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Liverpool Walk in Centre Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 April 2019

This service is rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out a short notice announced comprehensive inspection at Mersey Care NHS Foundation Trust and the following Walk in Centres were visited.

  • Old Swan NHS Walk in Centre at Crystal Close, St Oswald Street, L13 2GA
  • Liverpool City Centre NHS Walk in Centre at 6 David Lewis Street, Liverpool, L1 4AP
  • Smithdown Road Children's NHS Walk in Centre at Smithdown Road Liverpool L15 2LF

These inspections were carried out on the 20, 21 and 22 November 2018 as part of our inspection programme.

At this inspection we found:

  • The Walk in Centres are part of Mersey Care NHS Foundation Trust. As part of the trust governance arrangements there were structures, processes and systems of accountability in place to support the delivery of the trust strategy, ensure good quality and patient safety. However, these were still in their infancy and required further improvement. For example, many policies and protocols were from the previous provider organisation. The management team was aware of this and the trust transformation plan had target dates for replacing these.
  • The service did not have an overall comprehensive programme of quality improvement activities that included the Walk in Centres. However, there were monitoring systems whereby key performance indicators were reviewed monthly.
  • The service had appropriate systems to safeguard children and vulnerable adults from abuse. Systems for assessing, monitoring and mitigating the various risks relating to the safety of the premises were inconsistent across each Walk in Centre.
  • There were systems to assess, report, monitor and manage risks to patient safety. Staff we spoke with told us that feedback about the reported incidents needed to improve.
  • The service did not have reliable systems for appropriate and safe handling of medicines.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • There was limited evidence at each of the Walk in Centres to show the service made improvements through the use of completed clinical audits.
  • Staff had the right qualifications, skills, knowledge and experience to do their job when they start their employment and on a continual basis. However, the trust was experiencing high sickness, retention rates and staff vacancies and this resulted in the regular movement of clinical staff across the centres.
  • Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical supervision arrangements were not robust and nurses did not receive protected time to complete this. The provider did not undertake audits/reviews of clinical decision making, including non-medical prescribing to determine the competence of staff employed in advanced roles.
  • Staff involved and treated people with compassion, kindness, dignity and respect. In particular, staff displayed an encouraging, sensitive and supportive attitude for children and young people at Smithdown Road Children's NHS Walk in Centre.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs. However, some waiting times had increased. Where the service was not meeting the set targets, the provider was monitoring this.
  • The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care. There was confusion amongst staff about what information should be given to patients when they wanted to make a formal complaint.
  • Local leaders had the capacity and skills to deliver high-quality, sustainable care.
  • There was a focus on continuous learning and improvement at all levels across the Walk in Centres.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients with regards to ensuring there are systems to make sure that documents to authorise medicines are completed.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate supervision necessary to enable them to carry out their duties.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review the significant event reporting systems to ensure staff receive feedback when an incident has been reported.
  • Review the systems and processes in place to ensure the right skill mix is in place across each of the Walk in Centres when staff are moved to cover for staff absence. This review should include the views of all clinical staff.
  • Review the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. The provider should review the fire safety risk assessments for the Liverpool Walk in Centre and ensure that any actions required are complete and ongoing fire safety management is effective.
  • Review the system in place for disseminating safety alerts to all members to ensure there is evidence and monitoring in place that actions when required have been completed.
  • Review the waiting times for patients for initial assessment/triage to treatments. The provider should improve these waiting times so that services are responsive to the needs of children and young people across each of the Walk in Centre locations.
  • Review the service complaint handling procedures and establish an accessible system for informing patients how to make a complaint.

Inspection areas

Safe

Requires improvement

Updated 8 April 2019

We rated the service as requires improvement for providing safe services. This was because there were no systems to ensure appropriate authorisation of medicines, concerns were identified with regards to the management of the overall safety and limitations of the premises, feedback from staff was they were sometimes asked to cover areas outside of their usual clinical experience and they had concerns about this, the management of alerts and incidents could be improved.

