Bracknell Urgent Care Centre: A case study in improvement

What we found in October 2015

• Some shifts were covered by non-prescribing nurses so the GP on duty had to authorise all prescriptions and medicines administered. This delayed treatment for patients and extended the time that other patients waited to be seen.
• Policies and procedures for checking medicines were not implemented consistently and the staff we spoke with were unclear who was responsible for doing the checks.
• There was no evidence that anybody checked the competency of staff to administer medicines and no records of training in administering medicines.
• Two medicines in the medicines cupboard were out of date.

What we found in April 2016

• Arrangements for medicines management deemed as safe (including obtaining, prescribing, recording, handling, storing and security).
• Audits of medicines now ensure that prescribing is in line with best practice guidelines for safe prescribing.
• Prescription pads are stored securely and there are systems to monitor their use.
• The service has adopted Patient Group Directions (PGDs) to allow nurses to administer medicines in line with legislation. (PGDs are written instructions for supplying or administering medicines to groups of patients who may not be individually identified before presentation for treatment).

What we found in October 2015

• There was no robust system to identify, assess and manage risk.
• Governance arrangements had not identified that the lack of sustained local leadership had left staff at the service feeling unsupported.
• There was no response to concerns from staff about bullying and discrimination.
• There was a lack of support from senior management, with no lead nurse or regional medical director and a newly-appointed business manager, which resulted in staff feeling remote and at risk.

What we found in April 2016

• An overarching governance framework has helped to implement the strategy and therefore deliver good quality care. This includes arrangements to monitor and improve quality and identify risk.
• A fully engaged management team with CQC’s inspection process. They presented documents during the inspection to show action plans, including a working document, which was updated regularly, that assigned different actions to key members of staff.
• The service asked for feedback from staff and patients and acted on it.
• An awareness of, and compliance with, the requirements of the duty of candour and encouraged a culture of openness and honesty.
• There are systems to ensure that notifiable safety incidents are shared with staff, to enable them to take appropriate action.

What we found in October 2015

• Patients were at risk of harm because there were insufficient or inappropriately skilled staff on duty to carry out a robust assessment of their needs. This meant that patients were not being assessed and treated quickly enough.
• Staff received inconsistent support and training, some reported that they felt bullied, harassed and discriminated against.
• Limited recognition of the benefits of staff appraisal and little support for any additional training.
• Staff were afraid to report incidents and concerns for fear of reprisal.
• Local managers did not have authority to deploy enough staff, or with appropriate experience, to deliver care to patients in a safe and responsive way.

What we found in April 2016

• An effective system for reporting and recording significant events. Lessons were learned, action points were communicated with staff and most staff we spoke with could recall learning from recent significant events.
• A clear leadership structure, with staff feeling supported by management. The centre has a number of service-specific policies and procedures to govern activity and holds regular governance meetings.
• Staff and patients are asked to give feedback, and this is acted on. There was a patient participation group, a ‘you said, we did’ patient feedback board and increased engagement with Healthwatch Bracknell Forest.
• Engagement with staff was constructive and staff satisfaction was high.
• The service could demonstrate how it ensured that training for staff was specific to their role and was updated as appropriate.

What we found in October 2015

• Minimal monitoring to identify areas for improvement, for example, a limited number of completed clinical audits.
• Little assurance to confirm that improvements were made to ensure necessary action to improve outcomes for patients.

What we found in April 2016

• Clinical audit cycles in place, including self-audit.
• Recent audit completed for infection control, sepsis, x-ray, prescribing and needlestick safety.
• Findings were used to improve services and patient outcomes; for example, a review of antimicrobial prescribing habits ensured that staff adhered to prescribing guidelines and clinical governance.