HealthHero - Fox Talbot House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led - We looked for evidence that service leadership and management assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This service scored 86 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. All staff had contributed to the development of the service’s vision and strategy, which was kept under review.

Staff told us there was a positive team culture and they felt supported by senior leaders. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service and had a vision to deliver high quality care. The service carried out a ‘Great Place To Work Survey’ which demonstrated staff report feeling deeply connected to colleagues, striving for shared purpose and inclusive team dynamics. 80% of respondents said they ‘felt proud to work here’.

We received 72 staff feedback surveys as part of this assessment which highlighted positive themes. Staff said the service was a supportive place to work. There was a good working culture to ensure people’s outcomes were positive with a focus on reducing delays in access to care.

There were effective processes and systems for leaders to share their vision, practical experience and support with colleagues. This was shared through governance meetings and clinical discussions.

The service celebrated outstanding contributions through the service’s performance recognition awards. This initiative empowered staff to nominate colleagues who demonstrate company values and serve as role models within the organisation. Staff recognition was announced during monthly meetings and on internal platforms which helped build an inclusive culture.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Staff told us leaders at the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked across the integrated urgent care pathway. For example, leaders, including the service’s Medical Director and the Associate Director for Clinical Services regularly carried out clinical work in the service and supported clinicians during periods of high demand.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements in place as well as a whistleblowing policy.

The service had oversight of themes and trends which included positive outcomes for people, including staff being treated equally. Where constructive feedback trends were identified, leaders told us there were plans in place to review staff wellbeing and these areas were recorded on the service’s improvement plan. The service had set up new ways to support staff. For example, there was a forum where staff could share feedback and concerns informally. Additionally, there were extra communication channels to share updates about services, learn from experiences, and celebrate positive feedback through staff bulletins.

We reviewed the service’s incident management systems and processes, which demonstrated when something went wrong, people received a timely apology and were told about any actions being taken to prevent the same happening again.

There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued. For example, there were reasonable adjustments in place to support the risks posed to the health and safety for workplace display screen equipment, working whilst pregnant, lone working and movement and handling. We saw examples of Personal Emergency Evacuation Plans (PEEPs) to ensure staff with reduced mobility, sensory impairments, or temporary, long-term health conditions can safely exit buildings during emergencies. This demonstrated a commitment in supporting workforce safety. Staff had access to occupational health resources and wellbeing programmes in line with service’s Equality Diversity Inclusion (EDI) strategy. For example, the service implemented digital tools to support people with neurodiverse needs, such as using assistive technology, in completing administrative tasks. We received 72 CQC surveys as part of the inspection and staff demonstrated examples which highlighted their appreciated of adjustments being made to help them do their roles and reported they felt able to request support when needed.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service demonstrated oversight of ‘Enhanced ETC Validation’ (or simply Ambulance/Emergency Department Validation) to provide a high-level clinical review process designed to assess the appropriateness of ambulance dispatches or emergency department (ED) referrals generated by NHS 111. This safety netting process improved clinical appropriateness as well as strengthened shared decision making and collaboration with the NHS111 provider and local ambulance services. From December 2024 to March 2025, 55.2% of cases were safely managed through the Care Coordination service safety‑netting pathway, avoiding unnecessary ED attendance or ambulance deployment. 22.9% were directed to a community pathway, enabling people to receive timely and appropriate support closer to home. 18.9% required escalation to secondary care, demonstrating appropriate identification of those who genuinely needed acute intervention. Only 3% of cases required continued ambulance service involvement after clinical validation. This distribution showed the enhanced validation process prevented unnecessary use of emergency resources in the majority of reviewed cases. The high proportion directed to primary‑care and community services indicated people were able to safely receive care in lower‑acuity settings with the right follow‑up and safety‑netting in place due to leadership intervention.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. The service made use of the ‘Clinical Guardian’ system to assess clinician performance and identify areas for improvement. Audits specifically assessed the quality of consultation notes and decision-making of each clinician. Senior leaders audited call recordings and consultation notes each month to improve documentation accuracy and clinical clarity. Audit results informed capability checks and clinical training plans which reviewed knowledge of clinical tools, pathways and remote assessment methods. This improved clinical competence, aligning care and treatment with organisational expectations and Royal College of General Practitioner (RCGP) standards. There was a total of 8695 cases scored across the previous 12 month period, with 89.6% of total cases reviewed demonstrated safe care. Governance group audits involved minimum three auditors, enabling triangulated feedback and preventing individual bias.

The provider had established governance processes that were appropriate for their service. Staff were able to demonstrate how to access all required policies and procedures. Staff were able to give examples of how working arrangements had been adjusted due to past risks or incidents. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The service had a business continuity plan in place which gave guidance to staff for the preparation of major incidents. Governance arrangements prevented service disruptions should issues arose with IT systems, such as on-site servers, usage of multiple clinical systems and additional operational sites. The provider demonstrated healthcare system support by providing additional IT assistance for local community health organisations during an NHS system outage.

Information was stored securely in line with digital security standards with relevant information available in line with privacy, consent notices and general data protection regulations. This included how people’s data was used, choices regarding consent and how to protect online data through notices within the service or online via the service’s website. We noted data security processes were in place which was accredited and the NHS Data Security Protection (DSP) assessment toolkit was completed.

The service understood their duty to collaborate and work in partnership, to ensure services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service demonstrated oversight of local Integrated Urgent Care (IUC) service performance through quality framework reviews which consistently surpassed commissioned targets. The service sub-contracted the local NHS 111 contract and worked with the organisation to manage performance and developed a quality improvement plan. In line with NHS 111 IUC standards, we noted in November 2025, the local NHS 111 service received 7,260 calls of which 2.2% were abandoned against the 3% target. The mean average call answer time was 36 seconds against a target of 20 seconds. 94.4% of calls were triaged, with 50.8% of calls backs made within the 20-minute target. This meant people consistently received timely care during this period when contacting NHS 111 as a result of collaborative governance processes.

The service adapted to system pressures such as supporting local Emergency Departments (ED) during high-levels of demand that affected patient safety by deploying clinicians into a local ED. This demonstrated exceptional organisational flexibility and system‑wide responsibility. The team was awarded Health Service Journal (HSJ) awards for improving a reduction in system pressures and emergency department admissions and for ‘most effective contribution to integrated health care’ in 2024.

Staff had made adjustments to improve the coordination of their service with community healthcare services, centred on the care of those at higher risk of hospital admission. The service used additional clinical roles to provide extra support for a variety of people with more complex needs such as those who were vulnerable and assessed as frail. The service participated in several multi-agency reviews alongside NHS111, the local ambulance trust and 2 local hospitals in 2024. These reviews focused on complex cases involving multiple service touchpoints and were designed to support shared learning across the urgent and emergency care system.

For example, in May 2024, the service focused on the handling of urgent pathology results received out-of-hours. This review prompted a wider examination of how pathology cases were managed across services. This enabled key service improvements such as new standard operating procedure for managing out-of-hours blood results, staff shared learning of the importance of timely action on abnormal results and escalation process to multidisciplinary team meetings for both clinical and non-clinical staff. This led to improved communication across local services and reduced waiting times for further care and treatment when people had abnormal results.

Community providers shared positive feedback about their experience working with the service, such as community mental health and nursing teams. They highlighted a collaborative approach to monitoring and delivering care tailored to people's needs. This included support for individuals with poor mental health and those receiving end-of-life care.

The service worked with healthcare partners in the development and review of locally agreed clinical pathways. Feedback on outcomes following referrals were shared with both the service and the relevant healthcare providers. We spoke with commissioners of the services who told us that the provider was transparent and collaborative in delivering high-quality care. Local GPs also responded positively to the service being provided to their patients.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service demonstrated a proactive approach to learning and improvement, supported by structured audit programmes, clinical supervision and the use of digital tools such as ‘Clinical Guardian’ (the service’s auditing framework) and clinical triage systems. The service developed bespoke medicines optimisation audits, focusing on high‑risk medicines prescribing, controlled drugs and antimicrobial stewardship to ensure clinicians were providing evidence-based care and treatment. Between November 2024 and November 2025, 12,479 standard prescribing cases audited via ‘Clinical Guardian’, with a 95.96% positive outcome rate, demonstrating safe care and treatment was provided in relation to people’s prescribing. For example, the service audited gabapentin and pregabalin prescribing (medicines used to treat epilepsy, anxiety and neuropathic pain) which are controlled drugs that are frequently misused. Over the previous 12-month period, the audit identified 433 cases with 92.52% safe care and treatment outcomes and 2.35% outcomes of concern. The service identified particular concerns in these cases due to prescribing 30‑day quantities in urgent care settings is contrary to out-of-hours controlled drug NHS policy; issuing gabapentin at high doses is inconsistent with national guidelines and failure to safety‑net on dependency and adverse effects as well as allergy documentation. As a result, clinicians received advice and feedback with structured actions, such as, shorter courses prescribed, avoiding large quantities of controlled medicines and transitioning prescribing back to in‑hours GP teams where possible.

We observed examples of improved case flows within the clinical system which separated 111 clinical queue and CAS clinical queue for oversight of patient care and demand in activity. Follow-up audit outcome results showed an improvement in this prescribing area of all 261 cases reviewed.

The service developed an in-house faculty which delivered education and clinical skills development to improve service quality, whilst offering development opportunities for clinicians, and succession planning for future leaders. This provided system wide improvements, by diversifying and upskilling the clinical workforce who often performed multiple roles with healthcare partner organisations.

The service provided education sessions for internal staff and external healthcare trainees. At the time of our on-site visit, the service had 2 clinical staff members who were being supported with their university studies and on the job training for progression to Advanced Clinical Practitioner roles. The service held regular clinical education workshops with monthly drop-in sessions to upskill staff members. Recent examples of sessions included ‘interpretation of pathology assessments’ and ‘prescribing for end-of-life care’. In particular, the service supported staff with additional training which went above and beyond the training requirements set out for NHS urgent care services. Specifically, in relation to end‑of‑life prescribing and wider education on clinical pathways such as nationally established competencies for syringe‑driver practice. These enabled clinicians to recognise and manage urgent palliative symptoms during home visits whilst helping to reduce delays for those receiving end of life medicines.

Staff told us about opportunities for continuous professional development such as the ‘Teach and treat community pharmacist program’ in conjunction with the local commissioners, for independent prescribers and supervision sessions. This demonstrated a commitment to developing staff within the service by directly supporting clinicians to develop prescribing capability and quality of clinical decision making. As a result, the service audited antibiotic prescribing which identified 1054 Co-amoxiclav (medicines used to treat bacterial infection) cases with 89.55% safe care and treatment outcomes. In addition to, 637 Trimethoprim (medicines used to treat urinary tract infections) cases with 93.81% safe care and treatment outcomes. The audit demonstrated more appropriate antibiotic medicines prescribing, documentation of rationale, better adherence to national prescribing guidelines and where possible referrals to in-hours community pharmacy.