Safety systems and processes

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

  • The service had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents was available to staff. The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. Information provided by the trust pre- inspection shows that urgent care services made five safeguarding referrals between 1 August 2017 and 31 July 2018, of which two concerned vulnerable adults and three children.
  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (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 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. However, information across each of the locations was inconsistent. For example, we did not see an up to date fire risk assessment and legionella testing for the City Walk in Centre and there was a lack of effective oversight of the risks associated with these premises and how risks were being managed.
  • Smithdown Road Children's NHS Walk-in Centre provided services and treatment to children and young people only. In terms of a suitable and well-designed environment for children, we found the clinic area was not adequate to meet the needs of the high numbers of patients being treated at this location. The waiting room was small and was unable to provide seating for all children and carers attending when the service became busy. The service corridors were cramped with children’s prams and baggage, causing narrower corridor spaces for moving about the service. Some areas of the premises were inaccessible to wheelchair users, for example, some of the patient treatment rooms. There was no risk assessment carried out for these risks.
  • There was an effective system to manage infection prevention and control.
  • The provider ensured that equipment used was safe and 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. All staff reported risks on the provider’s Datix system. This was a patient safety web based system used across the trust to report incidents and patient safety risks. Reporting of incidents was high across the Walk in Centres however, staff we spoke with told us that feedback about the reported incidents needed to improve.
  • There were arrangements for planning and monitoring the number and mix of staff needed. Information provided by the trust pre- inspection indicated that between and , the trust reported an overall vacancy rate of 2% in urgent care services. Between and , the trust reported an overall turnover rate of 26% in urgent care services. Between and , the trust reported an average sickness rate of 5% for the last 12 months for urgent care services.
  • Issues with staffing levels were managed daily by the senior management team, this included when dealing with surges in demand. Staff reported to us that they frequently had to move centres when sudden staff shortages were reported and we had mixed feedback for how confident they felt when doing this at short notice. Staff said that they were sometimes asked to cover areas outside of their usual clinical experience and they had concerns about this. We spoke with senior managers for assurance of how decisions were made when moving staff. It was reported to us that if staff were required to relocate from one site to another, then a review of the skill mix would be undertaken and a decision made between the co-ordinator, nurse in charge in each Walk in Centres and the Clinical Service Manager.
  • 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. Staff told patients when to seek further help. They advised patients what to do if their condition got worse.
  • During the inspection we were told that a service level agreement was in place for the Smithdown Road Children's NHS Walk-in Centre with the local children’s hospital. This meant that clinical advice could be sought by the Walk in Centres staff if needed. The centre had a transfer policy for children and young adults when a transfer to the hospital was required. Until the ambulance arrived at the centre patients were supported by staff. However, we noted extremely long delays waiting for ambulance services to arrive and this caused a potential significant risk to patient safety. The provider was aware of this and meetings were being held with the ambulance trust to improve the response times, so patients could be transferred safely. This was a concern at each of the locations we visited. We were shown action plans that had been developed by both providers to improve this.
  • We found that each of the location visited was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.

Information to deliver safe care and treatment

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

  • Systems were in place to keep patient information secure. This included when information was other services, for example, a hospital, where a patient is being admitted, the ambulance service and a patient’s own GP.
  • 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.
  • 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 did not have full and 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.
  • There was a lack of evidence to show the provider 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.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.
  • Palliative care patients could receive prompt access to pain relief and other medication required to control their symptoms.
  • Systems were in place for staff to use Patient Group Directions. However, we found that the templates in use were not from the current provider and there were some staff signatures missing from the sample we viewed. This was reported to the trust board on the first day of the inspection and immediate actions were taken.

Track record on safety

The service had a good safety record.

