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We are carrying out a review of quality at Sheridan Teal House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 11 May 2020

This service is rated as Good overall. (Previous inspection March 2015 – Good)

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 Sheridan Teal House on 11 March 2020 as part of our inspection programme.

At this inspection we found:

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The service had good systems to manage risk so that safety incidents were less likely to happen.
  • Staff working at the service had the information they needed to support consistent and safe management of patients’ health needs.
  • Information was relayed to a patients’ own GPs in a timely manner, with appropriate follow up checks in place.
  • Staff told us they valued working in the service, and felt supported by the leadership team.
  • The service had an overarching governance framework in place, including policies and protocols.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The service proactively sought feedback from patients to evaluate the quality of the service being provided.

In addition, the provider should:

  • Continue to review national standards to ensure that they are met.
  • Review and improve processes to ensure that the organisation has assurance that all staff have completed mandatory training requirements such as child safeguarding training.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 11 May 2020

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.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Not all staff received up-to-date safeguarding training.
  • We found that some non-clinical staff had not received up to date child safeguarding training. After the inspection the provider sent us an updated training plan which showed their intention to further train all non-clinical staff to the appropriate level by June 2020.
  • Staff 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.
  • Staff induction, and any necessary refresher training, included infection prevention and control.
  • Staff had access to cleaning equipment, and all staff were aware of how to use universal spill kits in the event of spillage of bodily fluids. Infection prevention and control audits carried out by the host sites were shared with the provider.
  • 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.
  • We saw evidence of equipment calibration and that portable electrical appliance testing had been undertaken.
  • We reviewed three personal files and found that appropriate recruitment checks had been undertaken prior to employment, for example, evidence of references, qualifications and DBS checks.

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.
  • Systems to assess, monitor and manage risks to patient safety were sufficiently thorough. We spoke with three sessional GP’s who told us that a ‘rota master’ was used to schedule the shifts. GPs were contacted by email, text and direct phone calls in order to fill the shifts. There was an effective system in place for dealing with surges in demand. On the day of inspection we saw examples of staffing rotas. We saw that 90% of staff rotas were filled for March 2020.
  • If a GP shift wasnot filled in one site then the service either increased provision at alternative sites or employed doctors who worked from home and who were able to carry out a telephone consultation or home visit on a call-out basis, to meet demand.
  • There was an effective induction system for temporary staff tailored to their role.
  • There was an effective system in place for dealing with unexpected staff absence. Arrangements were in place to adjust staffing levels across the sites. The business continuity plan had information on how to deal with any risks associated with the rota.
  • 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 such as sepsis (a common and potentially life-threatening condition triggered by an infection) and emerging conditions such as COVID-19 (coronavirus).
  • The service had instructed GPs to ensure severe infections were reviewed as part of their clinical assessment of patients. Urgent care centres had written guidance for patients in relation to COVID-19 and staff could also provide isolation rooms for other infectious diseases.
  • Notices in the service advised patients that chaperones were available if required. We noted that a few drivers who may undertake chaperoning duties were not able to record their details on the patient’s clinical record. The service took action and amended their chaperone policy to include instructions on how drivers should add details to the clinical record when they acted as a chaperone (we were sent an updated copy a few days after the inspection) and all drivers had now received a copy of this. All the drivers had been contacted individually to inform them of the updated process.
  • 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 and controlled drugs minimised risks.
  • The service kept prescription stationery securely and monitored its use. Prescriptions were locked in a cupboard when not in use; records showing which printer they had gone into were maintained. All individual prescriptions were logged giving the patient’s NHS number, medicines prescribed and quantity.
  • We saw copies of antibiotic audits that had taken place in the last year. These looked at a variety of conditions, appropriate indication, duration and choice of antibiotics. There was a poster being developed which would be used along with feedback to clinicians to continue to encourage reductions in inappropriate prescribing. The main improvement from the audits was the reduction in the number of clinicians administering seven-day antibiotic courses, and a movement to five-day courses of antibiotics, where appropriate.
  • Patient safety and medicine alerts were reviewed by the management team, a recent change in the patient information leaflet for ibuprofen, a nonsteroidal anti-inflammatory medicine (can be used to treat painful conditions such as toothache, pain after operations and headache, including migraine) resulted in a new information leaflet being made available to all clinicians.
  • There were appropriate systems in place for managing medicines, including medical gases, emergency medicines and equipment. The service had reciprocal arrangements in place with their host sites for obtaining, maintaining and monitoring emergency equipment, including defibrillators and oxygen. Each site had a supply of emergency medicines, which was checked and overseen by LCD staff.
  • Staff demonstrated that medicines prescribed to patients, and advice and information given to patients in relation to medicines, were in line with legal requirements and current national guidance. The service had recently revised the guidance provided to patients about antibiotic prescribing for children with upper respiratory tract infections.
  • Palliative care patients were able to receive prompt access to pain relief and other medicines required to control their symptoms.

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.
  • Joint reviews of incidents were carried out with partner organisations, including the local NHS 111 service and urgent care services.

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.
  • For example, records showed that an incident had been logged whereby a patient with Type 1 diabetes had not been asked at triage stage if they had the ability to test their own blood glucose level. Following this incident, the next edition of the provider’s ‘Learning From Experience’ clinician’s bulletin included an article highlighting the importance of how this information would help determine whether a face to face assessment was required (and the level of urgency) or whether an emergency ambulance was required.
  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.



Updated 11 May 2020

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. The clinical lead for the extended hours service emailed information and alerts to individual staff members. The clinical pharmacist also took a lead role in reviewing, circulating and responding to medicines and patient safety alerts.
  • Telephone assessments were carried out using a defined operating model. Staff were aware of the operating model.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • 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.
  • Technology and equipment were used to improve treatment and to support patients’ independence. For example, the use of video consultations for patients living in care homes.
  • 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. Where appropriate clinicians took part in local and national improvement initiatives.

  • 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 NQR are used to show the service is safe, clinically effective and responsive. Providers are required to report monthly to their lead clinical commissioning group (CCG), Greater Huddersfield, on their performance against the standards which includes: audits and response times; whether telephone and face to face assessments happened within the required timescales; seeking patient feedback and actions taken to improve quality.
  • Local Care Direct (LCD) was also required to submit data to its commissioners on a monthly basis indicating the effectiveness and efficiency of the ‘West Yorkshire Urgent Care’ (WYUC) service.
  • We reviewed the most recent, complete dataset for the service, January 2020 which included a range of local and national performance indicators.
  • We noted that all local indicators had been met by the service. For the National Quality Requirements (NQR) there was one indicator, NQR12, where the service’s performance was outside the target range.
  • NQR12 sets standards for the percentage of cases which must be responded to within the timescale set via clinical assessment. There are three classes of response and LCD had not met two of the three in the period reviewed. The three classes are NQR12a – patients seen within one hour; NQR12b – patients seen within two hours; NQR12c – patients seen within six hours. NQR12a and 12b were not met and NQR12c was borderline (amber status as defined in the Greater Huddersfield CCG contract).
  • The data showed the following:

    • For NQR12a, 492 of 642 patients were not seen within one hour (77%), these patients were seen within the next hour.
    • For NQR12b, 1,833 of 5,324 patients were not seen within two hours (35%), these patients were seen within the next hour.
    • For NQR12c, of the six hour appointments, 396 of 4,908 patients were not seen within six hours (8%), these patients were seen in the next hour.

  • We were told that the service undertook audits on all calls that did not meet the NQR time frame to identify if this had caused an adverse outcome for the patient. The audits showed that no adverse outcomes had occurred.
  • LCD had been unable to meet NQR 12a and 12b since 2013 when a new contract and specification was put in place and NHS111 became the front end of the urgent care pathway. This had resulted in a significant increase in the volume of cases sent to the service and an increase in the acuity which was not foreseen and therefore not reflected in the contract specification.
  • For example, the service was contracted to respond to 160,000 cases per annum but had dealt with up to 265,000 cases per annum since 2013. The number of cases where responses were necessary within one hour or two hours was expected to be between 27% and 35% of all cases but was more than 60%. Responding to one hour and two hour cases on a timely basis required significantly more clinical resource.
  • The issue was escalated formally to commissioners in May 2013 and had been the subject to discussion at every monthly contract meeting, several workshops and an independent review.
  • The service had implemented a programme of work to address the issues and ensure patient safety was not compromised.
  • The independent review ensured that the failure of the NQR 12a and 12b had not resulted in a patient safety risk. The work included numerous developments of operational protocols around comfort calling of patients in the clinical call back queue with safety netting advice (using a custom built template to record responses), audits of patient outcomes (shared with commissioners), audits of patient re-attendance in other services (shared with commissioners). We looked at minutes of meetings with commissioners where this was discussed.
  • We saw minutes of engagement meetings which showed that commissioners had acknowledged that the challenges facing the service in respect of NQR 12 were understood and recognised as a shared risk requiring a shared solution as part of urgent care transformation plans.
  • The service made improvements through the use of clinical audits. There was evidence of action to resolve concerns and improve quality.
  • We looked at three single-cycle audits in detail.

    • Antibiotic prescribing for lower urinary tract infections (UTIs), the audit considered the indication for prescribing, choice of antibiotic, duration of the prescription and method of testing urine for protein, sugar and other abnormal constituents. The service evaluated lessons learned. Key lessons were recorded in an article in the November 2019 clinical bulletin to all staff. This included a reminder to follow the NICE guidelines for antibiotic prescribing.
    • An audit of 30 patient records to review whether entries were in standardised and in line with best practice guidelines had been undertaken. The results showed that two consultations included all observations; 24 records showed most observations were recorded and in four cases there were no observations recorded. The. key lessons were shared in an article in the November 2019 clinical bulletin which was shared with all staff.
    • Sepsis audit on recording the seven parameters for sepsis assessment: 50 patient records were sampled. Feedback had been given to clinicians regarding consistent recording of these parameters. A new template was developed as a result of audit and shared on the clinical IT system for all clinicians to use. The results of the audit was sent to all clinicians via a clinical bulletin, with emphasis on the importance of recording observations. An auto-consultation recording tool was being developed to prompt and ease the recording of observations on the clinical IT system.

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 and infection prevention and control.
  • We found that some non-clinical staff had not received up to date child safeguarding training. After the inspection the provider sent us an updated training plan which showed their intention to further train all non-clinical staff to the appropriate level by June 2020.
  • 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 enable them to meet them. Up to date records of skills, qualifications and training were maintained. We saw that the IPC (infection prevention and control) lead carried out IPC face to face training for new staff.
  • The service had developed two e-learning packages for clinical and non-clinical staff.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.
  • We also looked at a ‘HR Training and Development’ report from March 2020. This showed that all staffed had completed mandatory training and performance development reviews in the last 12 months.

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 and when they were referred to other services.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patients with specific vulnerability factors were identified via a ‘flagging’ system on the patient record. Most practices whose patients accessed this service shared a common clinical system, as did many community staff.
  • Staff could access a summary care record for patients registered at practices which used a different clinical system.
  • Staff communicated promptly with patients’ registered GPs so they were aware of any need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • 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 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 and transfers to other services. 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. The staff had been instructed to go to the door to greet the patient at the primary care centre if they were having difficulty communicating.
  • 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. We saw copies of consent being recorded on the clinical records with regards to discussions and planning of care records.
  • The provider monitored the process for seeking consent appropriately.



Updated 11 May 2020

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. 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.
  • Of the 64 CQC patient comments we received across all the sites, only three contained less positive as well as positive comments. Positive comments all eluded to a kind, caring and efficient service, with respectful and professional staff. Less positive comments referred to waiting times or receptionists asking too many questions.
  • We observed interactions between staff and patients and found staff showed a calm, friendly and welcoming manner. A lead member of staff told us about a patient who was visited by the OOH (Out Of Hours) doctor late at night. The patient needed medication that the service did not stock and the patient was unable to collect it. The visiting doctor and driver went to the pharmacy and collected the medication and took it back to the patient so that their treatment would not be delayed.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given).

  • Interpretation services were available for patients who did not have English as a first language. 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.
  • 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.
  • The provider also carried out a patient survey annually. The latest survey (October to December 2019), from which 764 responses were received, showed that:

    • 98% were highly likely or likely to recommend the service to family and friends
    • 100% understood the advice they had been given
    • 99% felt listened to and reassured
    • 100% felt the staff were friendly and helpful
    • 99% felt they were treated with care and concern

  • Areas for the provider to consider included:

    • Comments with regards to access for hearing impaired patients, where there was use of an intercom buzzer entry system. The staff had been instructed to go to the door if a patient was having difficulty communicating.
    • Following on from the patient survey the service approved replacing all the signage at Wharfedale General Hospital as the site had achieved UTC (urgent treatment centre) designation.
    • Individual comments about doctors’ attitudes were also fed back and a record was made in the Datix (patient safety web-based incident reporting and risk management software). If the same doctor had constantly received negative feedback this would be raised with them on an individual basis or by the clinical governance team.

  • All appointments were 15 minutes in length with GPs and advanced nurse practitioners to facilitate effective communication.
  • 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 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.



Updated 11 May 2020

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. For example, records showed that the provider had increased the size of its home visit fleet in recognition of the growing older population and the increased likelihood of home visits. The fleet increased from 18 to 23 to incorporate additional cars for patient transport services in order to transport patients to and from appointments at the primary care centres.
  • The provider engaged with commissioners to secure improvements to services where these were identified. For example, records showed that the provider had increased the number of sessional clinicians and this was growing at a steady rate. The service had a continual recruitment of sessional clinicians, on average they ran induction for 10 to 15 clinicians per month.
  • 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.
  • 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.
  • LCD was a provider of a ‘Special Access Services’ called Safe Haven. The Safe Haven service accommodates patients who have been excluded from mainstream primary care, and ensures that they receive the same level of patient care as everyone else. The Safe Haven service did not form part of our inspection.

Timely access to the service

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

  • All sites were open for patient appointments between 7pm and 8am Monday to Friday, and on a weekend from 6.30pm Friday to 8am Monday.
  • Patients could access the service either as a walk in-patient at the urgent care centres, via the NHS 111 service or by referral from a healthcare professional. Patients did not need to book an appointment.
  • The service had an appointment booking system in place to facilitate prioritisation according to clinical need; more serious cases or young children were prioritised. The reception staff had a list of emergency criteria they used to alert the clinical staff if a patient had an urgent need. The criteria included guidance on sepsis and the symptoms that would prompt an urgent response. The receptionists informed patients about anticipated waiting times.
  • Waiting times, delays and cancellations were minimal and managed appropriately. Where people were waiting a long time for an assessment or treatment there were arrangements in place to manage the waiting list and to support people while they waited.
  • The service engaged with people who were in vulnerable circumstances and took actions to remove barriers when people found it hard to access or use services.
  • Where patients’ 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.

  • The provider had developed a complaints form which was used when patients wished to make a complaint. The patient facing sites displayed information to guide patients specifically how to make a complaint about the extended hours service. This information was also available on the LCD website.
  • Only one complaint had been received by the Health service Ombudsman in the last year.  We saw that the service had contributed appropriately with information pertaining to the aspect of the complaint.
  • The service learned lessons from individual concerns, complaints and from the analysis of trends. It acted as a result to improve the quality of care.



Updated 11 May 2020

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 managers were accessible throughout the operational period, with an effective on-call system for staff 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 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. We saw that the vision was displayed on all LCD computer screens.
  • 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 that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values.


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 we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff, including nurses, and sessional staff 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. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • The service held fortnightly operational meetings and monthly board meetings. Communication with staff was via email or verbal feedback in meetings.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. The provider had recently refreshed several policies and procedures to support good governance, for example in the form of an appraisal policy, recruitment and induction policy. These policies were fully implemented and embedded.

Managing risks, issues and performance

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

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.

The provider had processes to manage current and future performance of the service.

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

Leaders had oversight of MHRA (Medicines and Healthcare Regulatory Agency) alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the Greater Huddersfield clinical commissioning group (CCG) as part of contract monitoring arrangements.

  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • The provider had developed a corporate risk log, which had been rated as red, amber or green to monitor and review identified risks. This included risks to quality and safety, compliance with regulation and workforce issues.
  • The provider had plans in place and had trained staff for major incidents.
  • The provider implemented service developments and where changes were made this was with input from clinicians to understand their impact on the quality of care. For example, a major service change involved the introduction of the MDT (multidisciplinary team)meetings. Also a ‘Physician Associate Preceptorship Programme’ was introduced which enabled a new healthcare professional who, while not a doctor, worked to the medical model, with the attitudes, skills and knowledge base to deliver care and treatment under defined levels of supervision.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.
  • Comprehensive data analysis was used to understand the detail behind the headline KPI (Key Performance Indicator) performance such as detailed patient outcome audits, breakdowns of clinical productivity and performance and a detailed root cause analysis of the factors leading to performance failures.
  • Evidence demonstrated how the performance and analysis had been shared and discussed with commissioners at monthly contract and clinical quality meetings and with other partners. Also the use of an independent review to determine underlying structural causes.
  • The development of operational and clinical protocols within the care pathway to ensure the safety of patients at all times.
  • The development and implementation of additional support roles within the WYUC (West Yorkshire Urgent Care) team to ensure patient safety.
  • The use of electronic systems and support tools to ensure clinical safety.
  • Effective clinical governance procedures to flag incidents and complaints and assurance gained through these processes in respect of patient safety.
  • A declining trend of complaints was recorded over the last 12 months and a very low rate of serious incidents.
  • High levels of service user satisfaction and ‘Friends and Family Test’ (FFT) results demonstrated from ongoing patient surveying of hundreds of patients each quarter.
  • 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 were able to describe to us the systems in place for them to give feedback. For example staff had access to a clinical tool which enabled them to raise issues and report them to management.
  • 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.
  • We saw copies of awards that the service were nominated or shortlisted for. These included:-

    • 2018, winner of the ‘Social Enterprise UK Award for Innovation’.
    • 2018, finalist in ‘Innovation Awards for Software & Telehealth’.
    • 2019, winner of the ‘HSJ (Health Service Journal) Partnership Awards’, partnership in innovation award for a bespoke application which helped services to manage availability of the clinical workforce.
    • 2019, shortlisted in ‘HSJ (Awards Partnership Award) for a bespoke application which helped services to manage availability of the clinical workforce.

  • The service had developed and was currently using the bespoke application. Local Care Direct, Doc Abode and ‘Yorkshire and Humber Academic Health Science Network’ had partnered to develop and trial the application. This was a real-time clinician deployment platform that safely connected a multi-disciplinary clinical workforce to NHS patient needs based on availability, proximity and expertise. The overall effect improved workforce capacity and patient outcomes in urgent care through digital innovation.
  • The benefits for clinicians were that the application provided a sustainable and motivational pattern of work and encouraged increased participation. For healthcare providers it provided access to a wider, more flexible workforce, improved operational resilience and efficiency, reduced clinical risk and minimised unscheduled hospital attendances. For patients it delivered speedier, more personalised care, and improved their experience and outcomes.
  • There were systems to support improvement and innovation work.