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Ambulance Service Good Also known as NHS 111 Service

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 4 September 2019

This service is rated as Good overall but Requires Improvement for providing effective services.

The previous inspection of this service was completed in January 2018 and the service was rated Requires Improvement overall, with Well-Led rated as Inadequate. We issued two requirement notices for Regulation 17: Good Governance and Regulation 18: Staffing.

At this inspection the key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection of the NHS 111 service provided by the Isle of Wight NHS Trust on 14 and 15 May 2019. This inspection included a review and follow up on breaches of regulations.

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about the service
  • Information from the provider, patients, the public and other organisations

At this inspection we found:

  • Positive steps had been taken to address the previously identified issues. For example, training for staff including safeguarding and the Mental Capacity Act 2005 had been completed by all available staff at the service.
  • Previous interim managers were now in formally recognised substantive roles and staff reported they were more aware of the management structure including senior managers. We saw evidence of a ‘who’s who’ diagram for the NHS 111 service’s management structure on the wall of the call centre. Staff reported there was a greater management presence and they felt more supported by the management team including team leaders.
  • Appraisals for all available staff at the service had been completed within the previous 12 months and the service had a new system to ensure appraisals were completed in a timely way.
  • Callers received a safer, more effective and responsive service than they had previously. However, patients were at risk of potential harm as the service’s call answering performance data was below national targets.
  • Additional performance support officers (PSOs) had been recruited so the NHS 111 service, they now provided 24-hour management cover. Staff were positive about this change.
  • There was an improved focus on staff well-being and staff achievements were widely celebrated within the service.
  • Facilities in the call centre hub had improved and staff had access to ergonomic chairs at their work stations.
  • 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.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • Staff treated people with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Whilst we identified no breaches of the regulations, there are areas where the provider should make improvements:

  • Continue to review call performance data to ensure national targets are being consistently achieved.

  • Continue to proactively monitor call demand to ensure staffing levels are appropriate.

  • Review how the service identifies significant or learning events that occur in the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 4 September 2019

At our previous inspection in January 2018, the NHS 111 service provided by the Isle of Wight NHS Trust was rated Requires Improvement because:

  • Not all staff had received training in adult and child safeguarding.
  • There was limited resilience in staff numbers to enable appropriate support and supervision for staff and ensure the service was always able to respond to emergency situations.
  • There were occasions where a clinician was not available to cover shifts this was outside of the terms of the NHS 111 license.

At this inspection in May 2019, the NHS 111 service was rated Good for providing safe services as we found:

  • Improvements had been made, for example safeguarding training had been completed by all staff, the service was working in adherence to the NHS 111 license regarding clinician availability. However, the service still did not meet the national performance targets due to limited resilience in staff numbers, specifically call handling staff.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider had 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 Trust 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 combined 999 and NHS111 service worked with other agencies to support patients and protect them from neglect and abuse, such as social services. 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 service confirmed all available staff had received safeguarding and safety training appropriate to their role. Staff we spoke to and personnel files we reviewed during the inspection confirmed safeguarding and other training modules had been completed.
  • Staff knew how to identify and report concerns. We saw staff had a clear awareness of how to identify concerning situations and respond appropriately. For example, terminated calls or background noise.
  • The NHS 111 service told us the estates team of the Trust and external contractors ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. We noted two fire doors within the call centre that did not close fully. We were told the issue would be raised with the estates team accordingly.

Risks to patients

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

  • The NHS 111 service used the Department of Health approved NHS Pathways system (a set of clinical assessment questions to manage telephone calls from patients). This was based on the symptoms they reported when they called. The tool enabled a specially designed clinical assessment to be carried out by a trained member of staff who answered the call. Once the clinical assessment was completed, a disposition outcome and a defined timescale were identified to prioritise the patient’s needs. At the end of the assessment if an emergency ambulance was not required, the call was managed appropriately. For example, when clinically appropriate an automatic search was carried out on the integrated Directory of Services, to locate an appropriate service in the patient's local area. We witnessed call handlers undertake the process appropriately? during our observation sessions of the service’s call centre hub.
  • There were arrangements for planning and monitoring the number and mix of staff needed. A resourcing team, who worked between 8am and 4pm, were responsible for organising staff rotas, for the Trust’s NHS 111 service and ambulance service. Outside of these hours it was the responsibility of performance support officers (PSOs) to manage arrangements for covering sickness or other absence in the NHS 111 service. (PSOs manage the call centre on a daily basis. They were responsible for monitoring ‘real time’ live call performance and offered support to call handlers to ensure a safe service is being delivered).
  • The PSOs had access to a fast text messaging service to support PSOs in arranging short notice sickness cover. This meant one text message could be created and then sent to all staff in one action, rather than sending out individual messages which could be a timely process.
  • At our previous inspection, we noted staff were not having suitable rest breaks in line with national health and safety requirements. We saw the NHS 111 service had introduced a rest break policy to ensure staff were having suitable rest breaks away from their desk area. We saw evidence of this policy and call handling staff we spoke to during the inspection confirmed rest breaks were happening, were appropriate and were in line with the new rest break policy. Staff told us this was a positive action which improved their well-being.
  • The resourcing team told us staff rotas were arranged two months in advance. Once provisionally created, the rotas were discussed between the resourcing manager and the service delivery manager to ensure appropriate shift cover was in place.
  • The resourcing team advised staff levels for shift cover were as follows:

