professionals based in care homes. The provider was also piloting an initiative to improve care for people living with Multiple Sclerosis and whom it was suspected had a Urinary Tract Infection. In addition, in collaboration with local providers of NHS services, the provider was developing an improved method of accessing ‘Coordinate My Care’ records. This enabled clinicians to access patients’ personalised care plans and therefore aid clinical decision-making.