HealthHero - Fox Talbot House

On this page

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as Good. At this assessment, the rating has changed to Outstanding.

This service scored 91 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. Staff told us they felt confident to raise concerns and understood their responsibilities under the Duty of Candour. There were clear systems to report, investigate and learn from incidents, complaints and feedback. Safety events were reviewed promptly, and lessons were shared through daily team meetings for multidisciplinary review for risk assessment and escalation, staff bulletins and newsletters.

The service provided examples where learning had led to improvements in practice. For example, following a significant event, referral processes were updated to ensure people had the legal ‘Right to Choose’ for secondary care providers. Staff described an open, no-blame approach that encouraged reflection and continuous improvement. Leaders demonstrated transparency when things went wrong, offering timely apologies and explanations to people affected.

Learning was embedded into quality improvement activities and leaders demonstrated systematic reporting of incidents, near misses, and never events through linking Learn from Patient Safety Events (LFPSE), a national NHS platform for recording and analysing patient safety events, to best practice for learning culture. The service accessed national data for benchmarking and identifying trends. We saw evidence of learning actions taken as a result of reported events. We reviewed a sample of incidents which demonstrated how actions were taken as a result of identified learning. This went above and beyond the contractual requirements set by NHS urgent care service commissioners.

Audits on incident reporting were carried out and actions taken as a response to themes and trends. This created a culture where safety was everyone’s responsibility, and feedback was used proactively to prevent harm and improve care. Staff told us they felt supported to raise concerns.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. Systems were designed to ensure continuity of care and safe transitions between services. The service used integrated platforms such as NHS recognised clinical systems, GP Connect, and Summary Care Record to share accurate information. Proactive measures, including urgent surgery messaging and direct calls to GP practices, safeguarded people during handovers. Daily system calls and Single Health Resilience Early Warning Database (SHREWD), a real-time data platform for the UK's NHS and social care system, provided an overview to identify and manage pressures in urgent and emergency care (UEC) by showing live demand, capacity, and bottlenecks across hospitals, ambulance services, primary care, and social care. Data supported real-time risk management during peak demand. The service carried out daily system calls and weekend planning ‘tactical’ calls which collaborated with system partners and commissioners to manage risk and demand in real time. This meant the service was able to support other local healthcare providers with providing urgent care and treatment for people during busy periods, ensuring people were able to access care when needed. Leaders told us about an example of how the service implemented ‘Winter pressures’ action plans which co-ordinated rota management with integrated urgent care pathway services during peak demands to ensure the impact on activity on staff and capacity was minimised. This reduced the time in which people’s care was safely reviewed and transitioned across available pathways, improving timeliness in accessible care. As a result, the service implemented Enhanced Emergency Treatment Centre (ETC) Validation, a clinical led initiative which strengthened oversight to manage urgent care demand during one of the most challenging periods of the year. A service audit between January to April 2025 showed a total of 4514 validations of which 93% of people were contacted within a 20-minute period as a result. The national key performance target for this standard is 90%, whilst national performance averages demonstrated 65.1% for the reporting period. This showed exceptional performance to ensure people’s care was followed up to determine further treatment following remote clinical assessment. Senior clinicians applied their expertise to ensure referrals were justified, reducing unnecessary Emergency Department (ED) and Urgent Treatment Centre (UTC) attendances whilst the initiative helped preserve capacity for genuine emergencies and supported more efficient patient flow. During the previous quarter (January to March 2025), the service demonstrated an average of 81.1% of calls initially given an ED disposition received a remote clinical intervention for validation. The goal is for a clinician to validate the need for ED and, where possible, downgrade the patient to a primary or community care setting. The national target is greater than 50%, with 45.1% the national average during the reporting period. This showed the service was exceptional in supporting and transitioning people’s care to the most appropriate care setting.

Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The service worked with other providers to deliver shared care and when people moved between services. The service’s clinical system automatically sent full case details to people’s GP service for continuity of care, a process called post-event messaging. As an additional safety netting mechanism, the service carried out urgent surgery messaging which involved the service contacting a person’s GP service for any cases requiring urgent review. This would include cases for vulnerable people, or people with severe mental illness, ensuring timely follow-up. The service provided audits to demonstrate zero missed cases through human checks to ensure critical information was acted upon quickly.

The service was supported by co-ordinators. These roles were effective in bringing together multidisciplinary teams to support people with complex health and care needs, such as arranging appropriate support via service referrals. Staff told us they were aware of their role to monitor and manage care when people moved between services, such as after referral to secondary care, or admission to hospital. A review of the service’s clinical system, which formed part of this assessment, indicated people’s care were being managed in a timely manner to support transition through services. For example, people received a streamlined transition from the NHS 111 service reviewed by the clinical assessment service to determine the most appropriate pathway and managed care-planning arrangements.

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

There were designated safeguarding children and adult leads at the service. There were multi-disciplinary meetings where safeguarding issues were discussed with local healthcare partners, and these were attended by clinical and management staff. External stakeholders were invited to safeguarding meetings where relevant, such as community nursing teams and GP practices. The service worked with system partners such as ambulance services, local authorities and the integrated care board (ICB) to discuss and co-ordinate vulnerable patient care, for example in relation to child protection plans. Safeguarding was embedded in case reviews, supported by a dedicated team and robust training mapped to Intercollegiate Guidance. Automated safeguarding referrals via the service’s clinical records system ensured timely action, and staff demonstrated vigilance in identifying risks. Systems were in place to appropriately refer people to the local authorities and information was shared amongst urgent care services where required. Safeguarding and chaperoning policies were accessible to staff.

Clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

All members of staff were up to date with safeguarding training in addition to the Mental Capacity Act and the Deprivation of Liberty Safeguards which were mandatory in line with the service’s policy.

We reviewed a sample of people’s records as part of our review of clinical records and saw care plans noted how people were to be supported to remain safe. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating patient and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened. Staff worked with people to understand and manage risks holistically. Shared decision-making and co-production were evidenced through a review of clinical records, which was supported by surveys and feedback mechanisms. Audits carried out by the service included a review of how people and families were involved in clinical decision-making and risk management. For example, the service carried out monthly audits to review performance for clinical care and treatment provided by clinicians. Monthly reviews had been carried out by the leadership team. In December 2024, the service identified the recording of patient safety netting advice for staff development within patient records, from 2357 records audited. Following consistent clinician feedback and supervision sessions, in November 2025, the service reaudited clinician performance and from 1822 records reviewed, showed an improvement in the record keeping, including prescribing and onward referral information, to inform positive outcomes of care and improved audit proficiency scores on a monthly basis. Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance from records we reviewed.

There were systems and processes to monitor, escalate and manage deterioration in people’s health. The service carried out audits to review National Early Warning System (NEWS) and Paediatric Early Warning System (PEWS) scores to ensure clinicians responded safely to deteriorating symptoms. This was carried out through a sample of 10% of all clinician’s cases to inform feedback and training needs. Clinical templates were available to systematically record safeguarding information and staff were aware of how to raise concerns and clinical pathways available. The audit data spanned across three key clinical streams NEWS, PEWS, and referrals to Emergency Departments (ED), of which data reflected a positive culture of raising concerns, with over 93% proficiency in each domain.

The service utilised electronic post-event message (PEM) correspondence was used to share information with in-hours GP practices, which included safeguarding and urgent care consultation records.

There were clear escalation pathways for acting upon system pressures of the local healthcare system, known as ‘Operational Pressure Escalation Levels’ (OPELs) which included collaborative working across multidisciplinary teams for safe, effective care.

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

All incidents, hazards, and risks were logged and managed via the health and safety risk register ‘RADAR’ system. This ensured effective tracking, investigation, and learning. There was a commitment to proactively identify and address environmental risks to ensure safe environments for people. We identified from the 2025 staff survey, 95% of respondents stated they felt the service was a physically safe place to work. The service demonstrated actions had been taken as a result of health and safety feedback such as the implementation of air conditioning units installed at Chippenham community hospital due to premises issues, ensuring a safe and comfortable environment for people who used the service.

All premises and equipment were otherwise well-maintained, including regular portable appliance testing and equipment calibration. Fire safety procedures had been managed in line with the Fire Safety Act 2021. Fire safety measures were managed and regularly reviewed such as fire extinguisher servicing; emergency lighting servicing and gas safety checks, recorded within the service’s fire policy.

The service had a business continuity plan which was monitored and reviewed regularly. Staff environmental risk assessments had been carried out and there was a regular review of these to ensure compliance with UK legislation. We saw examples of workplace assessments such as Display Screen Equipment (DSE) assessments being completed and ergonomic desks provided to support wellbeing.

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

Staffing rotas were mapped against demand profiles, to ensure all aspects of the service had cover arrangements, particularly during busy periods. The service held regular meetings, to forecast service demand, using data to predict possible periods of high demand. This data was used to plan rotas flexible and to improve service resilience. We saw evidence of workforce planning tools and real-time rota management which maintained safe staffing levels. Live shift management was in operation in order to monitor delivery and the impact on safety. The service implemented additional resources should it be required due to unexpected sickness or surges in demand. For example, the ability for GPs not on rota, to carry out remote triage via secure computer systems, for short periods of time. We identified for October 2025, 88% clinical workforce; 79% service coordination and 90% urgent care assistant team rota fill with intentional resiliency for unplanned absences. The annual national average for integrated and urgent care (IUC) staff sickness and absence rates for 2025 was 6.7%, whilst national IUC clinical workforce average of 92% rota fill. Despite the service experiencing lower than expected rota fill for this reporting period, previous key performance indicators for 2025 demonstrated consistent targets achieved. For example, the proportion of call backs by a clinician in agreed timeframes and proportion of patients receiving a face-to-face consultation in an IUC treatment centre or home visit exceeded national targets. Leaders had oversight of pre-planned buffers for unplanned absences and told us about planning methods for proactive safe staffing culture.

Staff told us the service ensured staff were supported in their roles, supervision and development was in place through appraisals. The service embedded supervision processes for its’ clinical staff. The service demonstrated examples of how cases had been reviewed by a GP supervisor with their clinical staff and discussed the quality of care to ensure prescribing was in line with national guidelines. Monthly clinical skills sessions were offered to all staff, covering topics such as Basic Life Support (BLS) (for adults and children), choking, venepuncture, anaphylaxis and sepsis management. Clinical education sessions were also available. We noted some sessions, including pathology result management and end-of-life cases, were mandatory prior to completion of probation as per service policy.

Staff discussed clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who were available on each shift. There were daily slots available for clinicians to seek support with the on-the-day duty GP.

Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals. There were systems to monitor staff training compliance, and all staff had completed mandatory training in line with service policy.

All recruitment and Human Resource (HR) records were kept in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 3 members of staff and information was available and up to date in line with service policy.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe practice was mitigated and prevented lone working. Lone worker devices and the use of ‘Webfleet’ tracking supported staff safety during home visits.

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

The service had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. Risk assessments and audits were completed at all sites. Each site also had carried out legionella servicing for each of the premises which confirmed no legionella bacteria was present within the water systems. Water temperature sampling was completed to monitor fluctuations in water temperatures to prevent the growth of legionella bacteria in line with national guidelines. Clinical waste arrangements were in line with national guidelines across all sites.

There was effective IPC leadership, with policies and checks carried out in relation to cleaning records. Audit checks had been carried out in relation to the environment and hand hygiene. Staff were aware of IPC procedures to ensure cleaning standards were adhered to and were trained in line with service policy. Clinical waste arrangements were effective to ensure safe storage and appropriate labelling and segregation. We saw evidence of records to ensure identified risks had been mitigated. For example, sites had retained and stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all the infection control products stocked, alongside Safety Data Sheets (SDS). Where any infection prevention and control issues had been identified, there was a process to identify and allow for remedial actions to be taken. Staff completed notifiable disease forms to UKHSA as required, to ensure national tracking of diseases and protect the public from preventable harm. Systems always ensured adequate personal protective equipment was in place.

The service demonstrated how they went above and beyond to support local services in relation to IPC. The service provided examples of their own rapid response and coordinated action to support local care homes during outbreaks, with positive feedback received from commissioners. Respiratory hoods were available at all bases for high-risk scenarios such as unexplained fever, rash, or recent travel. The use of these hoods exceeded standard national PPE requirements. This meant staff were protected even before a diagnosis was confirmed, reducing the risk of transmission, whilst safeguarding vulnerable clinicians and people visiting the bases. Staff received specific training to identify infection risks quickly and to use respiratory hoods correctly and confidently.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the administration and recording of medicines. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. Clinicians had access to GP Connect and people’s Summary Care Records for up-to-date medication history and allergy status before prescribing, to ensure safe care and treatment. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The service collaborated with system partners such as community pharmacies, to ensure people were able to access their medicines across urgent care pathways.

Medicines were stored securely and the service held appropriate emergency equipment and medicines. The service maintained appropriate fridge temperature records where vaccines were being stored, and cold-chain protocols were followed. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and controlled drugs. Waste medicines were recorded and disposed of appropriately.

Patient Group Directions (PGD), a legal document that allows certain healthcare professionals to supply or administer a specific medicine to a pre-defined group of patients without an individual prescription had been developed for non-prescribing clinicians but were, by necessity, too restrictive in scope, so were therefore not implemented. Patient Specific Directions (PSD), a written instruction from a prescriber for a medicine to be supplied or administered to a named patient, were therefore used, so senior clinicians could appropriately support non-prescribing clinicians working at the treatment centre base or on home visits.

Leaders demonstrated there was an effective system to ensure safety alerts were acted upon in a safe way to people.

During our assessment of a sample of medicine reviews, we found documentation included sufficient information to support future care planning. The service had demonstrated medicine reviews formed part of clinical supervision and appraisal processes to improve the quality of care delivered by clinicians and for learning purposes.