CQC warns South Western Ambulance Service NHS Foundation Trust about safety of NHS 111 service

The Care Quality Commission has told South Western Ambulance Service NHS Foundation Trust that it must make significant improvements to protect the safety of people using its NHS 111 services for Devon, Dorset, Cornwall and the Isles of Scilly.

Overall the service has been rated as Inadequate. A team of inspectors found the 111 service was Good for caring, but Inadequate for safety, effectiveness, responsiveness and being well-led. A full report of the inspection has been published.

Inspectors found that there were often not enough staff to take calls, or to give clinical advice when that was needed. Staff reported working long hours, many feeling high levels of stress and fatigue.

There was a high staff turnover and high sickness rates. Too many calls were abandoned, and patients were waiting too long for their calls to be answered and to be assessed, or to receive a callback with appropriate advice.

Calls were sometimes answered by staff who were not trained to assess patients' symptoms and there was a risk that patients needing urgent attention were not given priority or could be put into a long queue awaiting call back.

Following the inspection CQC issued a Warning Notice on 26 May requiring the trust to ensure that calls are responded to in a timely and effective manner, with enough suitably qualified staff on duty who are supported to deal with the volume of calls. The trust has been told that it must make significant improvements by 8 July 2016.

CQC has also told the trust that it must make a number of improvements including:

• The trust must continue to review staff numbers to ensure patients can access timely care and treatment when first calling the service and when receiving a call back.
• The trust must review the roles and responsibilities of Non Pathway Advisors (call handlers who are not trained to use the NHS Pathways triaging system) ensuring callers consistently receive the correct level of advice.
• The trust must ensure that the call queues awaiting initial assessment and callback are robustly monitored and managed by staff with clinical authority to intervene and allocate resources.

Professor Sir Mike Richards, Chief Inspector of Hospitals, said:

"NHS 111 services are an important part of the urgent care system, ensuring people have quick and easy access to healthcare advice and information - and urgent attention when that's appropriate.

"If patients needing help can't get a reply, if they are dealt with by someone who doesn't understand their immediate needs, or if they have to wait too long for a nurse or paramedic to call them back for an assessment before they are referred to the out-of-hours GP, it can have potentially serious consequences.

"We found that patients were at risk of harm because the triaging system was not good enough. Too many people whose call was urgent were not being assessed in relation to their medical needs in a timely manner.  A lot of people needing less urgent advice might have to wait all day for a call back.

"Despite the best efforts of staff - the service was not doing enough to identify why this was happening or what needed to be done to improve. The trust had known of these concerns but it took the staff to bring them out into the open to ensure that something was done.

"South Western Ambulance Service NHS Foundation Trust and the organisations who commission this service must ensure that all people who dial 111 in Cornwall, Devon, Dorset and the Isles of Scilly are dealt with promptly and safely, as patients deserve.

"Since our inspection we have been working closely with NHS England, NHS Improvement and the local commissioners to ensure that our most urgent concerns around the triaging of calls are dealt with. The trust leadership has told us that they are well aware of the issues that we have raised. We expect them to take action – and we will be monitoring the service closely to ensure these improvements continue."

The Care Quality Commission is currently inspecting all NHS 111 services. The inspection of the South Western Ambulance Service NHS Foundation Trust was brought forward after concerns were raised by patients, staff and former members of staff.

A team of 13 inspectors, including specialist advisors, conducted a full inspection of the NHS 111 service serving Dorset, Devon and Cornwall, visiting two call centres at St Leonards, Dorset, and Exeter, Devon on 8, 9 and 12 March 2016.

Inspectors found that patients who used the service were dealt with in a calm, patient and professional manner. Staff listened carefully to what was being said, checked information when necessary and were supportive and reassuring when responding to people calling in distress.

However the service had been consistently failing to meet national standards. Although 95% of calls should be answered within 60 seconds, the trust was achieving 72% at one time.

Inspectors saw calls being answered and then being placed on hold; although that means that the initial 60-second target was met, patients were not spoken with immediately to assess their clinical needs.

Staff said there were often too few clinical staff available. At one time during the inspection, there was only one clinical advisor immediately available at each of the call centres. Inspectors found evidence of urgent callers waiting for long periods to receive a call back from a clinical advisor. Despite being aware of this, the trust had not reviewed the calls in detail to identify the root cause.

Call advisors had been trained to use the NHS Pathways system – a computer based operating system that enables staff to make clinical assessments and triage callers according to their symptoms. But the trust did not do enough to monitor their staff or audit calls – meaning that poor performance could not be identified and managed, and that opportunities for identifying and learning from adverse incidents were missed.

Advisors who were not trained in the Pathways system often placed callers in a queue which could result in 50 to 60 patients waiting.

The Trust had taken only limited action to deal with staff's concerns about safety, or the large number of complaints from staff, patients or healthcare professionals. When significant incidents were identified, any attempts to learn the lessons were cancelled out by staff shortages or inadequate planning to meet demand.

This week CQC met with the trust, NHS England and NHS Improvement and NHS Dorset Clinical Commissioning Group, NHS Kernow Clinical Commissioning Group and NHS Northern, Eastern and Western Devon Clinical Commissioning Group to discuss the inspection findings further and consider next steps.

CQC inspectors will return to the trust in the near future to check that the required improvements have been made.

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