Archived: Wellington House

Letter from the Chief Inspector of General Practice

This service is rated as Inadequate overall. The service was rated as inadequate at our previous inspection in April 2017.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Inadequate

Are services well-led? – Inadequate

Following our comprehensive inspection at Wellington House on 24 and 25 April 2017 the location was rated as inadequate for the Somerset Out Of Hours (OOH) service with an inadequate rating for the safe, effective and well led domains, good for caring and requires improvement for responsive. Our levels of concern following that 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 of publication of the previous report 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. On 17 May 2017 we issued two 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. The provider was required to make improvements in respect of these specific deficits with a date to be compliant by 18 August 2017.

A focused follow up inspection was undertaken on the 24 August 2017 to assess if the regulatory breaches had been met in regard of the warning notices. We did not find full compliance with the warning notices and we issued further warning notices in regard of: Regulation 12 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Safe care and treatment; Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance and Regulation 18 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Staffing. The provider was required to meet the requirements of the warning notices, issued on 28 September 2017, by 15 November 2017.

We inspected the service on three days. A comprehensive inspection was carried out on the 16 and 17 November 2017 as part of an announced comprehensive inspection. In addition as part of this visit, we carried out an unannounced inspection on 11 November 2017 to Shepton Mallet Hospital and Bridgwater Hospital two of the five Somerset OOH treatment sites following information of concern received by the CQC.

Prior to our inspection the CQC had met regularly with the provider in meetings led by Somerset Clinical Commissioning Group to discuss actions in relation to the provider’s improvement plan and to have an oversight of actions undertaken by the provider in relation to the warning notices issued by us. Our key findings from this inspection were as follows:

• We found insufficient improvements had been made to manage risks relating to the health, welfare and safety of people, including completion of training for basic life support, fire safety and evacuation and infection prevention and control.
• With regard to medicine management, the systems to securely store and monitor prescriptions and medicines including controlled medicines remained inadequate.
• Patients care needs continued to not always be assessed and delivered in a timely way according to need. The service had not met all the National and Local Quality Requirements used to monitor safe, clinically effective and responsive care. For example, waiting times for some clinical assessments, and safe staffing levels did not show sustained improvement.
• Since our previous inspection in August 2017 there had been substantial changes within the leadership team. The registered manager and the regional director for the service were no longer in post. We found there were areas where the management of the service required further improvement and stability. The provider had installed a transitional management and support team at Wellington House to address the failings of the service. The team had identified several areas for improvement however, at the time of the inspection, not all of these actions had been implemented.
• The provider had taken steps to implement some changes in relation to the significant concerns set out in the warning notices but had not met the requirements. However the implementation of an overarching governance framework for systems and processes, including the action plan following our previous inspection concerns were not effective enough to sustain the quality of the service and to promote continued local development and improvement.

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

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that serious incidents, deaths or safeguarding referrals are subject to statutory notifications to the Care Quality Commission.

The provider should:

• Consider implementing a process or audit to monitor the process for seeking and recording consent.
• Improve the accessibility to the service for patients with a hearing impairment.

This service was placed in special measures in August 2017 in order for the provider to take steps to improve the quality of the services it provided. We found insufficient improvements have been made such that there remains a rating of inadequate for safe, effective and well-led. In addition the responsive domain has now been rated as inadequate. Therefore we are taking action in line with our enforcement procedures to impose conditions on the registration of the Wellington House location for Somerset NHS 111 and Somerset OOH services. This will lead to a variation of the conditions of the registration.The service will be kept under review and if needed measures could be escalated to urgent enforcement action.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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

We carried out an announced comprehensive inspection at Wellington House (known locally as Somerset Doctors Urgent Care) Out of Hours service on 24 and 25 April 2017. Overall the service is rated as inadequate.

We found the service inadequate for providing safe, effective and well-led services. The service requires improvement for responsive services. We found the service good for providing caring services.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, reviews and investigations were not thorough enough. Policy timelines had been missed. There was little evidence of learning being embedded in policy and processes.

• Systems, processes and practices to keep people safe had significant gaps and were a cause of concern. For example, there was a lack of the required level of safeguarding training provided for staff, infection prevention control arrangements did not keep people safe, arrangements for managing medicines including emergency medicines was not robust, there was an insufficient system for oversight of risk assessments and health and safety checks. The communication of access to emergency equipment was in need of improvement due to the variations in provision in each OOH treatment centre and the arrangements to undertake all necessary professional employment checks for all staff before employment commences were not always in place or were not recorded.

• Patient’s care needs were not always assessed and delivered in a timely way according to need. The service had not met all the National and Local Quality requirements. For example, waiting times for some clinical assessments. The provider told us they had submitted a recovery action plan to the service commissioners.

• Arrangements to monitor quality were not robust enough to support improvement.

• There was a system in place at the Out Of Hours (OOH) sites that enabled staff access to patient records. However some staff told us they had difficulty accessing the system due to the internet connection. OOH staff provided other services such as the local GP practices and hospital services with information following contact with patient’s as was appropriate.

• The service closely monitored training and continuous professional registration of agency staff. However there were significant gaps in recording and monitoring staff training for employed staff. In addition staff had not always received training for their roles. For example, chaperone and driver safety training.
• Staff did not always receive performance reviews or appraisals.
• Patient’s said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However there were significant gaps in patient complaint management.
• The service worked proactively with other organisations and providers to develop services that supported alternatives to hospital admission where appropriate and improve the patient experience.
• The OOH sites were easily accessible. However access for people with a hearing impairment could be improved. The vehicles used for home visits were clean and well equipped.
• There was a leadership structure. However the overarching governance framework for systems and processes 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.
• The provider was aware of the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. Systems were in place for notifiable safety incidents and complaints however the arrangements to ensure this information was shared with staff to ensure appropriate action was taken were inconsistent.

The areas where the provider must make improvements are:

• Ensure there are robust and effective systems and processes to assess, monitor and improve the quality and safety of the services provided and to assess monitor and mitigate risks relating to the health, safety and welfare of service users and others who may be at risk arising from the carrying on of the regulated activities. Such as staff training, recruitment processes medicines management, systems for health and safety checks, infection prevention control including the decontamination of clinical equipment and safe management of healthcare waste and improved access to emergency equipment.

• Ensure adequate staffing levels are in place to provide timely access to the service for all patients. To include appropriate and timely ‘comfort calls’.

• Ensure staff receive regular appraisals and/or performance reviews. To include regular auditing of clinician consultations in line with the Vocare GP face to face audit process policy.

• Ensure complaints and significant events are dealt with consistently with clear explanations of actions taken and the identification of learning or sharing of learning. Analysis of trends and themes should result in improvements of care and learning embedded in policy and processes.

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

The areas where the provider should make improvement are:

• The service should evidence safety checks for clinical equipment including use of clinicians own equipment.

• Review or carry out clinical audits including re-audits to ensure improvements in clinical care and other processes have been achieved.

• Improve the accessibility to the service for patients with a hearing impairment.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key questions or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

We carried out this announced comprehensive inspection of Wellington House (known locally as Somerset Doctors Urgent Care) NHS 111 and Out of Hours service on 24 and 25 April 2017. NHS 111 is a 24 hours a day telephone based service where people are assessed, given advice or directed to a local service that most appropriately meets their needs. For example, this could be to their GP, an out-of-hours GP service, walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, late opening pharmacy, or self-care home management advice.

This site provides services to the whole county of Somerset; the call centre received NHS 111 calls and was co-located with the Out of Hours call centre, we inspected the NHS 111 service located at Wellington House in Taunton.

Overall the service is rated as requires improvement. We found the service requires improvement for providing safe and effective and inadequate for well-led services. We found the service good for providing responsive and caring services.

Our key findings were as follows:

• The provider had taken steps to ensure all staff underwent a recruitment and induction process to help ensure their suitability to work in this type of healthcare environment. However, the provider was unable to produce the required documentation to demonstrate their recruitment policy and procedure had been followed. As a result they could not demonstrate the qualifications and experience of fitness of all the staff employed.
• The service had not met all the National Minimum Data Set and Local Quality requirements for example, failure to achieve the percentage of calls answered within the 60 second time period (standard eight). Appropriate action was undertaken where variations in performance were identified however there was evidence that improvement was not sustained.
• Staff were supported in the effective use of NHS Pathways which is a triage software utilised by the National Health Service to triage public telephone calls for medical care and emergency medical services.
• We found there was no regular consistent auditing of calls which is part of their NHS 111 contract. The service recognised this was an area for quality improvement and had a remedial plan in place however; there had not been an audit programme in place for the previous six months.
• We observed and listened to calls which demonstrated that people experienced a service that was delivered by dedicated, knowledgeable and caring staff.
• People using the service were supported effectively during the telephone triage process. Consent to triage was sought and their decisions were respected. We observed staff treated people with compassion and responded appropriately to their feedback.
• Clinical advice and support was readily available to call advisors when needed. Care and treatment was coordinated with other services and other providers.
• Evidence of learning from internal incidents and complaints was limited.
• There was an overarching governance framework across the NHS 111 service, however this was not co-ordinated and there appeared to be confusion about areas of responsibility.
• Arrangements to monitor quality were not robust enough to support sustained improvement.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• The provider was aware of the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. Systems were in place for notifiable safety incidents however the arrangements to ensure this information was shared with staff to ensure appropriate action was taken were inconsistent.

The areas where the provider must make improvements are:

• To ensure there are robust and effective systems and processes to assess, monitor and improve the quality and safety of the services provided and to assess monitor and mitigate risks relating to the health, safety and welfare of service users and others who may be at risk arising from the carrying on of the regulated activities.
• To undertake all necessary professional employment checks for all staff before employment commences.
• To ensure an accessible and organised system for oversight of risk assessments and safety checks and access to emergency equipment such as first aid and fire safety equipment.
• To ensure that statutory notifications are sent to the Care Quality Commission.
• To ensure staff have regular call auditing, including clinician consultations, in line with Vocare policy.
• To ensure that governance arrangements support sustained improvement.
• To ensure complaints and significant events are dealt with consistently and any learning is shared.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice