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Inspection Summary


Overall summary & rating

Outstanding

Updated 13 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hilltop Heights (Cumbria Health on Call) on 30th November, 2016. Overall the service is rated as outstanding.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for recording, reporting and learning from significant events.
  • Risks to patients were assessed and well managed.
  • Patients’ care needs were assessed and delivered in a timely way according to need. The service met the National Quality Requirements.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • There was a system in place that enabled staff access to patient records, and the out of hours staff provided other services, for example the local GP and hospital, with information following contact with patients as was appropriate.
  • The service managed patients’ care and treatment in a timely way.
  • Information about services and how to complain was available and easy to understand.
  • Improvements were made to the quality of care as a result of complaints and concerns.
  • The service had good facilities and was well equipped to treat patients and meet their needs. The vehicles used for home visits were clean and well equipped.
  • There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw some areas of outstanding service:

  • The provider was highly responsive to the the needs of the predominantly rural population. For example, a pilot for telehealth appointments had recently been completed. This had reduced the average time for patients in rural areas to be seen for either a routine base or home visit from 146 minutes to 32 minutes. They worked closely with other service providers, such as North West Ambulance Service (NWAS), for whom they provided GP-triage. NWAS told us the most recent data showed that in 93% of cases when this service was used, a hospital admission was avoided for the patient.
  • The leadership, management and governance assured the delivery of high quality care, and supported learning and innovation throughout the organisation. Leaders had an inspiring shared purpose and motivated staff to succeed. Staff we spoke to told us the executive team were highly approachable, and that this had a positive effect on staff morale.

  • Governance and strategy were proactive and innovative. The provider had been proactive in addressing the specific recruitment difficulties faced by the service in this geographical area. As a result of a collaborative recruitment drive six new salaried GPs had been employed. This in turn improved capacity to meet demand and safety, as reliance on agency staff was sometimes as low as 5% of shifts per week.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 April 2017

The service is rated as good for being safe.

  • The service used every opportunity to learn from internal and external incidents, to support improvement. Learning was based on a thorough analysis and investigation.
  • Information about safety was highly valued and was used to promote learning and improvement.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
  • When things went wrong patients were informed in keeping with the Duty of Candour. They were given an explanation based on facts, an apology if appropriate and, wherever possible, a summary of learning from the event in the preferred method of communication by the patient. They were told about any actions to improve processes to prevent the same thing happening again.
  • The out-of-hours service had clearly defined and embedded system and processes in place to keep patients safe and safeguarded from abuse.
  • When patients could not be contacted at the time of their home visit or if they did not attend for their appointment, there were processes in place to follow up patients who were potentially vulnerable.
  • There were systems in place to support staff undertaking home visits. Staff had access to a range of communication equipment to ensure they could contact each other.
  • Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • Risks to patients were assessed and well managed.

Effective

Good

Updated 13 April 2017

The service is rated as good for being effective.

  • Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.
  • We also saw evidence to confirm that the service used these guidelines to positively influence and improve the service and outcomes for patients.
  • Clinical audits demonstrated quality improvement.
  • CHoC was a member of Urgent Health UK (UHUK), which provided external audit of the service, and benchmarked performance against 23 other out of hours care providers in England. At the two most recent audits in 2015 and 2016, CHoC was given a rating of “highly commendable”, which is the highest of five ratings available. Only four providers currently have this rating.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 13 April 2017

The service is rated as good for being caring.

  • We observed a strong patient-centred culture.
  • CHoC commissioned Healthwatch Cumbria to carry out a survey into patient satisfaction between September 2016 and November 2016. From 1,676 respondents they found that 91% of patients were either very satisfied or satisfied with their overall experience.
  • CHoC ranked ninth highest out of all of the 211 clinical commissioning group (CCG) areas in England for patient satisfaction with their overall experience of the service in 2014.
  • Views of external stakeholders were very positive.
  • Feedback from the large majority of patients through our comment cards and questionnaires, and collected by the provider was very positive.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • There were systems in place to ensure that patients were kept informed with regard to their care and treatment throughout their visit to the out-of-hours service.

Responsive

Outstanding

Updated 13 April 2017

The service is rated as outstanding for being responsive.

  • Services were tailored to meet the needs of the local population, and the involvement of other organisations and the local community was integral to how services were planned.
  • A number of services were in place to meet the needs of the predominantly rural population. For example, a pilot for telehealth appointments had reduced the average time for patients in rural areas to be seen for either a routine base or home visit from 146 minutes to 32 minutes. This pilot was now being rolled out to other areas.
  • The provider offered GP-led triage for paramedics, to allow them to receive advice from CHoC GPs if they were unsure whether or not to admit a patient to hospital. During the in-hours period, the CHoC control room also acted as a single point of access for paramedics to contact GPs. Hospital admission had been avoided in 93% of cases where paramedics had used this service, reducing unnecessary hospital stays for patients.
  • In 2014, CHoC ranked second highest across all of the 211 clinical commissioning group (CCG) areas in England for the number of patients who responded that they knew how to contact the out of hours service.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • The service had systems in place to ensure patients received care and treatment in a timely way and according to the urgency of need.
  • Information about how to complain was available and easy to understand and evidence showed the service responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders. Complaints were investigated by the member of the executive and/or management team who was deemed most appropriate for the case, such as the medical director, senior clinical nurse lead, or the chief executive.

Well-led

Outstanding

Updated 13 April 2017

The service is rated as outstanding for being well-led.

  • The service had a clear vision with quality and safety as its top priority.
  • High standards were promoted and owned by all service staff and teams worked together across all roles.
  • Leaders had an inspiring shared purpose, strove to deliver and motivated staff to succeed. For example, staff told us that the medical director was involved in supporting staff and offering learning opportunities, and would suggest cases for nurse practitioners to treat, under their supervision, to increase their knowledge base.
  • There was a high level of constructive engagement with staff and a high level of staff satisfaction. In response to a staff survey, the provider was actively pursuing ways to improve staff well-being and encourage staff retention. For example, a salary sacrifice scheme which was set up with a medical indemnity provider in an attempt to reduce the cost to clinicians of paying for cover.
  • In response to difficulties recruiting GPs to out of hours services, the provider had become a Tier 2 sponsor, which allowed them to recruit medical staff who had trained in the UK but who required a visa to work here. The provider believed they were the only out of hours service in England to have become a Tier 2 sponsor.
  • The provider was aware of and complied with the requirements of the duty of candour, encouraging a culture of openness and honesty. The service had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

  • The provider used innovative approaches to gather feedback from people who used services and the public. They had commissioned Healthwatch Cumbria to conduct a survey which gathered the views of 1,676 patients. They also used the website I Want Great Care (www.iwantgreatcare.org) to gather feedback from patients.
  • The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear and proactive approach to seeking out and embedding new ways of providing care and treatment, and we saw multiple examples of this during the inspection, such as the telehealth pilot, the pharmacy triage pilot, and working with the ambulance service to reduce demand.