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i-HEART 365 Service - Out of Hours Service Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 10 January 2020

This service is rated as Good overall. (Previous inspection November 2018 – Good)

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 i-HEART 365 Service – Out of Hours Service on 14, 15 and 16 November 2019 due to registration changes since the last inspection. The service, under their old registration had been rated as inadequate at an inspection in February 2018 but then as good during a follow-up inspection in November 2018.

At this inspection we found:

  • 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.
  • 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.

The areas where the provider should make improvements are: 

  • Clarify the arrangements for accessing palliative care medicines on Sunday evenings until Monday morning and risk assess if a small stock of such medicines should be kept.

  • Review the alternative arrangements for faxing prescriptions to pharmacies in order to comply with electronic prescribing guidelines.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care 

Inspection areas

Safe

Good

Updated 10 January 2020

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. Details of health, wellbeing, care and support services were provided to patients and their carers and referrals made as necessary. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check. There was an effective system to manage infection prevention and control. 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. 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. There were systems in place to ensure the safety of the cars used during home visits. Comprehensive checks were undertaken at the beginning and end of every shift and the vehicles were regularly maintained. The vehicles had satellite navigation systems which were regularly updated. A GPS tracking system was in use which enabled headquarters to be aware of where the vehicle was at all times. This not only ensured the safety of drivers and clinicians but could also be used to manage demand. Drivers had undertaken all mandatory training, including basic life support and safeguarding as well as regular driver assessment tests.

Information to deliver safe care and treatment

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

Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way. The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

The systems and arrangements for managing medicines, including medical gases, emergency medicines and equipment, and controlled drugs and vaccines, minimised risks. The service kept prescription stationery securely and monitored its use. Arrangements were also in place to ensure medicines and medical gas cylinders carried in vehicles were stored appropriately. 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. Some medicine prescriptions were faxed to local pharmacy's to dispense. 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. Patients requiring palliative care medicines would be referred to the community nursing teams on Sunday evenings until Monday morning.

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, following an incident where medicines were found to be out of date the medicines checking process was reviewed and updated to include the details how to appropriately dispose of out of date medicines. 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. For example, staff contributed to a multi-agency review relating to the care provided to a patient, where learning was shared across the organisations.

Effective

Good

Updated 10 January 2020

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed.
  • Telephone assessments were carried out using a defined operating model. Staff were aware of the operating model which included use of a structured assessment tool.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical well-being. 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, following individual end of life care pathways.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to support people who contacted the service frequently. The service liaised with the NHS 111 service and the patients own GP practice to review care provided to patients. There was a system in place to identify patients with particular needs. For example, palliative care patients, protocols were in place to provide the appropriate support. We saw no evidence of discrimination when making care and treatment decisions.
  • 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, an audit was undertaken to review each prescriber's compliance following the local antiobiotic prescribing guidelines. Ten cases were reviewed for each prescriber and feedback given with learning identified for those whose score was less than average. Where appropriate clinicians took part in local and national improvement initiatives. For example, the Royal College of General Practitioners (RCGP) Universal Urgent and Emergency Clinical Audit Tool was used to review five calls for each clinician who performed telephone triage every four months. Findings were fed back to the staff and the most recent audit showed that all staff scored over 80%.

From 1 January 2005, all providers of out-of-hours services are 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.

The provider shared with us their NQR results for the service for the period April 2019 to September 2019 which was reported monthly. Full compliance against the NQRs is reported as achieving above 90%, partial compliance between 85% and 90% and non-compliance is achieving less than 85%.  

  • Generally, the service was meeting its locally agreed targets as set by its commissioner over the last six months where there was a requirement to see patients within two hours and six hours. Less urgent telephone assessment average achievement had increased by 11% in the last 12 months from 77% to 88%. 
  • The provider was also measured on the number of urgent calls requiring a call back within 20 minutes. The achievement ranged from 66% to 77%. This indicator was under review as some patients had already received an assessment from the NHS 111 service.
  • The urgent home visit performance had increased from 71% to 81% over the last 12 months.
  • Where the service was not meeting the target, the provider had put actions in place to improve performance in this area. The provider was aware of this and had identified further training for clinicians to use the patient record system and outcomes consistently.

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 adults and children, infection prevention and control and basic life support training.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable. 
  • The in-hours home visiting service conducted on average 50% of the visits within 3 hours. Staff explained that in-hours visit requests were sent to the service prior to 10am which meant that not all visits would be completed within three hours as the service was operational until 5.30pm.

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, referral to the rapid response team.
  • 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. There were established pathways for staff to follow to ensure callers were referred to other services for support as required. The service worked with patients to develop personal care plans that were shared with relevant agencies.
  • 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 had formalised systems with the NHS 111 service with specific referral protocols for patients referred to the service. 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 require them. Staff were empowered to make direct referrals and/or appointments for patients with other services.
  • Issues with the Directory of Services were resolved in a timely manner. For example, patients contacting the service with prescription queries were referred to the local designated pharmacies. Pharmacists could contact the service on a dedicated telephone number if they had any queries.

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. For example, advising patients and their carers about local carer's groups and resources.
  • 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. Staff had access to the patients summary care record.
  • 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 10 January 2020

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. 
  • All of the 26 patient Care Quality Commission comment cards we received were positive about the service experienced. This was is in line with the results of the NHS Friends and Family Test and other feedback received by the service.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given):

  • Interpretation services were available for patients who did not have English as a first language. 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.
  • The service monitored the process for seeking consent appropriately.

Responsive

Good

Updated 10 January 2020

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

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

  • The provider understood the needs of its population and tailored services in response to those needs. For example, GP's were provided with

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     laptops so they could work remotely from home to alleviate telephone triage pressures and provide call backs.  The provider engaged with commissioners to secure improvements to services where these were identified. For example, the in-hours visiting service was initially a pilot that had received positive evaluation by patients and GP practices in the area.  The service worked with the CCG and other GP practices to define and implement the service.

  • 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, babies, children and young people. We saw examples of alerts and care plans on patient records to assist staff caring for those patients during the out-of-hours period.
  • The facilities and premises were appropriate for the services delivered.
  • The service made reasonable adjustments when people found it hard to access the service. For example, for those patients requiring a prescription the details could be sent to the patient's local pharmacy for them to pick up.

Timely access to the service

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

  • The service operated from 6.30pm to 8am Monday to Friday and all day at weekends and public holidays.
  • Patients could access the via the NHS 111 service, by referral from a healthcare professional or by completing an online health assessment.
  • Following contact with NHS 111 patients were either booked into an appointment at the GP centre located in Barnsley Hospital, received telephone advice from a clinical advisor or a GP over the telephone or received a home visit.
  • Home visits were available for patients whose clinical needs resulted in difficulty attending the service
  • Patients who presented at the GP Clinic at the hospital without an appointment were referred to the GP streaming service run by this provider.
  • Patients were booked into an appointment to reduce waiting times. 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.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment. We saw the most recent key performance indicator (KPI) results for the service, from April 2019 to October 2019 which showed the provider was meeting most of the outcomes with the exception ofemergency face to face appointments.
  • The provider was aware of this and was reviewing the data.
  • Regular performance meetings were held to discuss performance against NQRs and action was taken to improve where appropriate. 
  • 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. For example, staff would notify patients of the delay and estimated time of their wait for a visit or an appointment.
  • 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. The service was co-located to the emergency department in the hospital and they worked closely with the hospital team to ensure smooth patient pathway where possible.

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. Seventeen complaints were received in the last year. We reviewed two 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. For example, following feedback from patients who used the out of hours service and the accident and emergency department. The concerns were individually investigated by each organisation and then one would take the lead to feedback to the complainant.
  • 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. For example, following a complaint relating to an incorrect referral to another care provider the pathway was reviewed and updated.  Staff were briefed of the update at meetings and via email to ensure future patients with similar symptoms were referred to the correct service.

Well-led

Good

Updated 10 January 2020

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 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.

  • Staff felt respected, supported and valued. They were proud to work for the service. Staff described how the service had developed and improved over the past three years.

  • 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. Patients were invited into the service to discuss their concerns. 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 time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

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

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. 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 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. Feedback from patients resulted improvements to the service.  For example, following feedback to the service from a person visiting the area, staff were re-briefed on the procedure for seeing temporary residents to the area who needed to see a GP.
  • Staff were able to describe to us the systems in place to give feedback through one to one meetings, attendance at meetings and also via the staff forum representatives. Staff who worked remotely were engaged and able to provide feedback through through email to managers and staff forum representatives. 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.

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. For example, the provider continued to proactively share and promote the work they had completed about Sepsis. They had contributed to the review of external incidents relating to sepsis led by other organisations.
  • 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.