You are here

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

Inspection Summary


Overall summary & rating

Good

Updated 12 June 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 an announced comprehensive inspection at Unit 3, FedBucks Limited as part of our inspection programme.

At this inspection we found:

  • The service had 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.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • 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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 12 June 2019

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.
  • In each of the rooms used for the Out of Hours service the provider had included a pack with details of local pathways and the provider policies to ensure all staff had access to them.
  • The provider worked with other agencies to support patients and protect them from neglect and abuse.
  • The provider was a part of the Child Protection – Information Sharing Project (CP-IS) which is an IT system that is designed to support health and social care staff to share information securely to protect society’s most vulnerable children. When a child attends an unscheduled care setting (such as an out of hours GP service, emergency department or urgent treatment centre) the staff are alerted if the child has a child protection plan, the social care team are notified of the attendance and both parties can see details of the child’s previous 25 visits to unscheduled care.
  • The provider was notified of any safeguarding concerns via the CP-IS system and made appropriate safeguarding referrals when required. We saw examples of safeguarding referrals being made to local multi-agency safeguarding hubs, in line with local protocols. We identified that when the provider made referrals or identified safeguarding concerns this was not added as a note to the system to warn future clinicians of these concerns. The system allowed the clinicians to view previous encounters and access to summary care records, once a referral was made and if a patient was then supported by Social Care then any future encounters would automatically be notified by CPIS. If the patient was not then supported by social care the system relied on clinicians checking back on previous records In response to our findings the provider immediately changed their protocol and alerted all clinicians to add these concerns as a flag on the computer system.

  • The provider worked with the local lead nurse for Exploitation and information was shared regarding children who have attended the out of hours who were known to the exploitation Team and due for review in their meetings.

  • 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). The provider policy was to undertake a DBS check every five years for all staff, we were unable to check compliance with this as the provider had only been providing the service for 12 months.
  • 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.
  • To provide additional safety and security to staff the service provided lone working devices where there was a potential for lone working (e.g. home visiting and reception staff).

  • 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. The provider had worked with local GP practices and clinicians to promote their service and encourage local staff to work for them. They had increased their staffing levels to deal with varying work demands. The provider would also use locum and agency staff when needed
  • There was an effective induction system for temporary staff tailored to their role. The provider had a detailed locum/agency handbook which directed staff to all the provider policies and protocols and included appropriate contact details for managers and other local services.
  • 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.
  • Most patients in the Out of Hours service were directed there and booked into an appointment slot by NHS 111. Each Out of Hours base was commissioned to accept walk in patients but this was rarely utilised.
  • The provider had given extra training to the shift managers and given them more autonomy to make decisions regarding scheduling of appointments and home visits. This was to ensure that staff who were on the ground could ensure the service ran as smoothly as possible. The provider felt that the staff working these shifts regularly had a more detailed and accurate knowledge of the staff on duty and of the geography they covered.
  • 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. Patients’ GPs were notified by 8am the day after attending the Out of Hours service, to ensure relevant information was shared in a timely manner.
  • 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. All medicines were dealt with by an outside pharmacy company who delivered the required medicines in labelled cassette boxes. Use by dates and stock levels were monitored by the pharmacy company and by the provider to ensure all were appropriate for use.
  • The service kept prescription stationery securely and monitored its use. We saw evidence that all staff were notified not to leave blank prescription stationery in the vehicles when they were not in use. Arrangements were also in place to ensure medicines carried in vehicles were stored appropriately.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service had audited antimicrobial prescribing. 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.
  • Arrangements for dispensing medicines kept patients safe.
  • 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 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, GP out-of-hours, 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 learned and shared lessons, identified themes and took action to improve safety in the service.
  • For example, an error occurred which resulted in incorrect patient records being printed. This could have resulted in an information governance breach. The provider changed the process to give the administrator a separate printer to prevent this from happening.
  • 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 provider took part in end to end reviews with other organisations. Learning was used to make improvements to the service.
  • The provider was in the final stages of implementing an online event reporting system which enables incidents to be shared across departments and promotes increased reporting and ownership or specific risks to relevant staff.

Effective

Good

Updated 12 June 2019

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.
  • Clinical assessments were carried out using structured assessment tools such as the National Early Warning Score (NEWS) to identify those who were at risk of developing Sepsis.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • 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, management plans for vulnerable people and child protection alerts were documented within enhanced summary care records.
  • Regular prescribing audits were undertaken by the provider. These included antimicrobial stewardship and individual clinician prescribing audits. The provider had recently employed an advanced nurse practitioner to undertake further audits on a structured basis.
  • Arrangements were in place to deal with repeat patients and information was inputted to the special notes section of the computer system to ensure coordinated care and that all staff had up to date information.
  • There was a system in place to identify frequent callers and patients with particular needs, for example palliative care patients, and care plans/guidance/protocols were in place to provide the appropriate support. We saw no evidence of discrimination when making care and treatment decisions.
  • The provider had recognised that they had a number of patients with learning disabilities who were frequent attenders and had accessed the local learning disability team and agreed that the team would give advice and support to the Out of Hours staff and the patients.
  • When staff were not able to make a direct appointment on behalf of the patient clear referral processes were in place. These were agreed with senior staff and clear explanation was given to the patient or person calling on their behalf.
  • Staff assessed and managed patients’ pain where appropriate.

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. For example, quality improvement work and an audit was carried out to ensure patients experiencing sepsis symptoms were assessed in accordance with recognised national guidance.

  • 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.

We saw the most recent NQR results for the service (June 2018 to February 2019) which showed the provider was achieving the following national performance indicators:

  • Speak with a GP - Routine cases who spoke to a GP within 6 hours ranged from 96% to 99%, against a target of 95%.
  • Base visit - Urgent Cases who were seen on site within 2 hours ranged from 84% to 94%, with a target of 95%.
  • Home visit - Routine home visits were completed within 6 Hours ranged from 91% to 99%, with a target of 95%.

There were four areas where the service was outside of the target range for an indicator throughout a few months. However, the provider was aware of these areas and we saw evidence that attempts were being made to address them.

We saw that monitoring of the service was being carried out during operational hours. A recruitment programme had been implemented which was beginning to demonstrate that additional GPs were being recruited to the service.

We saw that the service consistently met the target of 95% in some areas:

  • Routine cases who spoke to a GP within 6 Hours to speak with a GP was consistently above 96%.
  • Routine cases who were seen on site within 6 Hours when patients attended the base was consistently above 98%.

The service used information about care and treatment to make improvements.

  • The service made improvements through the use of completed audits. 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 provider had an audit schedule in place for each of the locations they delivered out of hours services from.
  • The service was actively involved in quality improvement activity.
  • The provider had developed a clinical navigation system within the Out of Hours service to review and direct patients to the appropriate service. Staff undertaking this role were trained appropriately and monitored to ensure the service was safe for patients.
  • The provider added an additional priority level into their assessment framework as staff felt that there was a gap between patients who were not assessed as urgent (and therefore needed to be seen within two hours) but should not wait for six hours, which was the next category available.
  • The provider added an additional priority level into their assessment framework (3 hours) as staff felt that there was a gap between patients who were not assessed as urgent, but the clinician wanted them prioritised above other routine cases.

  • Where appropriate, clinicians took part in local and national improvement initiatives. The provider had developed and implemented a bespoke training and learning system for their own clinicians and for local services to access. The ethos behind this service was that the provider wanted to offer a system wide learning platform for all primary care clinicians within the local area. This provided the service with the knowledge that appropriate training was offered to all the local clinicians. As the provider only wanted to employ local clinical staff for the Out of Hours service, to ensure they were knowledgeable regarding local procedures and services. This also afforded them the opportunity to promote the Out of Hours service to local clinicians whilst demonstrating the type of employer they were.
  • This training service had delivered over 40 different training programmes across all professions within primary care, including GPs, paramedics, nurses, health care assistants and administrative staff.
  • The provider worked with the local clinical commissioning group to offer a personalised care service (PCS). This involved working with patients who had been identified as being high users of primary and urgent care services. The PCS coordinators signposted patients to public and charity organisations to address key elements identified within their care, such as complex medical needs, housing concerns or mental health concerns. This resulted in patients linking in with organisations who support with social isolation or counselling services. The service aim was to ensure a positive impact on the quality of life for these patients by ensuring they have access to appropriate nutrition, housing and advice.

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, emergency procedures, infection control and management of medicines.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required. The lead nurse ensured that all advanced nurse practitioners and emergency care practitioners worked within their scope of practice and had access to clinical support when required.
  • Since taking over the service the provider had dramatically decreased the use of GP locums within the Out of Hours service.
  • 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.
  • A training matrix was maintained which showed that some refresher training was out of date for staff working for the organisation as a second employment who had not provided evidence of mandatory training updates. The provider policy was that staff were sent reminders regarding training were sent prior to the renewal date. If the training was not completed on time a further email was sent to staff warning them that their ability to book clinical shifts would be restricted. If not completed this would be reviewed by the clinical lead to decide whether the training required posed a clinical risk having not been completed.
  • 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 for supporting and managing staff when their performance was poor or variable. For example, the auditor within the organisation completed call listening and clinical note audits auditing the clinical decisions and record keeping of the clinical staff. These had been used for identification of training needs and poor performance. We were given examples to demonstrate appropriate action had been taken.

