At our inspection in August 2019 we rated the service as requires improvement overall due to shortfalls in good governance. We served a requirement notice under Regulation 17 for the provider to have effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
This service is rated as requires improvement overall. (Previous inspection August 2019 – Requires improvement)
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Requires improvement
Are services caring? – Good
Are services responsive? – Requires improvement
Are services well-led? – Requires improvement
We carried out an announced comprehensive inspection at Gloucestershire Out of Hours as part of our inspection programme to follow up on their previous breach of regulation. We undertook a site visit on 22 and 23 November 2021; remote interviews were carried out on 29 and 30 November 2021. We requested further information from the provider after the site visit, and this was received on 6 December 2021. This inspection also fed into a wider CQC piece of work looking at the urgent and emergency integrated care for patients in Gloucestershire. Details of the overarching system findings are included at the bottom of this summary.
At this inspection we found:
- The provider did not consistently ensure there were sufficient numbers of staff available to run the service, to ensure risk was minimised and the service could respond quickly to an increase in demand.
- Risks to patients were not adequately assessed, monitored or managed to maintain patient safety.
- Overall service performance was not always consistently monitored in a way that ensured patient safety.
- Systems and processes to manage risk were applied inconsistently, whilst learning was not always shared effectively and acted upon. There was a lack of clarity on how significant events and risks were identified and managed.
- Improvement was still needed to ensure learning and actions taken from incidents were understood and acted on by all relevant staff.
- There were risks to patients of not receiving effective care or treatment.
- There were shortfalls in systems and processes that did always not enable safe and effective care to be provided.
- Information gathered on service performance was not used effectively to ensure that all patients received appropriate care and treatment in a timely manner to meet their needs.
- Audits of service provision were not fully completed to enable and demonstrate that trends and themes were identified; appropriate actions taken; and systems to monitor performance were effective. Additionally, to ensure learning was effectively shared.
- There were shortfalls in personal development and support for staff. Not all staff had appraisals or supervision sessions, to enable them to develop their skills or reflect on their work.
- There was an organisational strategy, but it had not been implemented sufficiently to ensure that high-quality sustainable and consistent care could be provided.
- There were shortfalls in communication between senior leaders and staff groups, staff did not consider they had been fully engaged in the running of the service.
- Governance arrangements were not consistent to support the delivery of a safe, effective and well led service in a consistent manner. Limited attention had been paid to achieving and maintaining compliance with the regulations of the Health and Social Care Act 2008.
- Patients were not always able to access care and treatment from the service within an appropriate timescale for their needs.
- Staff involved and treated people with compassion, kindness, dignity and respect.
The areas where the provider must make improvements as they are in breach of regulations are:
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 persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
The areas where the provider should make improvements are:
The organisation should continue to work closely with all system partners to tackle the capacity pressures on urgent and emergency care in the health and social care system in Gloucestershire.
A summary of CQC findings on urgent and emergency care in Gloucestershire
Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. On this occasion we did not inspect any GPs as part of this approach. However, we recognise the pressures faced by general practice during the COVID-19 pandemic and the impact on urgent and emergency care. We have summarised our findings for Gloucestershire below:
Provision of urgent and emergency care in Gloucestershire was supported by health and social care services, stakeholders, commissioners and the local authority. Leaders we spoke with across a range of services told us of their commitment and determination to improve access and care for patients and to reduce pressure on staff. However, Gloucestershire had a significant number of patients unable to leave hospital which meant the hospitals were full and new patients had long delays waiting to be admitted.
The 111 service was generally performing well but performance had been impacted by high call volumes causing longer delays in giving clinical advice than were seen before the pandemic. Health and social care leaders had recently invested in a 24 hour a day, seven day a week Clinical Assessment Service (CAS). This was supported by GPs, advanced nurse practitioners, pharmacists and paramedics to ensure patients were appropriately signposted to the services across Gloucestershire.
At times, patients experienced long delays in a response from 999 services as well as delays in handover from the ambulance crew at hospital due to a lack of beds available and further, prolonged waits in emergency departments. Patients were also remaining in hospital for longer than they required acute medical care due to delays in their discharge home or to community care. These delays exposed people to the risk of harm especially at times of high demand. The reasons for these delays were complex and involved many different sectors and providers of health and social care.
Health and social care services had responded to the challenges across urgent and emergency care by implementing a range of same day emergency care services. While some were alleviating the pressure on the emergency department, the system had become complicated. Staff and patients were not always able to articulate and understand urgent and emergency care pathways.
The local directory of services used by staff in urgent and emergency care to direct patients to appropriate treatment and support was found to have inaccuracies and out of date information. This resulted in some patients being inappropriately referred to services or additional triage processes being implemented which delayed access to services. For example, the local directory of services had not been updated to ensure children were signposted to an emergency department with a paediatric service and an additional triage process had been implemented for patients accessing the minor illness and injury units to avoid inappropriate referrals. Staff from services across Gloucestershire were working to review how the directory of services was updated and continuing to strengthen how this would be used in the future.
We found urgent and emergency care pathways could be simplified to ensure the public and staff could better understand the services available and ensure people access the appropriate care. Health and social care leaders also welcomed this as an opportunity for improvement. We also identified opportunities to improve patient flow through community services in Gloucestershire. These were well run and could be developed further to increase the community provision of urgent care and prevent inappropriate attendance in the emergency departments.
There was also capacity reported in care homes across Gloucestershire which could also be used to support patients to leave hospital in a timely way. The local authority should be closely involved with all decision-making due to its extensive experience in admission avoidance and community-based pathways.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care