- For a normal week-day: minimum of four call handlers during the day and minimum of three at night, with one additional call handler for the evening; one dispatcher per day and night shift; two clinical advisors per day, as well as one clinical support officer and one clinical advisor available from 11pm to 8am; and one performance support officer per day and night shift.

- For a weekend or bank holiday, and the Tuesday following a bank holiday: minimum of seven call handlers during the day and minimum of four at night; one dispatcher per day and night shift; two clinical advisors and one clinical support officer per day shift, and one clinical advisor per evening and night shift; and one performance support officer per day and night shift.

  • Since our last inspection, the NHS 111 service had recruited a further two PSOs. This increased management oversight including 24-hour cover to support the call-handling team. We were told PSOs were no longer used to cover shifts elsewhere in the hospital or take calls within the call centre hub. This allowed the PSOs to concentrate on their substantive role which aimed at ensuring a safe service was provided.
  • The NHS 111 service had changed the way it covered vacant shifts. Shifts could be swapped with staff agreement, while cover requests to bank staff would be made before overtime was offered. We saw evidence of 16 vacant shifts that needed to be filled over the next month. As a result, the NHS 111 service remained reliant on staff goodwill to take on additional shifts.
  • There was a system in place for dealing with surges in demand. We saw NHS Pathways trained auditing staff (fully trained in the call handling process) were brought into the call centre hub to support front line staff when call volumes increased. This appeared to be a reactive, rather than a proactive, approach. The request for the auditors to join the call handling team was only made when the call volume numbers indicated a need. The service itself had not proactively identified times of the day when call volume numbers increased and had made arrangements for increased staff capacity to be in place prior to it happening.
  • However, the flow of call volume numbers did not appear to be consistent. The NHS 111 service was a small service in terms of the number of calls, in comparison to other NHS 111 services. The low numbers of calls and the unpredictable peaks in demands resulted in periods of high demand with all call handlers on live calls followed by periods of no inbound calls.
  • The NHS 111 service told us it had four staff vacancies at the time of the inspection, but it was awaiting confirmation of the pre-employment checks to be completed from the Trust’s Human Resources department of new starters joining the team who had recently been recruited following interviews. These new starters would be required to complete several months of training and then further mentoring before being able to handle calls independently. The resourcing team hoped the new staff, once fully qualified, would help with shift cover in due course when their training and mentoring period had been completed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify patients with severe infections, for example sepsis. Each desk had a folder with quick reference cards for staff to use if needed which covered topics such as sepsis and safeguarding.
  • 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. We saw call handlers advise patients what to do if their condition got worse.

Arrangements to deal with emergencies and major incidents

The practice had arrangements to respond to emergencies and major incidents.

  • The service had arrangements in place to respond to emergencies and major incidents. They had engaged with other services and commissioners in the development of its business continuity plan.
  • There was a comprehensive business continuity plan in place for major incidents such as power failure or building damage, as well as those that may impact on staff such as a flu pandemic. The plan included emergency contact numbers for staff. We saw the plan was updated in March 2019 following the extended role and cover provided by PSOs.
  • The plan included arrangements for setting up temporary switchboards, moving the integrated care hub base and back-up systems for power and computer systems. These included uses of paper-based systems if needed. There were details on actions to be taken at various time stages of the disruption. For example, what actions were needed in the first hour, then in the next 24-48 hours and if needed up to five days disruption. These were set out on ‘grab’ sheets which were clear and had relevant contact details.
  • In the event of the telephone systems being disrupted, there were procedures in place to re-route NHS 111 calls. Computer systems were able to be accessed remotely and there were laptops which had been loaded with the NHS Pathways and access to the NHS Pathways paper based back up system. This would allow staff to continue to work.
  • In the previous 12 months, the NHS 111 National Contingency Escalation policy had been actioned on two occasions due to emergency circumstances. (The National Contingency Escalation policy allows for 50% of the incoming calls to a NHS 111 service be redirected to another NHS 111 provider; in the case of the Isle of Wight, this would be to a NHS 111 provider on the mainland). The NHS 111 service did so when it experienced a complete loss of its telephone system and an occasion of when excessive staff sickness meant the service could not meet its minimal staffing level for a shift.

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.
  • The NHS 111 service told us it had not recorded any significant events since its previous inspection. However, our inspection identified a number of events that could have resulted in a significant or learning event being raised. For example, the two occasions when the NHS 111 service implemented the National Contingency Escalation policy.
  • 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. Due to the shared staff arrangements between the NHS 111 service and the Trust’s emergency 999 service, incidents and associated learning were correlated and shared as a whole. We saw evidence of learning points, which derived from significant events within the 999 service, being shared via the call centre hub’s monthly ‘Hubbub’ information reel which was also sent to all staff via email as well as the call centre’s information notice board. Examples of learning included the appropriate pathway choice for a child who had had a seizure, despite the seizure having stopped by the time the call to the service had been made, and the correct escalation of a fire-arm concern during a call.

Effective

Requires improvement

Updated 4 September 2019

At our previous comprehensive inspection in January 2018, the NHS 111 service Isle of Wight NHS Trust was rated Requires improvement for providing effective services because:

  • The NHS 111 service did not consistently meet expected targets on calls handling and response times. There was limited action taken to improve performance.
  • Records for the ambulance service clinical business unit showed that there were shortfalls in meeting the training targets set by the Trust for safeguarding and the Mental Capacity Act 2005.
  • Learning needs of staff were usually identified through a system of appraisals, meetings and reviews of service development needs. At the time of inspection 49% of appraisals for all staff who worked in the hub had been completed.

At this inspection in May 2019, the NHS 111 service remains rated Requires improvement for providing effective services because:

  • Although improving, patients remained at risk of potential harm as call answering performance data did not consistently meet national targets.

Effective needs assessment, care and treatment

  • Telephone assessments were carried out using a defined operating model, called NHS Pathways. (NHS Pathways is a set of clinical assessment questions designed to support and manage telephone calls from patients).
  • NHS Pathways enables a specially designed clinical assessment to be carried out by a trained member of staff who recorded the patients’ symptoms during the call. When a clinical assessment had been completed, a disposition outcome (i.e. what the patient needed next for the care of their condition) and a defined timescale was identified to prioritise the patients’ needs.
  • We saw evidence that all call advisors had completed a mandatory training programme to become licensed users of the NHS Pathways programme. Once training was completed, call advisors became subject to call quality monitoring against a set of criteria such as active listening, effective communication and skilled use of the NHS Pathways functionality.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • When call handlers required further clinical support for a patient, they had access to a clinical advisor based within the call centre hub. (Clinical advisors are clinically trained practitioners who can receive a call from a handler if the NHS Pathways assessment indicates the patient’s symptoms need further investigation). When a CSO’s support was required, call handlers would arrange for this either by a telephone call-back within 10 minutes direct to the patient or via a ‘warm transfer’. (A ‘warm transfer’ is when a patient is directly transferred to a clinical support officer without waiting for a call-back).
  • The NHS 111 service 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.
  • 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.
  • 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.

Monitoring care and treatment

  • Providers of NHS 111 services are required to submit call data every month to NHS England by way of the Minimum Data Set (MDS). The MDS is used to show the efficiency and effectiveness of NHS 111 providers. In addition, the NHS 111 service had established its own performance monitoring arrangements and reviewed its performance each day; weekly and monthly, as well as reviewing real time calls. The NHS 111 service had a real-time wallboard in the call centre which showed total call volumes and alerts of incoming calls.
  • The NHS 111 service submitted situation reports to NHS England and the clinical commissioning group, on a weekly basis which recorded details of how many calls were received; dispositions (outcomes) made; length of call time and whether call backs had been made within 10 minutes when needed.
  • From our review of these situational reports for this inspection, we found:

  • Between March 2017 and December 2017, the percentage of calls answered within 60 seconds ranged between 86.1% and 95.7%. The average over the 10-month period was 91.2%. Out of the 10 months, there was one month that the service met the national 95% target.
  • Between April 2018 and April 2019, the percentage of calls answered within 60 seconds ranged between 92.4% and 96.5%. The average over the same period was 94.1%, this increase of 2.9% was an improvement on the previous performance data. However, it was still slightly below the national target (95%). Between April 2018 and 2019, there were four months that the service met the 95% target. This again was an improvement since our last inspection.
  • Between March 2017 and December 2017, the percentage of calls abandoned (after waiting 30 seconds) ranged between 2.12% and 5.94%. The average over the 10-month period was 3.7%. Of the 10 month period, the target of less than 5% was achieved for eight months.
  • Between April 2018 and April 2019, the percentage of calls abandoned (after waiting 30 seconds) ranged between 1.5% and 3.6%. The average over the 13-month period was 2.9%, this decrease of 0.8% was an improvement since our previous inspection. Between April 2018 and 2019, the target of less than 5% calls abandoned was achieved every month (100%).
  • The NHS 111 service had low numbers of calls where a call back within 10 minutes was required. Figures we saw indicated approximately 55 calls a month required a call back from a clinician within 10 minutes. This equated to less than 1% of calls each month. At the May 2019 inspection, we saw improvements had been made to the service’s call-back rates. For example, at the previous inspection the average number of calls which were made within the recommended time of 10 minutes was 36.3%, whilst at the May 2019 inspection this had increased by 9.5% to 45.8%. But this was still below the national target of 50%.
  • In relation to the NHS 111 service’s ‘warm transfer’ performance data, average figures from April 2018 to April 2019 showed that the NHS 111 service was not consistently meeting standards for ‘warm transfers’ with a range of 90.5% to 95.1% of calls identified being transferred (the national standard expected is more than 95%). This gave an overall average for this period as 92.6%, with the 95% target achieved once in those 13 months. This had lowered by 2.2% since the previous inspection when the average was 94.8%.
  • Real-time data seen during the inspection on 14 and 15 May 2019 showed:
  • On 14 May 2019 at 9.20pm: 151 NHS 111 calls had been made since midnight. The total number of calls answered within 60 seconds was 119. This was equivalent to 78.81% of calls, which was below the national target of 95%. Of those 151 total calls made, 12 calls had been abandoned. This was equivalent to 7.36% which was above the national target of less than 5% of calls being abandoned.
  • On 15 May 2019 at 9.37am: 52 NHS 111 calls had been made since midnight. A total of 48 calls had been answered within 60 seconds. This was equivalent to 92.31%, below the national target of 95%. Of those 52 calls, two calls had been abandoned, which was equivalent to 3.92%, and met the national target of less than 5% calls abandoned.
  • Where the service was not meeting the target, the provider had put actions in place to improve performance in this area. We saw a standard operating procedure (SOP) identified the criteria and subsequent actions to take when the NHS 111 service experienced an exceptional increase in call volumes. The SOP was implemented for the following circumstances; the NHS 111 service experienced more than 5% lost or abandoned calls or the number of calls waiting to be answered was more than 12 calls. Based on the data we saw during the inspection for 14 May 2019, which indicated the criteria for the SOP implementation had been met, the NHS 111 service confirmed the SOP had been initiated appropriately.
  • The service made improvements through the use of completed audits. It is a condition of the NHS Pathways user licence and a National Quality Requirement for NHS 111 services that the Trust must regularly audit a random sample of patient contacts. The sample must include enough data to review the performance of all staff that provides care. The NHS 111 service had an audit team whose role was to audit calls and ensure the applicable standards were maintained.
  • Calls with identified themes were purposely selected, and the auditors listened and scored how the call handler managed the call. The system for audits was set out so that staff in their probationary period were subject to five audits for a period of six months, where the achievement needed to be a standard of 86% or above. After probation, this reduced to four per month, if staff continued to achieve an average of 86% or above. Members of staff who consistently achieved 94% or above had their audits reduced to three per month. When targets were not achieved, the rate of audits increased, and feedback was provided face to face and via email, rather than via email only. Any learning or development needs were identified, and additional support provided to enable staff to meet the expected targets.
  • The non-clinical call auditors also identified trends of ‘common fails’ such as not giving all care advice and not giving information on if a patient’s condition worsened. These were then highlighted to all staff via meetings and newsletters to be aware of.
  • There were also clinical auditors who monitored clinicians’ call handling. The structure for the number of audits was the same as for non-clinical audits.
  • We saw evidence of the audits identifying staff who were in need of further support and training.

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.
  • 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.
  • Training records provided by the Trust demonstrated that the service had achieved 86% in relation to the completion of its full programme of required training. This was above the 85% target for training completion.
  • The NHS 111 service confirmed all available staff had completed safeguarding training appropriate to their role. Further safeguarding training was already booked for July and September 2019.
  • The NHS 111 service confirmed 91% compliance with the completion of Mental Capacity Act 2005 training. However, on review of the training log, the three members of staff who had not yet completed the training were not members of staff for the NHS 111 service.
  • 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.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable. For example, when a pattern of failed audits for a staff member was identified, an action plan to support the staff member was created. The failed audits identified issues around a lack of probing and on occasions not answering or addressing all pathways questions. An action plan was put in place, adhered to and over time the staff member’s call quality improved. The most recent audits undertaken in April 2019 scored 95%.

Coordinating care and treatment

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

  • The NHS 111 service used a clinical patient management system designed to manage episodes of care quickly and safely. The entire patients’ journey could be measured and analysed from the initial telephone call, through to internal and external referral to another service. The system, with the patient's consent, automatically sent details of patient contact with the NHS 111 service to the GP practice they were registered with. This system was also used by the out of hours service and the 999 service which enabled effective communication and access to patient records.
  • Call handlers were trained to manage 999 calls, and this enabled close working between the teams. During every shift, we were told one call handler was ‘ring-fenced’ to answer 999 calls. All other call handlers on shift would answer all incoming calls, and if a 999 call came in when the ring-fenced staff member remained occupied with a previous 999 call, this would be answered by another call handler and appropriately managed. We saw evidence of this happening during our observed sessions in the call centre hub.
  • 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 NHS 111 service was not able to book appointments directly with a patient’s GP but would contact the practice to alert them of a patient’s needs. Where patients needed to be assessed by the out of hours GP service (a service also provided by the IOW Trust), the NHS 111 service would send information to those services for follow up. Staff knew how to access and use patient records for information and when directives may impact on another service for example advanced care directives or do not attempt resuscitation orders.
  • Protocols were in place between the ambulance service, hospital consultants and doctors in the A & E department, to assist the NHS 111 service to arrange the most suitable disposition. For example, patients with long term catheters or who were receiving chemotherapy could be referred to the paramedic team, who were able to administer intravenous antibiotics in the community, prior to a hospital transfer.
  • The NHS 111 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 arrangements in place to work with social care services including information sharing arrangements. A range of health professionals were able to access patient notes and record information in them. These included the Palliative Care team; district nurses; and the CRISIS team who provided 72-hour care at home to minimise inappropriate hospital admissions. Staff worked with other services to ensure people received co-ordinated care.
  • There were clear and effective arrangements for transfers to other services, and dispatching ambulances for people that require them.
  • Issues with the Directory of Services were resolved in a timely manner.

Consent to care and treatment

The NHS 111 service obtained consent to care and treatment in line with legislation and guidance.

  • The message greeting callers for the NHS 111 service alerted callers that continuing with the call showed that they gave consent. When needed, consent was recorded on the computer system, for example when passing the call to a clinician or the caller was not the patient.
  • Access to patient medical information was obtained with the patient’s consent.
  • 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 NHS 111 service monitored the process for seeking consent appropriately.

Caring

Good

Updated 4 September 2019

At our previous comprehensive inspection in January 2018, the NHS 111 service Isle of Wight NHS Trust was rated Good for providing caring services.

At this inspection in May 2019, the NHS 111 service was rated Good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We observed members of staff were courteous and helpful to people calling the NHS 111 service and treated them with dignity and respect.
  • The NHS 111 service gave patients timely support and information. Call handlers gave people who phoned into the NHS 111 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.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients. Staff were provided with training in how to respond to a range of callers, including those who may be abusive. Our observations were that staff handled calls sensitively and compassionately.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care.

  • Call handlers and clinical advisors were confident in navigating through the NHS Pathways programme and the patient was involved and supported to answer questions thoroughly. The final disposition (outcome) of the clinical assessment was explained to the patient and agreement sought that this was appropriate. In all cases, patients were given advice about what to do should their condition change or deteriorate.
  • We saw staff took time to ensure people understood the advice they had been given, and explained the referral process to other services where this was needed.
  • Staff were trained to respond to callers who may be distressed, anxious or confused. Staff were able to describe to us how they would respond, and we saw evidence of this during our visit.
  • Staff would adapt questions to enable patients to understand what information they were being asked for. Staff handled calls sensitively and with empathy and compassion.
  • There were arrangements in place to respond to those with specific health care needs such as end of life care and those who had mental health needs. This included care plans and special notes, though staff also understood that patients might have needs not anticipated by the care plan.
  • There was a system in place to identify frequent callers and care plans/guidance/protocols were in place to provide the appropriate support. There were also systems in place to respond to calls from children and young people.
  • The NHS 111 service worked with the local Healthwatch organisation to gather views on patient experience and shared information about complaints they had received to improve patient experience. There was a section on the Trust’s website which allowed patients to give feedback specifically on the NHS 111 Service.
  • At this inspection, the NHS 111 service provided evidence of patient feedback it had received.
  • Examples of comments received from patients included being reassured and put at ease by the advice they were given by the service; being impressed by the actions taken by the call handler and supervisor who arranged for an ambulance to be sent; and patients were satisfied and pleased with the NHS 111 service they had received.
  • Interpretation services were available for patients who did not have English as a first language.

Privacy and dignity

The NHS 111 service respected and promoted patients’ privacy and dignity.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions.
  • The NHS 111 service monitored the process for seeking consent appropriately.

Responsive

Good

Updated 4 September 2019

At our previous comprehensive inspection in January 2018, the NHS 111 service delivered by the Isle of Wight NHS Trust was rated Good for providing responsive services.

At this inspection in May 2019, the NHS 111 service remains rated Good for providing responsive services.

Responding to and meeting people’s needs

The NHS 111 service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The NHS 111 service understood the needs of its population and tailored services in response to those needs. The NHS 111 service had a system in place that alerted staff to any specific safety or clinical needs of a person using the NHS 111 service. For example, those receiving palliative care or chemotherapy.
  • The NHS 111 service engaged with commissioners and other services to secure improvements to services where these were identified. The NHS 111 service provided reports to the clinical commissioning group, these covered operational and clinical performance activity, serious incidents, complaints, outcomes of investigations and patient feedback. We also viewed minutes of public board meetings where the wider community could gain an understanding of how the NHS 111 service was responding to patients’ needs.
  • The NHS 111 service had introduced a new information exchange process to the support the prompt and concise transfer of information for a ‘warm’ transfer following patient feedback. The new process used the acronym RASH, which reminded call-handlers to provide consistent information to the clinical advisor covering Reason for speaking to clinician, Age of patient, Symptoms and Help given. This meant the information handover was quicker so patients spent less time waiting for their call to be transferred from a call handler to a clinical advisor.
  • The NHS 111 service made reasonable adjustments when people found it hard to access the service. There were translation services available. The NHS 111 service had in place arrangements to support people who could not hear or communicate verbally, such as text talk, a telephone system which allowed communication via written messages.

Timely access to the service

  • Patients were able to access care and treatment at a time to suit them. The NHS 111 service operated 24 hours a day, 365 days a year. The NHS 111 service took account of differing levels in demand when planning services. Nationally recognised times of increased activity to the NHS 111 Service included weekday mornings between 7am and 8am; weekday evening between 6pm and 9.30pm and the 24-hour period on weekends and bank holidays. Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • Call performance data demonstrated the NHS 111 Service had met the national target of less than 5% of calls abandoned on a monthly average in the previous 13 months. This indicated that incoming calls were being answered promptly and patients were accessing the service appropriately.
  • Referrals and transfers to other services were undertaken in a timely way. Details of patients who had contacted the NHS 111 service were sent to their GP by 8am the following morning and referrals to other services such as social services were made via secure information systems. The Isle of Wight health and social care services used the same computer software systems, which enabled timely communication and allowed all services to access patient information once consent had been gained from patients.

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. Three complaints were received in the last year and we found that they were satisfactorily handled in a timely way.
  • The NHS 111 service learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care by also using themes of complaints to direct the focus of its monthly audits performed on calls taken by both call handlers and clinical support officers.

Well-led

Good

Updated 4 September 2019

At our previous comprehensive inspection in January 2018, the NHS 111 service provided by the Isle of Wight NHS Trust was rated Inadequate for providing well-led services because:

  • There was a lack of stable leadership team for the ambulance service, which was responsible for the NHS 111 Service. There was representation of ambulance services at board level but limited information to demonstrate oversight of NHS 111. The trust did not have a succession plan for the development of new leaders.
  • At this inspection staff raised concerns about the number of managers in interim roles and their ability to make decisions.
  • Staff reported that more senior managers, not involved directly with the daily management of the NHS 111 service were not always visible. They were not confident these managers were aware of risks to the service provided, such as concerns around the resourcing system for planning shifts.
  • Systems for capturing patient views on the service provided, had not been actioned.
  • Staff surveys were completed, but there was limited evidence to show that concerns were being acted upon and resolved. Responses to whether staff considered they were well supported had worsened.
  • Service performance was discussed at senior management and board level, but limited action was taken to improve achievement against national targets.
  • Evidence of delays in clarifying leader’s roles and responsibilities had led to staff not feeling appropriately supported.

At this inspection in May 2019, we saw improvements in these areas and the NHS 111 service is rated Good for providing well-led services.

Leadership capacity and capability

Operational leaders responsible for the NHS 111 service had the capacity and skills to deliver the service strategy and address risks to it.

  • The structure of the NHS 111 service had been reviewed and all areas now had operational managers or leads in substantive roles. These included a service delivery manager, a business manager, a performance support officer quality and audit lead, and a directory of services officer and Integrated Urgent Care (IUC) lead. These members of staff reported to the head of the ambulance service who in turn reported directly to the head of the integrated urgent care division.
  • Operational leads were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them within the scope of their roles and responsibilities. The operational leaders had attended a leadership conference earlier in 2019 and all of them were being supported to take part in the compassionate leadership program.

  • Staff said they were respected, supported and valued by their immediate line managers. Staff confirmed they had improved knowledge about senior management figures due to a ‘who’s who’ display on the call centre hub wall. On review of the display, each management individual with the Isle of Wight NHS Trust related to the NHS 111 service was identified by name and role.
  • Staff reported that line managers ‘walked the floor’ and they were approachable.
  • Following additional recruitment, performance support officers were now accessible in the call centre on a 24-hour cycle.

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 provider now had implemented new values creating the acronym of CARE: Compassionate; TeAm-working, ImpRoving, ValuEd. We saw evidence of the CARE values being visually displayed throughout the call centre hub. 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. Staff in the NHS 111 service told us about the Trust’s new CARE values and confirmed that they felt improvements to the NHS 111 service were happening.
  • The strategy was in line with health and social priorities across the region. The NHS 111 service planned the service to meet the needs of the local population.
  • The NHS 111 service monitored progress against delivery of the strategy.

Culture

The NHS 111 service was working towards a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • Staff told us their feedback and ideas for improvement were welcomed by management and operational leaders. Staff told us they had suggested a change to the arrangements of their shift patterns as well as different shift start and end times which the service had implemented.
  • Leaders and managers acted on behaviour and performance consistent with the vision and values. We saw evidence of staff being recognised and congratulated on achievements. For example, staff were awarded with token pin badges when they had supported callers to the service with a baby being delivered, or when a patient had been successfully resuscitated. Staff also received written commendation from the service delivery manager for their efforts in those situations and, if possible, were provided with an update on the patients they had supported. Staff were also recognised for achieving 100% in their monthly audit results. Staff told us they felt valued by leaders.
  • We saw evidence of the resourcing and administration team being awarded a Recognition of Outstanding Service Award in 2019. This had been awarded by the Ambulance Leadership Forum and Association of Ambulance Chief Executives.
  • 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 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. We saw results from the service’s most recent staff survey for 2018/19. Which identified areas that staff felt the service had improved and the areas that still required improvement.
  • We saw evidence of a letter to all staff, dated 1 May 2019, produced by the Head of the ambulance service, which the NHS 111 service was based within, that offered responses to the service’s most recent staff survey. The letter laid out responses to staff comments on the survey and offered explanations into new service developments. The letter finished by further inviting feedback and ideas from all staff on how the service could be improved more.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All available staff had received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff 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.
  • Staff were able to access occupational health services and a confidential telephone counselling service.
  • 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. Staff we spoke to during the inspection confirmed that staff morale in the NHS 111 service was better and they felt they were being listened to.

Governance arrangements

The Trust had an overarching governance framework for NHS 111 services to support the delivery of the strategy and service. This outlined the processes and procedures and there were reporting structures in place, from operational front-line reports on performance, through senior management meetings and business meetings to board level.

  • 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.
  • The NHS 111 service attended monthly clinical governance meetings. Attendees including the Clinical Lead for Unscheduled Care, the NHS 111 service’s operational leaders and the local clinical commissioning group’s commissioning lead. These meetings were agenda-based and minuted. We reviewed the minutes from the meetings that occurred between November 2018 and March 2019.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding.
  • Operational leaders were now in recognised substantive roles, rather than interim roles, as seen at our previous inspection. Staff told us this more formal structure had contributed to how better supported they felt.
  • NHS 111 service specific policies were implemented and were available to all staff.
  • Staff were able to access Standard Operational Procedures on their computer and we found these were regularly reviewed and updated.
  • Learning from complaints and significant events were shared throughout the entire Ambulance service which included the NHS 111 service.
  • Operational staff knew who to go to for guidance and support. They were clear about their line management arrangements as well as the clinical governance arrangements in place.
  • There were a range of mechanisms to cascade information, which included a ‘Don’t Trip Up’ short focussed newsletter to highlight Tips, Reminders, Information and Probing. There was a monthly information release, called the ‘Hubbub’ that was sent to all staff via email and displayed on one of the call centre’s overhead monitor screens on a rolling basis. Staff meetings were held regularly in the Hub and minuted.

Managing risks, issues and performance

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

  • The NHS 111 service had improved its process to identify, understand, monitor and address current and future risks including risks to patient safety. Staff changes, such as the increased number of performance support officers to offer 24-hour cover to the NHS 111 service, this meant there was an improved resilience to managing shifts safety.
  • Operational leaders 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. The NHS 111 service was improving with regards to its call performance, but it was still not achieving national expected targets in some areas on a consistent basis. Leaders were aware of these areas.
  • Service audits 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.

Engagement with patients, the public, staff and external partners

  • The NHS 111 service was open to receiving feedback or complaints from patients. Information on how to do so was to callers so that complaints or compliments would be made via their website; in writing; or verbally on the telephone.
  • Following a review of its feedback processes, including the Trust’s website and the service’s own feedback form, the NHS 111 service told us it had seen an increase in the number of responses it was receiving. For example, in the first six months the service had received 100 responses, this had recently increased to 240 responses received. The general tone of the feedback was that patients were satisfied with the NHS 111 service they had received.
  • 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.
  • In 2018, the NHS 111 service was issued with a Care Quality Commission report which highlighted two regulatory breaches relating to governance and staff training. We found the majority of actions had been completed during our inspection in May 2019.
  • 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 were systems to support improvement and innovation work.
Checks on specific services

Emergency operations centre (EOC)

Requires improvement

Updated 12 April 2017

There was no assurance all staff members had received an annual appraisal, with learning plans developed as part of this process. There was no formal system for ensuring those Community First Responders registering for duty were competent in their role. Call handlers had not had training in the Mental Capacity Act (2005) or learning disability or dementia awareness.

The proportion of emergency calls resolved by telephone advice was lower than expected and calls abandoned before being answered was consistently higher than expected.

Staffing levels in the EOC consistently did not meet the planned levels. Although staff worked flexibly to manage the potential risk.

Staff they felt there was insufficient knowledge and experience amongst the senior managers within the clinical business unit to effectively manage the service. They also raised concern about the number of managers in interim roles and their ability to make decisions.

There was no clear vision or strategy for the service. The number of meetings and the complexity of the reporting structure made it difficult to clearly see how oversight of the quality and risk of the service were maintained. The risk register was not reflective all of the current risks.

There was no formal process for engaging with patients.

Staff were aware of how to report incidents and learning from incidents was displayed for staff to read, however most staff where not able to describe any learning from incidents.

Staff were aware of how to give safe advice on self-medication.

Staff had a good understanding of how to recognise and report safeguarding.

The EOC had plans and back up arrangements to ensure service continuity in the event of a business continuity incident.

The service co-ordinated effectively with other emergency and community healthcare services.

The service used the accredited NHS pathways system to triage calls and provide clinical advice.

The trust consistently had the shortest waiting times of any trust in England for call answering. The proportion of patients who re-contacted the service following discharge of care, by telephone within 24 hours was lower than the England average.

Staff treated people with dignity, respect and kindness during all interactions.

The service made reasonable adjustments and took action to remove barriers to enable people to access the service easily.

Staff in the EOC spoke highly of the support they were given from their direct line managers and were proud of the strong sense of team work.

Patient transport services

Requires improvement

Updated 12 April 2017

The service was able to meet the individual needs of patients and was accessible to patients who met the eligibility criteria set by commissioners. There was good use of risk assessments to reduce the risks to patients and staff.

Team leaders demonstrated strong leadership and used their skills and experience to improve the service.

There were systems in place to manage anticipated resource and capacity risks with a flexible workforce. A new late shift had been agreed to extend the operating hours of the service and facilitate discharge from the emergency department.

Staff were caring and compassionate in their interactions with patients and made an effort to develop supportive relationships with patients, particularly regular users of the PTS.

Staff reported incidents, received feedback and learning was shared across the service. However, staff were not familiar with their responsibilities under the Duty of Candour regulation.

Staff were positive about the induction process and the support they received from their team leaders. All permanent staff had received an appraisal in the previous 12 months.

Policies relating to the PTS were past their review date. There was no regular monitoring of the quality and performance of the PTS through, for example, setting of key performance indicators (KPI) including the national KPI for arrival and collection time of patients attending for dialysis.

No audits of the service had been carried out, including infection control audits to ensure compliance with policies and procedures.

Although staff said they had undertaken mandatory training, the trust did not provide data to confirm uptake of all the mandatory training.

Radio reception and connectivity in some areas of the island was poor which meant staff used their own mobile phones to contact dispatch or use satellite navigation systems.

Limited feedback on patients’ experience was obtained for the service and patient information on complaints was not readily accessible.

Emergency and urgent care

Inadequate

Updated 12 April 2017

The ambulance station was not secure. The trust could not be assured that staff were reporting all accidents and incidents and learning was cascaded. Front line staff did not have an understanding of the duty of candour. The mobile data terminal used to provide staff with patient information and navigation was unreliable. Confidential information, medicines and cleaning products were not always securely stored.

Staffing levels meant shifts operated at minimum staffing levels, which made it difficult to support the transfer of patients to the mainland. Compliance with mandatory training was below the trust target level of 80% and not all staff had received an annual appraisal. Staff had not completed specific training on supporting patients experiencing a mental health crisis.

For patients, for whom English was not their first language or who were not able to communicate verbally there were no communication aids on the ambulances.

The governance framework used to monitor the quality and risks of the service was not effective. The risk register did not reflect all of the current risks of the service.

Delays in handover at the emergency department and the service running at minimum capacity meant people could not always access the service in a timely way. The trust response times were consistently below the expected target and patient outcomes where not as expected for patients suffering a heart attack. The trust did not monitor if they has responded to complainants within the agreed timeframe as part of the quality monitoring of the service.

Morale was low amongst ambulance staff. While they had confidence in their immediate managers they felt there was insufficient knowledge and experience amongst the senior managers within the clinical business unit to effectively manage the service. There were no team meetings and memos and emails were the main route for communication

Staff followed infection prevention and control procedures to reduce the risk of the spread of infection. Vehicles were clean and tidy and staff kept ambulance well stocked.

Staff provided care to patients in line with national guidance. The service had processes in place for staff to get additional clinical advice, if needed, and completed audits to monitor staff adherence to national clinical guidelines.

The service had a comprehensive induction programme in place for staff. Staff had an individual learning plan in place to support their development.

There was good multidisciplinary team working between ambulance crews and other emergency teams. The multi-agency hub was used effectively to co-ordinate care with other agencies when patients were discharged at the scene. The proportion of patients who had suffered stroke who followed the correct initial patient’s pathway was good.

Staff asked patients for consent before starting observations or treatment and completed mental capacity assessments when patients were unable to provide consent.

Ambulance staff took the individual needs of people accessing the service into account when providing care and treatment. Frontline staff were focused on giving good quality care to patients.

The trust had processes in place to respond to feedback from patients and members of the public. Managers investigated complaints and provided a written response to the complainant.

Staff provided compassionate to patients and their families care. They were kind and showed empathy when caring for patients.

Other CQC inspections of services

Community & mental health inspection reports for Ambulance Service can be found at Isle of Wight NHS Trust.