Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Care UK – East of England on 28 February 2017. The service provides out-of-hours GP and dental services. 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 recording, reporting and learning from significant events.
• Learning from significant events was cascaded nationally throughout the organisation. The organisation sent out a national quarterly clinical newsletter in which several similar significant events were shared and discussed. For example we saw a newsletter in which, amongst several other significant event analyses, three different presentations of a pulmonary embolism (blood clot on the lungs) were described, with questions posed to the reader, these had all been raised as significant events from different services within the organisation.
• Risks to patients were assessed and well managed.
• Patients’ care needs were assessed and delivered in a timely way according to need. The service met the National Quality Requirements.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The service maintained appropriate standards of cleanliness and hygiene. For example, the dental van was visibly clean and clutter free. Infection control practices were followed, reviewed and audited to test their effectiveness.
• There was a system in place that enabled staff access to patient records, and the out-of-hours staff provided the local GP and hospital, with information following contact with patients when appropriate.
• The service managed patients’ care and treatment in a timely way.
• Patient feedback was strongly and consistently positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The service worked proactively with other organisations and providers to develop services that supported alternatives to hospital admission where appropriate and improved the patient experience.
• The service had good facilities and was well equipped to treat patients and meet their needs. The vehicles used for home visits were clean and well equipped.
• There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding service:

• There was a strong focus on continuous learning and improvement at all levels. The provider had made use of an external contractor who had been given an open brief to seek and devise development opportunities into elements of service delivery in the out-of-hours.
• The provider proactively sought patients’ and staff feedback and engaged patients in the delivery of the service. For example, in the primary care centres there were posters in the waiting areas that encouraged patients to comment on the services provided. The provider conducted surveys of patients’ experience on an ongoing basis. In January 2017, 255 patients had responded to surveys and 99% had expressed overall satisfaction with the service they had received. The trends in feedback were closely monitored, and the results illustrated an upward trend from the February 2016 overall satisfaction score of 88%.
• The provider had created an in-house learning mobile app for staff to use on their phones and handheld tablet devices. This had led to a high uptake of training courses for all staff within the organisation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Harmoni HS Ltd was founded in September 1996 by two doctors as a GP co-operative in Harrow. As of November 2012, Harmoni is a wholly owned subsidiary of Care UK with the core business being the delivery of out of hours care and NHS 111 services. Harmoni employs more than 1,700 clinical and non-clinical staff members.

The location inspected was based in the Suffolk local authority area and is registered to provide two of the six regulated activities which are: transport services, triage and medical advice provided remotely and treatment of disease, disorder or injury. The Harmoni – Suffolk out-of-hours base location reports to the NHS Ipswich and East Suffolk Clinical Commissioning Group (CCG).

The central administration and coordinating centre has eight satellite locations which provide services to people in and around the Ipswich area. The main base location is also the call handling and triage centre for National Health Service (NHS) 111 telephone calls across the Suffolk region. We visited the main central base in Ipswich where patients are not seen, and two other locations where patients attended for consultation and treatments. The two other locations visited were at Bury St Edmunds and Ipswich Hospital NHS Trust. Three of the remaining six location do not all open during the week on a regular daily basis and are opened on an ad hoc basis when required to provide a service.

The provider was chosen as part of the new wave inspection programme project and the visit was announced. The team was made up of five specialist advisors and a compliance inspector and the visit was conducted whilst the provider was working operationally.

During our inspection we spoke with six patients who were using the out-of-hours emergency GP service, and approximately 20 members of staff. Staff members included the regional medical director, director of operations / registered manager, doctors, lead nurse and operational staff such as call handlers and drivers.

The provider had satisfactory governance systems in place to protect patients from the risk of abuse and ensure that they received the appropriate safe emergency care and treatment. Medicines kept on the premises were stored appropriately and securely and staff received the training in the safeguarding of children and adults.

We found that the service had systems in place to ensure that the provider could effectively respond to the needs of the patients accessing the out-of-hours service safely. The provider monitored the call handlers to ensure that information was recorded and used effectively to prioritise patients appropriately according to how urgently they required care. Information regarding the care received by patients was shared with the people’s usual GP in a timely manner to ensure continuity of care between the different service providers.

Patients received a caring service. Patients told us that they were happy with the care they received and that they were involved in the decisions about their care. We were told that staff were polite and respectful and we observed this to be the case. There was opportunity for people to provide feedback as Care Quality Commission questionnaires had been made available in the waiting area prior to our visit. The provider also carried out regular satisfaction surveys to capture people’s views. The provider had a strategy in place for capturing the views of the GPs and ethnic minority groups within the area. There was easy access to the locations we visited with car parking availability at both sites.

The service was responsive to patients’ needs. Staff had access to the appropriate equipment, training and support. Although there was an expectation that medical staff would provide some of their own equipment. The provider carried out the appropriate employment checks on new and temporary staff to ensure that they were able and safe to carry out their roles.

The organisation was well led. There was a clear governance structure in place and a process for disseminating information to all members of staff. There was a complaints policy and procedure in place as well as a process for escalating incidents to senior managers by the duty coordinators. All complaints and incidents are reviewed through the Clinical Governance Committee. Staff told us that they felt supported and that the service was well-led. There were regular team meetings to ensure that information was cascaded to all staff team members; this included learning from incidents and any changes to practice across the organisation as well as locally.

The inspection did not highlight any non-compliance with the current Health & Social Care Act (2008) regulations.

We carried out a routine inspection on 31 January 2013 and found that there were not always enough qualified, skilled and experienced staff to meet people’s needs. We also found that some medical staff had not received their training as planned.

On the 15 April 2013 we carried out a follow up inspection to make sure that the action plan we had been provided with was implemented. We found that there were now enough qualified, skilled and experienced staff to meet people’s needs. We also found that all staff now received appropriate professional development.

During our inspection we spoke with five members of staff and four people who used the service. We found that care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. The range and numbers of staff could respond to peaks and troughs of demand.

When demand was extremely high escalation and contingency plans had been put in place. One staff member we spoke with told us, “It can be very busy in the evenings and at weekends but I’m never sitting there thinking I can’t cope.”

Arrangements were in place for the recording, handling storage and administration of medication. The correct checks were undertaken before staff began work. There were effective recruitment and selection processes in place.

There were not always enough qualified, skilled and experienced staff to meet people’s needs but there were plans to address this. Most clinical staff were up to date with mandatory and statutory training but some medical staff had not received their training as planned. A staff member we spoke with told us “They’ve been very good with training – they regularly advertise other opportunities and events.”

There was evidence that learning from incidents and investigations took place and changes were being implemented.

One person we spoke with told us, “I found the system very helpful – they were able to tell me as well where I would find a pharmacy open and where to go if I needed more help.”

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of the Care UK East of England NHS 111 service for Suffolk, Lincolnshire and Milton Keynes on 20 and 21 July 2016. The service operates from a single call centre in Ipswich but can also be operated from two other Care UK call centres at Southall (London) and Bristol.

NHS 111 is a telephone-based service where callers were assessed, given advice and directed to a local service that most appropriately met their needs. For example, this could be a GP service (in or out of hours), walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance, late opening pharmacy or home management.

Overall the service is rated as ‘Good’.

Our key findings were as follows:

• There were systems in place to help ensure patient safety through learning from incidents and complaints about the service.
• The provider had taken steps to ensure that all staff underwent a thorough recruitment and induction process to help ensure their suitability to work in this

type of healthcare environment.

• Staff were trained to use the NHS Pathways clinical triage system effectively and safely and there were effective systems in place to monitor staff usage of the system. There were high levels of call audit that was in excess of the minimum requirement. This helped to enable the timely and effective management of poor or potentially risky performance.
• Patients experienced a service that was delivered by dedicated, knowledgeable and caring staff.
• Patients using the service were supported effectively during the telephone triage process. Consent to triage was sought and their decisions were respected. We saw that staff treated patients with compassion, and responded appropriately to their feedback.
• Clinical advice and support was readily available to health advisors when needed. Care and treatment was coordinated with other services and other providers.
• All opportunities for learning from internal incidents and complaints were used to promote learning and improvement.
• There was an overarching governance framework across the NHS 111 service, which supported the delivery of the strategy and good quality care. This included arrangements to monitor quality and identify risk.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Risk management was embedded and recognised as the responsibility of all staff.
• The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The provider had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
• There was a strong focus on continuous learning and improvement at all levels.

The areas where the provider should make improvement are:

The provider should ensure that all complaints are dealt with in a consistent way, ensuring all dates were recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice