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Broomwell Healthwatch Ltd Good

This service was previously registered at a different address - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 21 January 2020

Inspection areas

Safe

Good

Updated 21 January 2020

The provider had comprehensive systems in place to keep people safe and to assess and reduce all possible risks to achieving service delivery. Information governance was a priority and all opportunities were taken to learn from incidents and improve the service offered.

Risk assessment processes were comprehensive although the provider did not use a confidential health questionnaire for new staff to ensure working conditions were suitable. Also, there were indications formal communication with staff could be improved.

Safety systems and processes

The service had clear systems to keep people safe.

  • The service had contracted an external company to help manage aspects of health and safety. The provider had conducted safety risk assessments using the comprehensive tools supplied. We saw any identified risks had been addressed. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. Health and safety was discussed regularly in management meetings.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. The service did not use confidential health questionnaires for new staff to check whether working conditions were appropriate although they told us of an instance when conditions had been changed for a staff member when this had been needed.
  • Disclosure and Barring Service (DBS) checks were undertaken for all staff. (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 safety training appropriate to their role. They knew how to identify and report concerns.
  • There was an effective system to manage infection prevention and control. There was a legionella risk assessment in place for the building dated 31/10/2018 which had been repeated on 28/11/2019. (Legionella is a term for particular bacteria which can contaminate water systems in buildings.) The management company for the building was testing the water temperatures in the wash facilities used by staff to ensure they were safe, although there was no random testing of water temperatures in the kitchen used by the provider. Staff told us this would be added to the temperature testing following our inspection.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. All staff trained annually in the use of display screen equipment.
  • We saw fire risk was formally assessed, fire drills and weekly fire alarm testing was recorded, and staff received fire training annually.

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. Leaders used historical data related to service demand to determine the numbers of staff needed each day and produced rotas accordingly. They had never used locum staff. Employed staff were generally able to cover holidays and unexpected absences and the provider had a list of its own additional bank staff if needed. All back-office staff were trained in call-taking and could cover non-clinical staff unexpected absence or surges in demand if necessary.
  • There was an effective induction system for staff tailored to their role. This included all provider mandatory training.
  • When patients were judged to be at serious risk, there was a clear escalation policy that mandated that the patient’s clinician was immediately informed by telephone call, so the risk could be appropriately managed. If the referring service could not be contacted, the service policy was to contact the patient themselves and instruct them to attend the local A&E department. We saw a letter from a patient’s relative thanking the provider for their prompt action for one such urgent situation.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual assessments of images and clinical judgements were recorded and managed to ensure accuracy. Patient information was protected to the highest standards and all staff had trained in information governance.
  • The provider had made comprehensive arrangements to protect online services. There were strong back-up systems for both the telephones and computers and a back-up site for alternative premises was in place should it be needed in the event of an emergency. The back-up site had access to all existing online patient information. The provider had also put a separate online computer system in place should the regular system become corrupted by a computer virus.
  • The service tested all business continuity plans for use in an emergency regularly, including the use of the back-up site. Any improvements indicated by this testing were made.
  • The provider had worked with two external consultancies over the last two years towards achieving the ISO 27001 standard and the cyber essentials standard. (ISO 27001 is the international standard that lays out the specifications for implementing an information security management system.) As a result, many changes had been made to the computer system and patient data management to increase the security of the online systems.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The provider stored patient previous ECGs on the system for comparison purposes. They had introduced a feature to their computer software that allowed for the system to identify a previous ECG for a patient even if they had changed GP practice. They had also implemented a “today” button on the system to ensure only the most recent ECG was interpreted and an old ECG was not sent by mistake. In addition, the possibility of selecting the incorrect email address to send the ECG results to was reduced by storing email addresses in separate GP practice folders.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.

Track record on safety and incidents

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. All aspects of the service were monitored, both administrative and clinical.

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. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. Incidents were reported to a director who created an incident report and recorded it on an online incident log. Action taken as a result of incidents were reviewed at a later date to ensure they had been effective.
  • Because the service operated continuously and did not close, and the nature of the business did not allow for full team meetings, all learning from incidents and changes to policy and procedure were communicated to staff using an email system. Staff told us they felt it would be useful to have additional more visual feedback such as the use of notice boards.
  • 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, the settings on the air conditioning unit in the computer server room failed and the server became very hot and staff started receiving error messages when sending emails. The settings were reset, and the room cooled, and the provider obtained a sensor and an alarm to alert staff in the future if a similar problem occurred.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable incidents.