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, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services, for example, for those patients at the end of life.
  • Staff communicated promptly with patient's 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. If a patient required urgent follow up by their GP, in addition to the electronic notification sent to GP practices by the start of the following day, the service would telephone the GP surgery to ensure this was actioned.
  • 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.
  • There were clear and effective arrangements for booking appointments, transfers to other services, and dispatching ambulances for people that require 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 those with learning disabilities or mental health concerns.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

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 12 June 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. Call handlers 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 end of life care and those who had mental health needs.
  • For example, the service had a dedicated telephone line for the local hospice staff to call for advice and support.
  • All of the 40 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. For example, in February 2019, 100% of patients who responded said they were either extremely likely or likely to recommend the service to their family and friends.

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. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • 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.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials 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.

Responsive

Good

Updated 12 June 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.
  • The provider engaged with commissioners to secure improvements to services where these were identified. For example, the provider offered a post-exposure prophylaxis (PEP) service for staff within the local trust who may have been exposed to infections due to a sharp’s injury.
  • The provider improved services where possible in response to unmet needs.
  • 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, staff had access to ‘special notes’, additional notes about the patient’s health, social situation, past medical history and medicines.
  • The provider had worked with other services, such as the local accident and emergency department and NHS 111, to identify frequent users or urgent care services. These patients were flagged on the system and were offered appropriate intervention in accordance with their individual needs.
  • 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 appropriate for the services delivered.
  • The service made reasonable adjustments when people found it hard to access the service.
  • The service was responsive to the needs of people in vulnerable circumstances.

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. The service operated Monday to Friday from 6.30pm to 8am and for 24 hours during weekends and bank holidays. The service also provided improved access GP appointments during set times.
  • 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 or young children could be prioritised as they arrived. 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.
  • There were areas where the provider was outside of the target range for an indicator, however where the service was not meeting the target, there was an awareness of this and we saw evidence that attempts were being made to address them and were detailed within the recovery plan.
  • There were systems in place to manage waiting times and delays. For example, patients could be contacted and their appointment transferred to a site where there was better capacity. Where people were waiting a long time for an assessment or treatment the reception staff we spoke with demonstrated how they would inform patients of waiting times.
  • The service engaged with people who are in vulnerable circumstances and took actions to remove barriers when people found it hard to access or use services.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • 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. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. Four complaints were received in the last year. We reviewed these complaints and found that they were 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 learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. We saw examples of processes being changed following complaints from patients.
  • The Clinical Director responded to feedback from the clinical team about the recent amalgamation of the education evenings with secondary care. These were felt to be inappropriate and not applicable to urgent care therefore the service reintroduced their own monthly educational evenings on relevant topics or in relation to complaints or incidents. The meetings are very well attended by their own staff and practice staff within Bucks. For example, palliative care updates, sexual health and HIV updates).

Well-led

Good

Updated 12 June 2019

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.
  • Senior management was accessible throughout the operational period, with an effective on-call system that staff were able to use.
  • 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 worked closely with the clinical commission group, taking on extra relevant services in order to deliver the General Practice Nursing 10-point plan and GP five year forward view, both of which are government strategies aimed to addressing the ongoing challenges within general practice.
  • The provider monitored progress against delivery of the strategy.
  • The provider 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.

  • All staff told us they felt respected, supported and valued and 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.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We saw examples of the service responding to complaints and events appropriately and offered an apology to patients when things went wrong.
  • 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.
  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work. The provider had just employed a further advanced nurse practitioner to undertake more detailed reviews of their clinical work.
  • There was a clear process in place to support GP registrar training which had recently received a positive report following a Deanery inspection.

  • 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.
  • The service encouraged and responded to feedback from all members or staff regarding all aspects of their role within the service. For example, following feedback from staff the service reviewed the operational pay structure which resulted in increases in pay, they negotiated cheaper parking rates for staff at working at a local NHS trust site and introduced a new priority system for the out of hours triage.

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. There was clear evidence of action to resolve concerns and improve quality.

The provider 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 used information technology systems to monitor and improve the quality of care.
  • 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.
  • We spoke with and received feedback from 30 employees across all staff groups during the inspection. All of the clinicians responded positively to the improvements that were being implemented and felt the feedback they gave was responded to.
  • Staff were able to describe to us the systems in place to give feedback. Staff who worked remotely were engaged and able to provide feedback. We saw evidence of the most recent staff survey and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • The provider sent out a regular newsletter to all staff detailing any new developments or changes to services. The newsletters were also used to celebrate and thank staff for their contribution to specific pieces of work.

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.
  • There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. There were systems to support improvement and innovation work.