Sheridan Teal House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 1 quality statement from this key question, Safe systems, pathways and transitions. We have combined the scores for this area with scores based on the rating from the last inspection undertaken in 2022, which was good. Our rating for this key question remains good. This assessment had partly been triggered by concerns raised with Care Quality Commission regarding the closure of certain NHS111 referrals into the service during periods of high demand. We found that the service provided safe care and treatment for patients who had been referred into urgent care. However, the process of closing some lower urgency referrals at times of high demand carried with it some risk. This risk had been recognised by the provider. This risk was not felt to be a breach of Regulations, but was a risk that the provider needed to continue to keep under review.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We discussed with the provider the handling of NHS 111 referrals from the point of entry into the service to completion, with a focus on bulk closures caused by demand pressures. They told us that they were aware of the risks associated with this decision process, but felt that during periods of escalating demand, this process was required to ensure that more urgent and serious cases were dealt with. We reviewed data which demonstrated that the majority of referrals into the service had a 1 or 2 hour disposition and only 10% of referrals fell into the less urgent 12 and 24 hour disposition. The provider had put in measures to mitigate the risks associated with closures which included audits, exemptions for some groups, giving staff the ability to escalate the seriousness and urgency of cases when these were identified, and the provision of safety netting advice to those whose cases had been closed. Audits showed that the majority of closed cases had not recontacted NHS 111, and no harm to patients had been identified. The provider fully understood the challenges they faced, and felt that this was the only viable action in relation to managing the acuity and numbers of cases which had been referred to them by NHS111. This approach had been endorsed by stakeholders. Staff we spoke with were passionate about their role. However, some staff we spoke with had reservations around closing live referrals because of the associated risks. Some staff also said that they felt that the process of closure was on occasion inconsistently applied, and relied heavily on individual decisions made by duty managers and others. Other concerns we heard from staff included poor on the job training, which they felt initially impaired their ability to fully deliver their roles. We raised this with the provider who told us that whilst they felt that initial training of staff was satisfactory, they would look into this further.

The commissioning body informed us that they met regularly with the provider to discuss operational risk and performance. For example, contract meetings were held on a bi-monthly basis, and the provider met with stakeholders on a monthly basis at a patient safety and quality meeting. The commissioner confirmed that the provider had not met all the local contractual key performance indicators in relation to response times. For example, in June 2024 77% of patients received a face-to-face consultation, within their home residence, within the specified timeframe, against a target of 95%. Both the commissioner and provider were conscious of the challenges associated with meeting these targets over a wide geographical area and with increasing demand. Notwithstanding this, the commissioner informed us that the provider also met and exceeded other performance indicators such as patients seen within 30 minutes of a booked appointment in an urgent treatment centre where in June 2024, they achieved performance of 96.5% which was above the target of 95%. The commissioner confirmed that they were aware of and had agreed the procedures put in place by the provider to close less urgent referrals during periods of escalating demand, and to prioritise in their place those with greater urgency such as 1or 2 hour dispositions.

The assessment examined the handling of NHS 111 referrals focusing on closures made under OPEL (Operational Pressures Escalation Levels). OPEL, allowed the management of referrals when there were growing demand pressures, and a need to prioritise and reconfigure services to cope with urgent cases. This closure process had been agreed by the commissioners. If demand reached a level when it was seen that the referral queue was under growing pressure, the provider’s procedure allowed it to close referrals categorised as routine (usually 12–24 hour cases). In May 2024 3,528 referrals had been closed using this process (from 21,820 direct NHS 111 referrals received). The OPEL protcol was used to support decisions to invoke these measures. Closures had some exclusions based on potential risk; such as patient age. Patients were notified of closures. This was usually done by text, or telephone if there was no mobile number. Safety netting advice regarding a worsening of the presenting condition was also given to the patient. If possible, patients were offered a face-to-face appointment before closure. This closure process was felt to carry with it some risk. Firstly, there was a potential risk that cases could be closed for patients who had more serious conditions than that categorised by NHS111. We were told by staff of cases when it had been recognised that a condition was potentially more serious than originally categorised, and they had escalated this. Secondly, closures were made by non-clinical staff, under a clinically agreed protocol. The provider informed us that a full clinical assessment of cases prior to closure would not be feasible due to capacity issues. Thirdly, the use of text messaging to communicate closure and give advice presumed that patients had capacity understand the message. Finally, some staff told us they felt that the process of closure was inconsistent at times, and based on individual decisions made by duty managers.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.