  • There were some comprehensive risk assessments in place but there were gaps in the risks and information held at some of the centres in relation to safety issues.
  • The provider monitored and reviewed activity via the trust wide Datix system. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • We observed an appropriate range of safety information being monitored across each of the Walk in Centres. Overall, this performance information showed that it was safe across the previous year with shortfalls in performance for waiting times and triage targets. Evidence was presented to show that performance was reviewed by team leaders, senior staff and the trust board monthly or more frequently if required.

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. Policies and procedures were in place for this. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. However, comments made to us from staff was that feedback about reported incidents did not always happen.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and acted to improve safety in the service.
  • 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. However, this system was not centralised with management oversight and there was no evidence that actions, when required, had been completed at the Walk in Centres.

Effective

Requires improvement

Updated 8 April 2019

We rated the service as requires improvement for providing effective services. This was because there was very little evidence to support the use of clinical audit to improve outcomes for patients. Although staff received suitable training and appraisal there was limited clinical supervision.

Effective needs assessment, care and treatment

The 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.

  • 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.
  • We were told that team leaders discussed new guidelines at monthly meetings and this was shared with staff at daily ‘huddle’ meetings. However, there was no robust system in place to gain assurance that these guidelines were followed across the Walk in Centres.
  • Patients’ needs were fully assessed and clear clinical pathways were used by staff. This included their clinical needs and their mental and physical wellbeing. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. For example, newly arrived asylum seekers were frequent attenders at the Walk in Centres and staff treated them with care and compassion.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. 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.
  • In the Walk in Centres where diagnostics were arranged, there were arrangements in place to ensure that the results were reported on externally.
  • We observed arrangements in place to support patients who were at risk of suicide or self-harm.
  • Staff assessed and managed patients’ pain where appropriate.
  • All staff we spoke with were happy with the quality of care they were able to provide.

Monitoring care and treatment

The provider did not have an overall comprehensive programme of quality improvement activity that included the Walk in Centres. However, there were monitoring systems in place, whereby key performance indicators were reviewed monthly by senior managers and the trust board.

The provider used key performance indicators (KPIs) that had been agreed with its clinical commissioning group to monitor their performance and improve outcomes for people. The performance areas reviewed were:

  • Patients who had left without being seen
  • Unplanned patients who had re-attended within 7 days
  • Patients seen within 4 hours
  • Patients seen within 2 hours
  • Patient demand
  • Patient attendance.

Where the service was not meeting the target, the service was monitoring this monthly and action plans were in place.

There was further evidence the service reviewed the effectiveness and appropriateness of the care and treatment provided. Activities such as reviews of KPI data, significant event and complaints analysis. This was reviewed across all of the Walk in Centres and the information collected fed into the trust wide governance and monitoring systems.

We found variable evidence to show the service made improvements through the use of completed clinical audits across every location. Some examples included;

  • An audit of use of Nitrofurantoin PGD used for treating lower urinary tract infections was undertaken over a 6-month period to look at the compliance of the nurses to the PGD’s directions. However, a second audit cycle had not yet been undertaken.
  • Half yearly audits were conducted within Old Swan Walk in Centre to ensure the service was able to evidence that it supported patients who potentially had a DVT and improved the patient journey whilst avoiding inappropriate attendances at A&E.
  • At one of the centres we observed that some audit activity included a retrospective review of patient records however, this was not carried out across each of the locations we visited.

However, there was no systematic programme of clinical audit which was used across each of the Walk in Centres to monitor quality and systems to identify where action should be taken if required.

Effective staffing

  • Staff had the right qualifications, skills, knowledge and experience to do their job when they started their employment, took on new responsibilities and on a continual basis. However, the trust was experiencing high sickness, low retention rates and staff vacancies and this resulted in the regular movement of clinical staff across the Walk in Centres. We were informed by staff that at times this had resulted in staff providing care beyond the normal competency of their role and nurses told us sometimes they lacked confidence when required to work in a setting outside of their normal working environment. Training competences were in place to support staff but these did not sufficiently cover the training and qualifications that would be needed to do this safely.
  • A service review of the Walk in Centres undertaken in July 2018 and updated in November 2018 showed there were a total staff of 88.87 of which 72.09 were clinical bands 3-8a. The report indicated this was insufficient to meet the demands of the Walk in Centres and it had been agreed that from a recent recruitment drive the service had offered four new band 5 development posts. The report stated this will help to support and develop the staff to the competency levels required to work within a Walk-In Centre. However, at the time of inspection it was too early to assess the impact of this.
  • A documented induction process which included identification of training needs, orientation to the service, and familiarisation of key policies was in place.
  • 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 trust set a completion target for training courses of 90% for some courses and 95% for other. The overall training compliance for urgent care services overall was 83% against this target.
  • The trust provided staff with ongoing support and this was confirmed by staff during our discussions. This included one-to-one meetings, appraisals and mentoring and support for revalidation. The service discussed numerous models of clinical supervision and suggested they used both formal and informal models. Brief ‘huddle’ staff meetings took place daily and during this time staff were supported to plan the day and discuss any issues. However, formal clinical supervision ensuring all clinical staff had access to regular protected time for facilitated, in depth reflection was not taking place across the Walk in Centres.
  • There was also a lack of consistent evidence to demonstrate how the provider ensured the competence of staff employed in advanced roles by completion of audits of their clinical decision making, including non-medical prescribing. Only one of the Walk in Centres undertook regular audits of nurses’ records to monitor on-going competence of staff.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

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, local links had been made with a service to support men with mental health needs to ensure prompt referrals could be made.
  • Staff communicated promptly with patients’ 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.
  • 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. An electronic record of all consultations was sent to patients’ own GPs.
  • There were clear and effective arrangements for booking appointments, staff were empowered to make direct referrals and/or appointments for patients with other services.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may be in need of extra support. For example, all staff had received suicide training to help prevent or support vulnerable patients at risk.
  • We observed posters and leaflets promoting healthy lifestyles across the Walk in Centres.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this, including patient information.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

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

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • All staff we interviewed demonstrated a good understanding of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004 and other relevant national standards and guidance.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Caring

Good

Updated 8 April 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information. 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 19 patient Care Quality Commission comment cards we received were positive about the service experienced. This was 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.
  • Staff we observed were respectful and compassionate to patients and their carers. Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff displayed an encouraging, sensitive and supportive attitude for children and young people at Smithdown Road Children's NHS Walk-in Centre.
  • 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 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. In some locations the reception area was open and staff were aware of the need to ensure conversations could not be over heard.

Responsive

Good

Updated 8 April 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The service 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, higher numbers of patients attended the Liverpool Walk in Centre at lunch time so a higher number of staff worked across these hours.
  • The provider engaged with commissioners to secure improvements to services where these were identified. The provider had been operating under the new contract since April 2018 and regular meetings were taken place with the commissioners as services developed.
  • The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. For example, patients who were on a safeguarding risk register. Care pathways were appropriate for patients with specific needs, for example those at the end of their life, babies, children and young people.
  • Overall the facilities and premises were appropriate for the services delivered. However, we found the clinic providing services to children (Smithdown Road Children's NHS Walk-in Centre) was not adequate to meet the needs of the high numbers of patients being treated in this location. The waiting room was small and was unable to provide seating for all children and carers attending when the service was busy. The service corridors were cramped with children’s prams and baggage causing narrower corridor spaces for moving about the service. Play areas and facilities were observed in the waiting area and treatment rooms.
  • The provider made reasonable adjustments when people found it hard to access the service.
  • The service was responsive to the needs of people in vulnerable circumstances. Staff interviewed had a good understanding of how to support patients with mental health needs and those who were newly arrived asylum seekers.
  • A suicide prevention protocol was in place and some clinicians were suicide prevention trainers. All staff had received this training.
  • A suicide prevention protocol was in place and some clinicians were suicide prevention trainers. All staff had received this training.

Timely access to the service

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

  • Systems were in place to ensure patients who “walk-in” were clinically assessed within 15 minutes of arrival. This assessment normally included a set of observations. A triage system followed this initial assessment with patients prioritised for treatment, or offered pre-booked appointments, where this was clinically necessary. Following an assessment, patients were given an appointment slot which was intended to be no more than two hours after the time of their arrival. Operational information was used by senior managers to monitor this.
  • Patients were able to access care and treatment at a time to suit them. The service operated each day from 8am to 8pm.
  • Patients could access the service either as a walk in-patient, or by referral from a healthcare professional. Patients did not need to book an appointment.
  • Patients were generally seen on a first come first served basis, although the service had a system in place to facilitate prioritisation according to clinical need where more serious cases or young children could be prioritised as they arrived. The reception staff had a list of emergency criteria they used to alert the clinical staff if a patient had an urgent need. The criteria included guidance on sepsis and the symptoms that would prompt an urgent response. The receptionists informed patients about anticipated waiting times and there was a display system keeping patients up to date with the waiting times.
  • The KPIs used were for patients being seen, assessed and either discharged or referred on within 4 hours, triaged with 15 minutes, left without being seen and unplanned attendances within 7 days. Performance reports dates across September 2017 to September 2018 showed that performance was variable for triage and assessments being completed on target. meeting the 15-minute triage assessment with the highest centre increasing form a 23-minute wait for triage to a 25-minute wait in October 2018. Patients who had left without being seen was above target and unplanned attendances within 7 days was above target.
  • Patient information was collected on arrival to ensure that each patient, both children and adults, were treated as individuals, with their needs, preferences and their ethnicity, language, religious and cultural backgrounds being respected.
  • The service was aware that some vulnerable patients such as asylum seekers were attending and to address this, staff facilitated access to translation services and more time was given for their appointment.
  • The service had systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • Staff we spoke with demonstrated a good understanding of how to support patients with mental health needs and dementia.

  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Patients we spoke with said the walk-in system was easier to use to have their needs assessment and met.
  • Referrals and transfers to other services were made in a timely way.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was not easily available at the locations we visited. There was confusion amongst staff about what information should be given to patients to complain.
  • The complaint policy and procedures were in line with recognised guidance. There were no reported complaints for the Walk in Centres in the last year.
  • We were told that issues would be investigated across relevant providers, and staff were able to feedback to other parts of the patient pathway where relevant.
  • Systems were in place for the service to learn lessons from individual concerns and complaints and also from analysis of trends.

Well-led

Requires improvement

Updated 8 April 2019

We rated the service as requires improvement for providing well led services. This was because the provider did not have an overall comprehensive programme of quality improvement activity that included the Walk in Centres. There was no systematic programme of clinical audit which was used across each of the Walk in Centres to monitor quality and systems to identify where action should be taken if required. Concerns were identified relating to medicines management, the management of the overall safety and limitations of the premises and access to clinical supervision.

The Walk in Centres are part of the Mersey Care NHS Foundation Trust. As part of the governance arrangements there were structures, processes and systems of accountability in place to support the delivery of the trust strategy. Evidence was provided to the inspection team to demonstrate these systems were regularly reviewed and improved. This included plans for the transition of the Walk in Centres from the previous provider. At the time of inspection some of these plans were in their infancy.

This inspection focused on the leadership capacity and capability, culture, governance, managing risks, issues and performance, appropriate and accurate information, engagement with patients, the public, staff and external partners and continuous improvement and innovation across the Walk in Centres

Leadership capacity and capability

Local 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. However, the service had identified this as a development area for some staff and training opportunities were in place to support them.

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 approachable, though some staff reported more senior managers were not as visible.

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 trust had a vision for what it wanted to achieve and transformational plans for how the vision and strategy would be put into place. Staff we spoke with were aware of the trust plans and what the core vision was for the organisation. The trust Statement of Purpose sets out their vision as the following:

Our vision is to strive for Perfect Care'.

Perfect Care means:

Setting our own stretching goals for improvements in care rather than aiming to meet minimum standards set by other organisations.

Getting the basics of care right every time.

Making improvements to the care we provide because we know it’s the right thing to do for patients and because we care about the care that we provide.

Helping people to try improvements, learn from their mistakes, and apply what works more rapidly.

Helping our people to innovate in ways that create better quality and outcomes for the people we serve whilst reducing cost’.

Culture

The service had a culture of high-quality sustainable care.

Staff felt respected, supported and valued. They were proud to work for the service.

The service focused on the needs of patients.

Leaders and managers acted on behaviour and performance consistent with the vision and values.

Openness, honesty and transparency were demonstrated when responding to incidents and complaints. Though staff reported to us that they did not always have feedback about some of the incidents they had reported.

Systems and procedures were in place to ensure the trust met the duty of candour. There were no examples shown to demonstrate this across the Walk in Centres.

Policies were in place to support staff to raise concerns without fear of recrimination. All staff we spoke with confirmed they felt comfortable reporting concerns and they were confident appropriate actions would be taken.

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. However, formal clinical supervision for nurses was not taking place and there was a lack of evidence that the service regularly reviewed the effectiveness of care and treatment through clinical audits, including peer reviews and consultation audits.

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 set out and understood by staff, though at the time of inspection they were in their infancy and required further work and development.

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 policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. At the time of inspection, a number of policies and procedures in place were from the previous provider organisation. The management team was aware of this and the trust transformation plan had target dates for replacing these.

We found a number of Patient Group Directives that had not been reviewed, updated or adequately signed during the inspection. Confirmation was received by the trust that actions had been taken for this.

Managing risks, issues and performance

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

There were systems to assess, monitor and manage risks to patient safety. All staff reported risks on the provider Datix system. Staff we spoke with told us that feedback about the reported incidents needed to improve.

The service had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations but this was not consistently applied across the Walk in Centres.

Leaders had oversight of serious untoward 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.

Risk assessments were not consistently completed for all of the centres and we identified a lack of effective oversight of the risks associated with these premises and how risks were being managed.

There was limited evidence at each of the Walk in Centres to show the service made improvements through the use of completed clinical audits across each location. The service did not undertake audits/reviews of clinical decision making, including non-medical prescribing to determine the competence of staff employed in advanced roles.

The provider had plans in place and had trained staff for major incidents.

The provider implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The provider 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 obtained via the Friends and Family Feedback cards.

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.

Weekly Walk in Centre team leader meetings were held. Performance information was reviewed here along with monitoring of specific action plans such as staff training and sickness levels. This meeting gave opportunity to clinical team leader roles to provide feedback to senior managers at the trust and to share their views and concerns about the services they managed. Minutes of the meetings held for meetings held form September 2018 to November 2018 confirmed this.

Staff we spoke with could describe to us the systems in place to give feedback, such as the team leader and daily huddle meetings. We saw evidence of the most recent staff survey and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.

The service was transparent, collaborative and open with stakeholders about performance.

The service had recently taken part in a Health Watch listening event across the four Walk in Centres. At the time of inspection the report for this had not been received by the provider.

Continuous improvement and innovation

There was a focus on continuous learning and improvement at all levels across the Walk in Centres. Mersey Care NHS Foundation Trust was a new provider for these services and staff and patients had experienced a number of recent changes to systems and processes at the time of our inspection. 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 development of a workstream to closely monitor response times from the local ambulance trust. This included establishing engagement meetings, agreeing a designated named Advanced Paramedic to each Walk in Centre and ensuring any serious untoward incidents that occurred as a delay with the ambulance trust.

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.