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Croydon GP OOHs Service Good Also known as Croydon UCC

Inspection Summary


Overall summary & rating

Good

Updated 7 January 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out this announced comprehensive inspection on 27 November 2018. We had previously carried out an announced comprehensive inspection on 26 September 2017. At that time the service was rated as requires improvement. It was rated as requires improvement for the safe, effective and well led domains and good for caring and responsive.

The areas where we said that the provider must make improvement were:

  • Develop effective systems and processes to ensure safe care and treatment including, the storage and dispensing of medicines and ensuring that non-calibrated equipment is not stored where it might be used. The service should ensure that targets relating to the time taken to stream patients are met.
  • Develop effective systems and processes to ensure good governance including ensuring streaming services are clear and understood by all staff. They should also ensure patient group directives are in place for nursing staff. The service should review that performance data meets national guidelines.

Since the last inspection the service no longer provided urgent care services, and was out of hours only.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. The provider had taken steps to assure itself that incidents were not missed.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided.
  • The service was below target levels for National Quality Reporting (NQR) standards in some areas, but not by a significant margin, and performance was improving since the last inspection.
  • Audits were in place to monitor the performance of staff at the service.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • The service had a clear system for managing and learning from complaints.
  • The service had an overarching governance framework in place, including policies and protocols which had been developed in conjunction with its partner organisations.
  • 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.

The areas where the provider should make improvements are:

  • Review which audits are undertaken to ensure that high risk, high cost and high dependency medicines are used in line with guidelines.
  • Continue to review NQR standards to ensure that they are met.Inform all doctors that they should use only equipment provided by the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 January 2019

At our previous inspection on 26 September 2017 we rated the provider as requires improvement for providing safe services and stated that the service must:

  • Ensure that only safe equipment is available for use by staff.

We also stated that the service must:

  • Ensure the proper and safe use of medicines.
  • Ensure that streamers at the service review patients in line with national target times.

These two areas were relevant to the urgent care centre for which the service no longer has responsibility.

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, 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. Staff we spoke with were clear about their responsibilities and could outline to whom to report, and were all trained to the required level. The service made referrals as required.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Safeguarding policies and procedures were clear and the service could co-ordinate with GP services in the area to determine which patients were at risk. 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).
  • 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. There were systems for safely managing healthcare waste.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. However, we noted that one member of clinical staff was utilising their own equipment which had not been calibrated.

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, and controlled drugs and vaccines, minimised risks. The service kept prescription stationery securely and monitored its use. Arrangements were also in place to ensure medicines and medical gas cylinders carried in vehicles were stored appropriately.
  • Although the service had carried out audits of 1% of all consultations, they had not carried out sufficient audits to ensure that high risk, high cost and high dependency medicines were used in line with guidelines. The service stated that these would be completed in the future.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. There was evidence of actions taken to support good antimicrobial stewardship.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.
  • Patients receiving palliative care were able to receive prompt access to pain relief and other medication 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 A&E department, 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 had not reported any serious events in the past year.
  • 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.
  • 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.

Effective

Good

Updated 7 January 2019

At our previous inspection on 26 September 2017 we rated the provider as requires improvement for providing effective services and stated that the service must:

  • Ensure that it meets national targets for the management of patients.

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 provider monitored that these guidelines were followed.
  • Telephone assessments were carried out using a defined operating model which included processes for assessing patients’ symptoms through triage, with options including calling the patient in for an appointment or a home visit.
  • 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 took into account the needs of those whose circumstances may make them vulnerable. For example, Croydon has a large number of residential and nursing homes which require home visits, and the service was staffed to accommodate this demand.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • There was a system in place to identify frequent callers and patients with needs, for example patients receiving palliative care, and care plans and protocols were in place to provide the appropriate support.

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. The service routinely reviewed 1% of all consultations and provided feedback as required.

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 clinical commissioning group (CCG) on their performance against the standards which includes: audits; response times to phone calls: whether telephone and face to face assessments happened within the required timescales: seeking patient feedback: and, actions taken to improve quality.

Performance against the NQR for out-of-hours providers for the last three months showed the following:

  • The service had a target that home visits would be completed within two hours of calls in in 95% of urgent cases. In the three months before the visit the service had achieved between 88.24% and 100%, with a year to date average of 88%, below the set target. The service had increased staffing levels at weekends to address this.
  • The service had a target that home visits would be completed within six hours of calls in 95% of routine cases. In the three months before the visit the service had achieved between 95.37% and 100%, with a year to date average of 97.01%, in line with the set target.

We saw evidence of daily performance monitoring undertaken by the service including a day by day analysis and commentary. This ensured a comprehensive understanding of the performance of the service was maintained.

  • The service had a plan of audits which involved at least one audit per month. This included the following:
  • A notes audit which involved a review of one per cent of all cases.
  • A review of all clinicians within three months of them commencing work with the service.
  • All clinicians had records reviewed on an annual basis as part of the appraisal process.

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.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • 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 through the service quality audit programme for supporting and managing staff when their performance was poor or variable. Measures included direct staff feedback, mentoring and supervision,

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 or when they were referred. Care and treatment for patients in vulnerable circumstances was coordinated with other services. Staff communicated promptly with patient's registered GP’s so that the GP was aware of the need for further action. There were established pathways for staff to follow to ensure callers were referred to other services for support as required.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • 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.

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 such as through alerts on the computer system.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The provider monitored the process for seeking consent appropriately.

Caring

Good

Updated 7 January 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • All of the 33 patient Care Quality Commission comment cards we received were positive about the service experienced. This was is in line with the results of the NHS Friends and Family Test and other feedback received by the service.

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.
  • 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.
  • Staff communicated with people in a way that they could understand.
  • 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 7 January 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its population and tailored services in response to those needs. For example, Croydon has a large number of residential and nursing homes which require home visits, and the service had ensured that it was able to cope with the extra demand for home visits.
  • The provider had regular contract meetings with the commissioner to discuss performance issues and where improvements could be made.
  • 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 there were alerts about a person being on the end of life pathway. 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 temporary in nature, but were appropriate for the services delivered. The service was due to move to new more modern premises five days following the inspection.

Timely access to the service

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

  • Patients were able to access care and treatment at a time to suit them.
  • Patients could access the out of hours service via NHS 111. The service did not see walk-in patients and walk in patients were referred to the adjacent urgent care centre.
  • 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. The service had recently responded to waiting times at weekends by adding a further 12 hours of GP time.
  • Patients with the most urgent needs had their care and treatment prioritised. This system ensured that patients were safe.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.

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. One complaint had been received since the last inspection. We reviewed this complaint and found that it was satisfactorily handled in a timely way.
  • Issues were investigated across relevant providers, and staff were able to feedback to other parts of the patient pathway where relevant. The service provider worked in partnership with the providers of the accident emergency department and urgent treatment centre, and the provider of two walk in centres in the local area to share learning.
  • The service learned lessons from individual concerns and complaints and from analysis of trends.

Well-led

Good

Updated 7 January 2019

At our previous inspection on 26 September 2017 we rated the provider as requires improvement for providing well led services and stated that the service must:

  • Ensure that policies and protocols are available and that staff are aware of them.

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.
  • Managers at the service were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them, and had developed action plans so that these areas might be addressed.
  • 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.
  • 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 said that they ensured that 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.
  • 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 needed. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff were considered valued members of the team. They were given protected time for professional 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.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

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

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

The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA 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 local CCG as part of contract monitoring arrangements.

Clinical audit had a positive impact on quality of care and outcomes for patients. However, the service had completed limited audits to ensure that high risk, high cost and high dependency medicines were used in line with guidelines.

The providers had plans in place and had trained staff for major incidents.

The provider implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service 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.

  • Staff were able to describe to us the systems in place to give feedback. The service had implemented its own patient feedback as there had been limited response to the friends and family test. The feedback showed that patients were satisfied with the service provided.
  • 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.

  • 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 were systems to support improvement and innovation work.