Letter from the Chief Inspector of General Practice

We carried out an announced desk based review on 11 April 2017 to follow up concerns we found at Ashgate Manor Primary Care Centre on 10 November 2015. Overall the service is rated as good.

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

• There was a process in place to ensure the safe handling and security of blank prescription pads held at Ashgate Manor Primary Centre and when distributed to other locations.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

 We carried out an announced comprehensive inspection of Derbyshire Health United NHS 111 service at Ashgate Manor on 10 November 2015. Overall the provider is rated as good.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording serious incidents. Staff knew how to and understood the need to raise concerns and report incidents and near misses. However, not all serious incidents identified through complaints were investigated through the serious incident procedure.
• The provider was monitored against the Minimum Data Set (MDS) and Key Performance Indicators (KPIs). The data provided information to the provider and commissioners about the level of service being provided. Where variations in performance were identified, the reasons for this were reviewed and action plans implemented to improve the service.
• Staff were trained and monitored to ensure they used NHS Pathways safely and effectively.
• Information about services and how to complain was available and easy to understand. Complaints were fully investigated and patients responded to with an apology and full explanation.
• There was strong and clear leadership from a clinical and senior management perspective. Staff felt supported by senior management and directors who were visible on shifts on a daily basis to support the smooth running of the service.
• The provider proactively sought feedback from staff and patients, which it acted on.
• There were robust safeguarding systems in place for both children and adults at risk of harm or abuse as well as frequent callers to the service.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• The provider had a clear vision and strategy to deliver high quality, safe and effective healthcare and promote good outcomes for patients. The provider was responsive to feedback received from patients and staff and used information available proactively to drive service improvements.

However there were areas of practice where the provider should make improvements:

• Ensure that records of complaints include details of the outcome and/or the impact for the patient.
• Ensure that when potential serious incidents are identified through complaints, these are investigated through the serious incident procedure.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Derbyshire Health United (DHU) evening and overnight district nursing service on 9 & 10 May 2016. As part of this inspection we visited Ashgate Manor where the north district nursing team were based. Overall the service is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Staff knew how to and understood the need to raise concerns and report incidents and near misses.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Staff had received extended training relevant to their role. For example, staff had undertaken training in varying aspects of end of life care, dementia awareness and domestic abuse awareness.
• A care concern referral process had recently been introduced. This system enabled referrals to be made where the concerns for the patient did not relate to suspected abuse but related to care needs or welfare of the patient.
• Through the comment cards patient completed for us, they said they were treated with compassion, dignity and respect. The also told us they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Patient information was available in different languages. Complaints were fully investigated and patients responded to with an apology and full explanation.
• Vehicles used to visit patients in their own homes were clean and well equipped.
• There was a clear leadership structure and staff felt supported by their team leaders and the senior management team.
• The provider proactively sought feedback from staff and patients, which it acted on.
• There were innovative approaches to providing integrated person-centred care. Rightcare plans were developed by the patient’s GP and shared with the evening and overnight district nursing service for clinically high demand patients including nearing end of life and those with complex health needs. Special notes were used to record relevant information about patients.
• There were effective safeguarding systems in place for both adults and children at risk of harm or abuse. There was an effective system in place for adults to support people about whom there were care or welfare concerns.
• There were clinical supervision and appraisal processes in place for all clinical roles and support was provided for those members of the nursing team who were required to revalidate.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw several areas of outstanding practice including:

• A daily comfort call system was in place for patients referred into this service with palliative care needs and those patients who were at the end of their life. These patients received a telephone call on a daily basis to assess their care needs and received priority visits when required.

• DHU worked towards achievement of a quality target to achieve a minimum of 95% of all requests for urgent visits to be achieved within a four hour time frame. During the period 1 April 2015 – 31 March 2016, a total of 18,361 patient contacts were recorded. The overall achievement of this target was 99.75% of urgent visits attended within a four hour timeframe. Data was monitored on a monthly basis and any reported breaches of this target were investigated on an individual basis to ascertain whether an actual breach had occurred.

• DHU carried out an end of life care admission audit which involved a review of all hospital referral rates and emergency 999 calls for terminally ill/palliative care patients. This audit monitored reasons for admission to hospital and any further communication with or actions taken by DHU and identified whether a Rightcare plan was in place for these patients. This enabled DHU to continually monitor the appropriateness of unplanned admissions to hospital and use of emergency services. The results of this audit showed that 75% of either hospital admission or emergency 999 calls were appropriate or unavoidable. Results highlighted that 50% of cases did not have a Rightcare plan in place. Reasons for either admission or an emergency 999 call were recorded for those cases deemed inappropriate to enable DHU to monitor trends and action plans were implemented as a result of this audit.

• An out of hours coordinator was in place on a daily basis who was also supported by a clinical lead who provided clinical oversight and support in the community to the nursing teams. The out of hours coordinator continually monitored the location of all members of the nursing teams when working in the community via the ‘Adastra’ electronic system and ensured regular communication with staff throughout their shift. The coordinator continually monitored and re-allocated workloads across all nursing teams to ensure work was re-allocated to other teams should a nursing team require to spend more time with a patient dependent upon their care needs, whilst ensuring other patients received a home visit as soon as possible by the most appropriate team. This system also ensured achievement of the quality target to achieve a minimum of 95% of all requests for urgent visits within a four hour time frame

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice