Letter from the Chief Inspector of General Practice

We carried out an announced focused follow up inspection at Wellington House (known locally as Somerset Doctors Urgent Care) on 24 August 2017.

Following our comprehensive inspection at Wellington House NHS on 24 and 25 April 2017 the location was rated as inadequate for the Out of Hours service with an inadequate rating for the safe, effective and well led domains, good for caring and requires improvement for responsive. We rated the NHS 111 service as requires improvement with requires improvement rating for safe and effective, good for caring and responsive and inadequate for well-led. Our levels of concern following this inspection were significant and we placed the provider into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

The serious concerns were such that we took further steps to ensure the provider made changes to the governance of the service to reduce or eliminate the risks to patients. The provider was required to make improvements in respect of these specific deficits, as outlined in the warning notices of 17 May 2017 to be completed by 18 August 2017.

We issued warning notices in regard to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance and Regulation 12 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Safe care and treatment.

This focused follow up inspection was undertaken on the 24 August 2017 to assess if the regulatory breaches had been met in regard to the warning notices. Other areas of non-compliance were planned to be reviewed at a later date by a comprehensive inspection when the provider has had time to implement all the changes required.

The provider had taken steps to ensure the significant concerns that had been found in relation to the warning notices for Regulations 12 and 17 had or were in the process of being addressed. For example we found evidence that the concerns around emergency medicines, calibration of clinical equipment, health and safety relating to risk assessments and COSHH (control of substances harmful to health) and complaints had been rectified. Infection prevention and control measures had been improved.

The provider had implemented changes to the management and administration system for safer recruitment and for mandatory learning and development. However there were still gaps in the safer recruitment process such as pre-employment references and the completion of mandatory training such as safeguarding, basic life support, fire safety and evacuation and infection, prevention and control had not been completed by all staff. With regard to medicine management, the systems to securely store and monitor medicines including controlled medicines remained inadequate. The service had not met all the National Quality Requirements used to monitor safe, clinically effective and responsive care which meant patients’ care needs continued to not always be assessed and delivered in a timely way. Further concerns remained unmet, the implementation of an overarching governance framework for systems and processes, including the action plan following our previous inspection concerns, required attention to improve the quality and safety of the services and to mitigate risks relating to the health, safety and welfare of staff and service users.

In addition we found new concerns with infection prevention and control measures such as such as spillage and contamination relating to used sharps. There was limited evidence of learning being embedded in policy and processes; for example, there were ongoing incidents of missing blank prescriptions and blank prescriptions not being held securely. Additional concerns around patient confidentiality were raised with the service.

There were also areas of service where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all patients are treated with dignity and respect.

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

• Ensure that serious incidents, deaths or safeguarding referrals are subject to statutory notifications to the Care Quality Commission.

The provider should:

• Complete resulting actions from the health and safety risk assessment relating to lone working as a priority.

• Enable staff at Out Of Hours sites staff to easily identify which equipment has been calibrated and which equipment they need to re-calibrate regularly such as blood glucose monitors and which is safe to use.

In this situation with the issuing of warning notices, we returned to check the progress the provider was making in regard to the key concerns. The service remains under special measures until we have returned to carry out a comprehensive inspection at the end of this six month period after the initial report was published. If the service has failed to make sufficient improvements the CQC will consider taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This service is rated as Good overall. (Previous inspection 05 2018 – Requires Improvement).

The key questions are rated as:

Are services well-led? – Requires Improvement

We carried out an announced focused inspection of the Somerset NHS 111 service at Wellington House on 10 January 2019. This was to review the quality of the service following four previous inspections carried out at the service in May 2018 and April, August and November 2017 where we issued warning notice’s as a result of finding significant areas of concerns.

On 16 May 2018 an announced focused follow-up inspection was carried out. We found the delivery of high-quality care was not assured by the leadership and governance in place at the service. Significant issues that threaten the delivery of safe and effective care were not adequately managed. There was limited evidence that actions to address previous CQC concerns had resulted in sustained improvement to the service. Insufficient improvements had been made such that there remained a rating of inadequate for well-led. Following that inspection, we issued a further warning notice in respect of:

• Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.

At this inspection we found:

• There was evidence that actions to address previous CQC concerns had resulted in improvement to the service.
• There was improvement and stability within the local and regional leadership team who demonstrated prioritisation of previous non-compliance.
• Significant issues that threatened the delivery of safe and effective care had been reviewed and managed. For example, overnight calls had been diverted to central call centres where sufficient staffing ensured the service delivery within the required call targets.
• There were improvements in national Minimum Data Set requirements with service performance in line with national averages although in some areas these remained below national target levels.
• Patients were mostly able to access care and treatment from the service within an appropriate timescale for their needs.
• There was evidence of continuous learning and improvement at all levels of the organisation. The service had processes in place to learn and share lessons from safety incidents. Reviewing learning to improve performance was limited to call-auditing and individual staff reviews.
• The provider had implemented new governance systems and processes to measure the quality of the service and to promote continued development and improvement of the service. At the time of our inspection this was new and therefore limited evidence to show effectiveness.

• Incidents and complaints were not always completed within provider policy timescales and processes to identify and manage these risks were not effective. This meant limited evidence that duty of candour had been applied in a timely manner.
• The provider had a planned audit programme and we saw some evidence of quality improvement work.

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

• 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:

• Consider a formal system to demonstrate evidence of how learning from incidents and quality improvement work has been embedded and improved quality of care delivery.
• Continue to develop the programme of audits to identify impact on patient care.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice