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Tower Hamlets Out of Hours GP Service Good

Inspection Summary


Overall summary & rating

Good

Updated 7 December 2018

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 an announced comprehensive inspection of the out of hours service run by Tower Hamlets GP Care Group, which is registered with CQC under the name ‘Royal London Hospital’. This service is also known as ‘Tower Hamlets GP Out of Hours Service'.

At this inspection we found:

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The service had an overarching governance framework in place, including policies and protocols which had been developed at a provider level and had been adapted to meet the needs of the service locally.

There are areas where the provider should make improvements:

  • Develop effective systems and processes to ensure that the service meets national targets. Take steps to ensure clinicians produce comprehensive clinical consultation notes to aid effective review and quality improvement.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 December 2018

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. For example, we reviewed three governance committee meeting minutes and saw that collaborating with external agencies was in effect and encouraged 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.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. There was an effective system in place for dealing with surges in demand.
  • We reviewed the service rota and saw that there were no gaps. However, we were informed of competing local challenges which may affect the services’ future ability to retain and attract GPs. The provider had been proactive in raising this issue with the Clinical Commissioning Group and other stakeholders within the borough.
  • 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.

  • 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.
  • Arrangements were also in place to ensure medicines carried in vehicles were stored appropriately. The service did not carry an oxygen cylinder in the service’s vehicle. This decision was appropriately risk assessed.
  • Arrangements for managing medicines, including medical gases, emergency medicines and equipment minimised risks.
  • We also noted that the temperatures in the medicines stores at the base locations were monitored and recorded daily.
  • The service carried out medicines audit in line with their service agreement to ensure prescribing was in line with best practice guidelines for safe prescribing. The service did not prescribe high risk medication, requiring regular monitoring by the service, such as lithium, warfarin and methotrexate.
  • Palliative care patients 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 provider had recently implemented a monthly service assessment booklet for each site following staff recommendation. These included health and safety, infection prevention and control and medicines management assessments that were carried out monthly for each site. Results and issues were fed back to the management team and where appropriate issues were placed on the risk register for escalation and action.
  • 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. Incidents were escalated to the Tower Hamlets GP Care Group, Executive Team.

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, staff received training on how to identify and manage patients experiencing difficulties after an incident involving a patient complaining of stomach pain.
  • 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 agency staff.

Effective

Good

Updated 7 December 2018

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. These were available on the intranet system, emailed to staff and in folders in each clinical room.
  • 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.
  • Arrangements were in place to deal with repeat patients, including engaging with the local NHS acute trust to share information to identify, monitor and support those patients who frequently called the NHS 111 service and those who also frequently attended the hospital emergency department.
  • There was a system in place to identify frequent callers and patients with needs, for example palliative care patients, and care plans and protocols were in place to provide the appropriate support.
  • Staff provide palliative care patients advice on pain within care guidance.

Monitoring care and treatment

From 1 January 2005, all providers of out-of-hours services have been 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 the clinical commissioning group on their performance against standards which includes audits, response times to phone calls, whether face to face assessments happened within the required timescales, seeking patient feedback and actions taken to improve quality.

  • For the period April 2018 to July 2018, the service’s performance regarding urgent or less urgent consultations within two and six hours ranged between 94% - 100%. The commissioners’ performance target was 95% for both indicators.
  • For the period April 2018 to July 2018, the provider’s performance regarding urgent visits within two hours ranged between 57% and 60%. Routine visits within six hours within the same period ranged between 94% and 95%. The commissioners’ performance target was 95% for both indicators.

We reviewed minutes of the service’s board meeting; which attributed the service not meeting the ‘urgent visits within two hours target’ to the initial assessments carried out by the service’s call handlers. Since 1 August 2018, initial assessments of patients have been carried out by the NHS 111 service. The provider also added that, the service did not have a mobile working solution that would enable a visit to be recorded when it occurred. Therefore, GP visits were being recorded when the GP returned to the services’ base location, which was often after two hours.

The provider informed us that this had been discussed with GPs to encourage them to record consultations in as timely a manner as possible. We were unable to assess the impact of these discussions due to the service changes on 1 August 2018, which resulted in the provider delivering a new service model; the KPIs for this model had not yet been agreed with the commissioners.

The service had made improvements through the use of completed audits.

  • We reviewed four audits in total, two of which had gone through two complete cycles. We noted that they were clinically relevant to an urgent care setting. We also saw evidence of how they had positively impacted on quality of care and outcomes for patients.
  • For example, in 2015/16, the service audited compliance with local antibiotic prescribing guidelines. Two repeat cycles were carried out between January and March 2018. The results demonstrated a marked reduction in the overall prescribing of the antibiotics. Within two of the audits reviewed, the auditor noted that record keeping did not enable a conclusion regarding treatment decisions, to be drawn from the audit process.
  • The service had systems in place to meet the national quality requirements for auditing at least 1% of clinical patient contacts.

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 basic life support.
  • 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. 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. Newly appointed GPs were routinely audited within three months of joining the service. Subsequent reviews were carried out every six months.
  • The provider had processes in place to manage staff when their performance was poor or variable.
  • 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 and staff were encouraged and given opportunities to develop.

Coordinating care and treatment

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

  • Staff communicated promptly with patients’ registered GP’s so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • 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.
  • An electronic record of all consultations was sent to patients’ own GPs.
  • 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, transfers to other services, and dispatching ambulances for people that required them. Staff were empowered to make direct referrals and/or appointments for patients with other services.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may be in need of extra support such as through alerts on the computer system.

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 December 2018

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. Receptionists gave people who phoned into the service clear information. There were arrangements and systems in place to support staff to respond to people with specific health care needs such as dementia and those who had mental health needs. All staff had received training in basic life support and dementia awareness.
  • All the 39 patient Care Quality Commission comment cards we received were positive about the service experienced. This was in line with the results of the NHS Friends and Family Test and other feedback received by the service. One of the 39 mentioned experiencing a long waiting time.
  • When we spoke with base reception staff they stressed the importance of treating patients with respect, compassion and dignity.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, informing patients this service was available.
  • 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, for example, communication aids were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

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

Responsive

Good

Updated 7 December 2018

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 by providing vehicles to facilitate home visits where patients could not attend the centre.
  • 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 and vulnerable adults.
  • The provider understood the needs of its population and tailored services in response to those needs. Consultation times were increased from 12 to 15 minutes so clinicians were able to provide a comprehensive assessment of needs.
  • The provider engaged with commissioners to secure improvements to services where these were identified. For example, we saw evidence of the provider raising concerns about patient safety due to the service sharing space with an ambulatory service. As a result, the service was relocated to another location within the hospital in September 2018.
  • The facilities and premises were appropriate for the services delivered. Such as facilities accommodate people with physical disabilities, such as age related limited mobility or inability to walk due to impairments.
  • The service was responsive to the needs of people in vulnerable circumstances. In response to an incident involving a sick patient waiting in the reception area, the provider made changes to the seating position of the receptionists so that they would be better placed to see patients more easily.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs. At the time of inspection, the service had not collected performance data since due to the commencement the NHS 111 Service on the 1 August 2018, which led to the provider no longer carrying out patient assessments and triaging calls.

  • Patients were able to access care and treatment at a time to suit them. The service operated seven days a week from 6:30pm to 8am and 24 hours at weekends and bank holidays.
  • Patients could access the out of hours service via NHS 111. The service did not see walk-in patients and a ‘Walk-in’ policy was in place which clearly outlined what approach should be taken when patients arrived without having first made an appointment, for example patients were told to call NHS 111 or referred onwards if they needed urgent care. The staff we interviewed were aware of the policy and understood their role with regards to it, including ensuring that patient safety was a priority.
  • Patients were generally seen on a first come first served basis, although the service had a system in place to facilitate prioritisation according to clinical need where more serious cases could be prioritised. 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 are in vulnerable circumstances and took actions to remove barriers.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs. For example, the patient’s own GP or a local pharmacist.
  • The appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available and it was easy to do. However, information outlining how to make a complaint was not clearly visible within the service. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. Seven complaints were received in the last year. We reviewed all of the complaints and found that they were satisfactorily handled in a timely way.

The service learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care. We saw examples of learning from complaints and other patient feedback being shared through the services internal bulletin, in developing staff training packages and through management of staff performance.

Well-led

Good

Updated 7 December 2018

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.
  • 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 integrated urgent care priorities across the region. The provider worked with commissioners to meet the needs of the local population.
  • The provider monitored progress against delivery of the strategy.

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.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We reviewed a complaint from a patient who had experienced a long waiting time on attending the service. The response letter provided an apology and outlined the process of prioritising patients dependant on need. 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 in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • All 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. 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 Clinical Commissioning Group 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 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.

  • 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 to give feedback. Staff told us they felt engaged and were able to provide feedback through their line manager.
  • 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.