The Care Quality Commission
  • Doctor
  • Out of hours GP service

Archived: Staffordshire House

Overall: Good read more about inspection ratings

Unit 5, Riverside, 2 Campbell Road, Stoke On Trent, Staffordshire, ST4 4RJ 0300 123 0812

Provided and run by:
Staffordshire Doctors Urgent Care Limited

Important: The provider of this service changed. See new profile

All Inspections

20 September 2018

During a routine inspection

This service is rated as good overall. The previous inspection on 21 March 2018 rated the practice as requires improvement.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

Following our comprehensive inspection at Staffordshire House on 21 March 2018 the location was rated as requires improvement for the Staffordshire Out of Hours (OOH) service with a requires improvement rating for the safe, effective, responsive and well-led key questions, good for the caring key question.

We carried out an announced comprehensive inspection on 20 September 2018 to monitor that improvements had been made.

Our key findings from this inspection were as follows:

  • We found improvements had been made to manage risks relating to delays in treatment being provided.
  • The skill mix and staffing levels had been reviewed and we saw that safe care and treatment was now being provided in a timely way.
  • There were effective systems and policies governing the health, welfare and safety of people. These included training for all staff who acted as chaperones and criminal checks on all staff.
  • Systems for the management of medicines including controlled medicines were comprehensive and effective. Prescriptions were securely stored and their use was monitored.
  • The recruitment of new personnel into the governance team had strengthened arrangements and supported an overarching governance framework for systems and processes.

The provider had recruited and trained associated healthcare professionals and reduced the dependence on GPs.

  • Patients’ care needs were seen to be assessed and delivered in a timely way according to their needs. The service had improved performance against the Local Quality Requirements which monitored clinically effective and responsive care. For example, home visit response times showed sustained improvement and achieved contractual targets for the past three months.

There was one area of the service where we recommended that the provider should make improvements:

  • Continue to improve the evidence to support that mandatory training has been completed by GPs.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

21 March 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This service is rated as requires improvement overall. The previous inspection on 22 March 2017 rated the practice as 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

Following our comprehensive inspection at Staffordshire House on 22 March 2017 the location was rated as requires improvement for the Staffordshire Out Of Hours (OOH) service with a requires improvement rating for the safe, effective and well-led key questions, good for caring and responsive key questions.

We carried out an announced comprehensive inspection on 21 March 2018 to monitor that improvements had been made.

Our key findings from this inspection were as follows:

  • We found improvements had been made to manage risks relating to shared learning from significant events and incidents.
  • The recruitment process had been strengthened and there were effective systems and policies governing the health, welfare and safety of people. These included training for all staff who acted as chaperones and criminal checks on all staff.
  • Systems for the management of medicines including controlled drugs were comprehensive and effective. Prescriptions were securely stored and their use was monitored.
  • The provider had taken steps to implement changes in relation to the governance. The recruitment of new personnel into the governance team had strengthened arrangements and supported an overarching governance framework for systems and processes. These arrangements were supported by a new Director of Quality and Nursing recruited to the Vocare Group.
  • 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 Local Quality Requirements used to monitor clinically effective and responsive care. For example, waiting times for some clinical assessments, and long delays overnight posed risks to patient safety.

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

Importantly, the provider must:

  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
  • Ensure care and treatment is provided in a safe way to patients.

The provider should:

  • Continue to improve the evidence to support that mandatory training has been completed by GPs.
  • Review the training and clinical supervision for paramedics new to primary care.

For more information on these requirements, please refer to the requirement notice at the end of this report.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Staffordshire Doctors Urgent care out of hours service on 22 March 2017. Overall the service is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for recording, reporting significant events. However, the learning outcomes were not always embedded in policy and process.
  • Risks to patients were assessed and managed.
  • Patients’ care needs were assessed and delivered in a timely way according to need. The service met the National Quality Requirements in most areas although there was a pattern of performance being below the required targets at weekends.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Most staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The out of hours staff provided other services with information following contact with patients as appropriate. For example, the local GP and hospital,
  • The service managed patients’ care and treatment in a timely way. However, they found it difficult to achieve the target response times at weekends.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The service worked proactively with other organisations and providers to develop services that supported alternatives to hospital admission where appropriate and improved the patient experience.
  • The service had good facilities and was well equipped to treat patients and meet their needs. The vehicles used for home visits were clean and well equipped.
  • There was a clear leadership structure and staff generally felt supported by the management team. However we found areas of improvement were needed in the clinical leadership and governance.
  • The service proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Review the clinical governance and leadership arrangements to ensure that:
  • Audits carried out on clinicians’ performance are acted on to minimise risks to patients and are carried out in accordance with the policy.
  • Clinicians are able to access the summary care records of patients.
  • A review is carried out on the protocol for using untrained staff who acted as chaperone outside of the curtain.
  • Further improvements are made to ensure effective communication of shared learning from incidents.
  • Policies and protocols are implemented but did not always govern activity. For example, the temperature storage parameters for oxygen and medication when in transit.

The areas where the provider should make improvement are:

  • Implement a protocol to cover medicines in transit and how they may be affected by temperatures outside of the recommended storage parameters.
  • Continue to explore ways to meet the target response times for patients to be seen at weekends.
  • Ensure nurses providing care to children are competent and appropriately trained.
  • Ensure that computer hardware and systems have the facility to produce patient information leaflets.
  • Review the access and availability of diamorphine to ensure that treatment can be provided across all services in a timely manner (diamorphine is a medication used to treat pain; particularly pain caused by cancer).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the Staffordshire Doctors Urgent Care NHS 111 service at Staffordshire House and Elizabeth House on 16 June 2016. NHS 111 is a telephone-based service where callers are assessed, given advice and directed to a local service that most appropriately meets their needs. For example, this could be a GP service (in or out of hours), walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance, late opening pharmacy or home management.

Overall the provider is rated as good.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Staff knew how to, and understood the need to raise concerns and report incidents and near misses. All events recorded were reviewed and categorised by the head of assurance.

  • The provider was monitored against the Minimum Data Set (MDS) and Key Performance Indicators (KPIs). The data enabled the provider and commissioners to review the level of service being provided. Where variations in performance were identified, the reasons for this were reviewed and action plans implemented to improve the service.
  • Staff were trained and monitored to ensure they used the NHS Pathways system safely and effectively.
  • Information about services and how to complain was available and easy to understand. Complaints were fully investigated and when appropriate, patients were responded to with an apology and full explanation.
  • There was clear leadership from a clinical and senior management perspective. Staff felt supported by senior management and a management rota was in place to ensure presence at busy times.

  • There were safeguarding systems in place for both children and adults at risk of harm or abuse as well as frequent callers to the service. Safeguarding concerns were raised to the local safeguarding board but there was no evidence of any follow up from the provider.

  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • The provider had set clear priorities and strategies to achieve them. These included integration with the GP out of hours’ service and innovation to improve patient care.

However there were areas of practice where the provider should make improvements:

  • Review the safeguarding procedures to consider if a follow up to referrals and concerns should be implemented.
  • Ensure that standard operating procedures (SOPs) are reviewed and updated where necessary in line with the review dates on the documents and that outdated SOPs are removed.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 July 2013

During a routine inspection

We spoke with seven patients and 14 members of staff on the day of our inspection. One patient told us, 'I am very happy with the service'. Another patient told us, 'I am really happy, it was brilliant. The doctor was lovely'.

Patients told us that they were happy with the care and treatment they received and they were treated with dignity and respect. We saw that reception staff were polite and respectful toward patients both on the telephone and face to face.

There was an effective system to regularly assess and monitor the quality of service that patients received. Comments and complaints patients made were responded to appropriately and most of them within a timely manner.