Effective

Good

Updated 21 January 2020

Staff development and training were central to the organisation. Quality improvement was prioritised and learning opportunities maximised.

Formal staff appraisal was in place for all staff apart from those working in back-office functions such as accounts and secretarial roles.

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 ECGs in line with current legislation, standards and guidance.

  • The clinical team were able to interrogate the digital data in detail, focusing on single periods of time or periods of abnormality when conducting their assessment.
  • There was a programme of continual professional development for clinical staff based on best practice guidelines. Service policies and procedures reflected these.
  • Clinicians had enough information to make or confirm a diagnosis. Previous patient ECGs were available to view to enable comparisons to be made.
  • We saw no evidence of discrimination when making decisions.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The provider had implemented a continuous rolling quality assurance system. Every interpretation of an ECG was subject to a review by another clinician within 24 hours. Outcomes of this peer review were summarised and where possible learning points were identified. Managers took the appropriate action to address any training needs or system changes. If errors in interpretation were identified, these were immediately rectified with the client. Staff we spoke with confirmed they took the opportunity to review results of peer reviews informally throughout the day although formal ongoing feedback was not available if errors or learning points had not been identified.

  • The service had audited 179,136 ECG reports from 01/01/2019 to 11/12/2019 using the peer review process. This had resulted in a correction rate of 0.27% with only a very few being significant.
  • Administration processes were also audited on an ongoing basis. There was a peer review process in place where all emails sent to referring practices were checked by another member of the administration team to ensure details were correct. Any errors were reported on a log and discussed monthly with managers. As a result of this monitoring the provider had implemented improvements to the call-taking protocol and software changes had been made. There was also formal discussion with staff when needed. Managers periodically arranged for staff calls to be listened to, to check the call protocol was being followed.
  • The provider audited time taken on a call with a customer to ensure these were timely. We saw evidence of audits for the last two years indicating targets had been met for all calls. Evidence indicated generally over 95% achievement of less than 20 minutes elapsing from when the ECG was received to when the completed written report was emailed back.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. New clinical staff were required to pass an ECG examination before employment and there was an ongoing training programme delivered by consultant cardiologists and senior health professionals.
  • The provider had an induction programme for all newly appointed clinical staff. This included a mentoring period during which time they were supervised, and further training given, including a three-day in-house ECG course. All staff ECG interpretations were continually peer reviewed and there was a random audit of ECG interpretations by an independent consultant cardiologist every one to two weeks. The service had also introduced a new review system in 2019 and every clinical member of staff had had 200 ECGs audited by a cardiologist. We were told this review was planned to be repeated every 18 to 24 months.
  • There was continual managerial support for staff. The two directors of the organisation worked at the service daily, one often working to take calls from customers alongside staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or the Nursing and Midwifery Council (NMC) and were up to date with revalidation.
  • 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.
  • All clinical staff had an annual face-to-face appraisal and discussion with a director at the service. The service had also implemented a more formal appraisal process for all call-takers in the ECG call room. Administration staff in the back-office told us they had not had an appraisal. However, they said they could approach managers at any time with any concerns and we heard where requests for training or service changes had been supported.

Coordinating patient care and information sharing

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

  • Staff communicated effectively with other services when appropriate. Referrers to the service requested a written response within a timeframe appropriate for the ECG result. This was agreed by the provider to ensure results were reported in a timely way. There were systems in place to communicate urgent results immediately. Should no contact be made with the referrer, the service would contact the patient directly and instruct them to attend A&E.
  • Before interpreting an ECG, clinicians at the service ensured they had all the necessary information to report the results.
  • The provider ensured staff were always available at all times of the day. There was a minimum of two staff working at night to take calls and interpret ECGs. Customers using the service at night were generally prisons, community hospitals and oil rig companies.

Consent to care and treatment

The service obtained consent to review patient data via their commissioning, data sharing agreement.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • The service ensured appropriate data management agreements were in place with their clients to support the sharing of information.

Caring

Updated 21 January 2020

Responsive

Good

Updated 21 January 2020

The organisation provided timely services to suit clients’ needs and took opportunities to learn from any clients’ complaints.

Responding to and meeting people’s needs

The service organised and delivered services to meet clients’ needs.

It took account of clients’ needs and preferences.

  • The provider did not have any direct patient contact, but it took account of the views of the commissioning clinical commissioning groups (CCGs) and participating GPs in delivering services. They met with CCGs when it was needed. The provider sent out questionnaires to all the GP practices using the service every year. In 2019, they received 241 responses to the survey which were very positive. They confirmed the style of reporting was appropriate and the speed of response was good. One hundred percent of practices confirmed they would like to service to continue. All comments on responses were reviewed, and action taken where necessary to improve services.
  • The facilities and premises were appropriate for the services delivered.
  • The service leased out equipment to GP practices when needed and serviced and maintained it appropriately.

Timely access to the service

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

  • Clients had timely access to initial assessment, test results, diagnosis and treatment. All 12-lead ECGs were reported on verbally on the telephone at the time of transmission. Written reports were sent approximately 15 minutes later or within a timescale agreed with the client if not needed urgently.
  • Holter ECGs and event loop data were transmitted digitally and reports prepared for returning to clients digitally according to service protocols.

Listening and learning from concerns and complaints

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

  • The provider had a comprehensive complaints policy in place and took complaints seriously. The service identified learning from all feedback and discussed and shared it with all members of their team. Where appropriate, changes were made to mitigate against a reoccurrence of the error. They had received three complaints in the last year and had used them to effect improvements to the service. For example, clinical staff were reminded that for an ambulatory ECG, a short burst of atrial fibrillation (an abnormal heart rhythm) would have to be 30 seconds or longer before they should recommend consideration of anticoagulation medicines (medicines that help prevent blood clots).
  • The service informed clients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • Complaints were reported to clinical commissioning groups (CCGs) as necessary.

Well-led

Good

Updated 21 January 2020

Leaders demonstrated they had the capacity and skills to deliver a high-quality service in an open and supportive culture. Governance arrangements were comprehensive, and every opportunity was taken to undertake and learn from quality improvement.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • The service had implemented high level on and off-site backup IT data systems, and encrypted software to mitigate against data loss or damage.
  • Clinical competencies were assured by multiple systems of quality assurance and audit, both in-house and by external auditors.
  • 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; they had developed a medical administration and call taking team manager to ensure administrative processes and procedures were effectively monitored and carried out.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality assessments to assist clinicians to make timely clinical judgements.

  • There was a clear vision and set of values. The service had a realistic strategy and told us about their business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them. They told us they worked to achieve the highest level of service possible for providing correct and suitable interpretation to customers.
  • The service maintained a continual focus on consistently delivering a timely and accurate product; they reviewed clinicians’ and the team’s performance throughout the day to ensure they delivered their 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 clients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. The service had a whistleblower policy in place. Staff told us although they had never had the need to raise concerns regarding managers of the service, the procedure to do this with someone outside the organisation was not available.
  • There were processes for providing staff with the development they need. This included appraisal and one-to-one conversations. The majority of staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Staff 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.
  • There were positive relationships between staff and teams. Staff we spoke with told us they worked well as a team and were supported by managers.

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.
  • Staff were clear on their roles and accountabilities. They told us they were trusted and respected in performing their roles and supported to make judgements.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. All were accessible to all staff on the service shared drive and changes were communicated through targeted emails.

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. There was a risk assessment programme in place and changes implemented as a result of incidents and complaints were monitored to ensure they were effective.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their assessments on a daily, one to two-weekly and annual basis. Auditing was done both in-house and by external consultants. Leaders had oversight of incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff to deal with disruption to the service. The provider had practiced their disaster recovery system for all possible circumstances, including using the organisation back-up site. Any indicated improvements to the plan had been implemented.

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 clients.
  • Quality and sustainability were discussed in relevant meetings. Regular meetings were scheduled to focus on IT, administration and service management.
  • The service used performance information which was reported and monitored, and management and staff were held to account. Any changes indicated were implemented as soon as they were identified.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • There were comprehensive arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with staff and external partners

The service involved staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the staff and external partners and acted on them to shape services and culture.
  • Whole staff meetings were very infrequent. The last clinical staff meeting had been held in May 2018 where changes to staff working practice had been implemented following staff suggestions, such as extending the paid lunch break and changes to staff holidays. We saw examples where changes had been implemented following informal ad-hoc contact with directors such as amendments to the call-taking protocol.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. The provider sent out an anonymous staff survey each year related to patient safety and acted on any suggestions for improvement. They also used a questionnaire for clinical staff after every cardiology teaching day.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. The provider was working towards achieving the ISO 27001 standard and the cyber essentials standard. (ISO 27001 is the international standard that lays out the specifications for implementing an information security management system.) Changes had been made to the computer system and patient data management to increase the security of the online systems.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • There was a comprehensive programme of peer review and audit to assure the competence of clinicians working in the service and supporting administration system audits.