Cudmore 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 all quality statements in the safe key question. The service regularly reviewed, analysed, and learnt from events and incidents. The service had systems, practices, and processes to keep people safe and safeguarded from abuse. The service had systems for the appropriate and safe use of medicines which required additional monitoring.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

Managers encouraged staff to raise concerns when things went wrong, staff understood how to raise concerns and report incidents both internally and externally. Staff told us learning from events and incidents was shared in meetings, peer to peer reviews and staff bulletins. However, some staff told us learning was not always shared with the wider team for the purpose of learning as a result of a concern. Staff told us leaders were approachable and promoted an open non-blame culture. However, some staff told us leaders were not always visible at evenings and weekends. Leaders were aware of this and were looking at ways to improve with an increased presence of area managers at weekends and the recent appointment of 2 additional clinical managers to assist with visiting treatment centres at evenings and weekends.

The service had policies and procedures to support the learning culture. Significant events and complaints were discussed at meetings. There was a system to monitor incidents and complaints. This included undertaking an investigation led by the patient safety review group into the cause and actions identified to address the concerns. The service had a system for the auditing of systems and processes. Audits identified areas of concern, actions taken and provided a clear audit trail to demonstrate continuous improvement.

We received no specific feedback in this area.

Staff were knowledgeable about their responsibilities to ensure patient referrals to other services were actioned promptly and in line with policies and procedures.

Partners did not provide feedback about safe systems, pathways and transitions as part of this assessment.

There were appropriate referral pathways to refer people to other services to ensure people’s needs were met. Staff were proactive in supporting people to manage their own health care needs with systems and processes to facilitate this. The service had a right care car which bridged the gap in emergency care in the daytime and helped GP providers when they were at capacity by visiting patients with acute care needs in their home environment, reducing the need for hospital admission. The 111 calls were outsourced to an external provider. Kernow CIC regularly monitored the safety information submitted to the commissioners and NHSE. Call abandonment rates were between 5% and 21% for the service between July 2023 and June 2024. The NHSE target is 3%. The performance in this area had improved over the last 3 months. The mean time to answer calls between July 2023 and June 2024 was between 69 seconds and 426 seconds, with the NHSE target being 20 seconds. However, in the last 3 months there had been significant improvements in this area with the service achieving between 81 and 75 seconds to answer calls. The service had delivered similar results to most providers in England in the last year but were still below national targets. Data showed between 71% and 76% of calls, between July 2023 and June 2024, had been forwarded to a clinician in the Clinical Assessment Service (CAS). This was consistently above the target of 50% and ranked the highest performer. This was above the national target.

Staff were trained to appropriate levels for their role. They were aware of the systems and processes to keep people safe and safeguarded from abuse. Staff felt confident in raising concerns. Staff knew what a safeguarding lead was and how to access them. However, not all staff knew the name of the safeguarding lead.

Partners did not raise concerns regarding safeguarding at the service.

The service followed systems and processes to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns. We saw the service had implemented policies and procedures which demonstrated partnership working with other agencies and local safeguarding teams.

We received no specific feedback in this area.

People’s needs were discussed during telephone and face to face consultations. Staff informed people about risks and documented this on their patient record. Staff involved people in their consultations to ensure they were informed of risks and their views listened to. Staff were confident in the systems and processes to enable them to respond to a deteriorating patient.

There were adequate systems to assess, monitor and manage risks to patient safety. These had been shared with staff. Appropriately trained staff completed consultations and provided specific advice to people. Risks were recorded on patient records.

Staff were aware of their responsibilities to ensure the environment was safe for people, including their role in responding to an emergency. Staff had completed appropriate training including health and safety, fire safety and information governance.

The facilities and premises were appropriate for the services being delivered. Equipment was fit for purpose and in good working order. Portable appliance testing (PAT) and calibration had been completed on equipment. Environmental risks had been assessed in each location and where necessary, appropriate actions taken. During our onsite assessment at one of the treatment centres we observed a member of staff dealing with a patient who displayed violent/aggressive behaviour. The staff member called for assistance from security and informed the clinician on duty and managed the situation calmly and safely.

The service had made reasonable adjustments when people found it hard to access services. The service was responsive to the needs of people in vulnerable circumstances. Health and safety risk assessments had been carried out and appropriate actions had been taken. We saw safe systems and processes were in place to support a safe environment.

We received no specific feedback in this area.

Staff told us there were enough staff to provide a safe service during the day. However, some staff told us there were not enough staff at evenings and weekends. There was a reliance on sessional staff to provide a safe service. Leaders were aware of safe staffing levels and responding appropriately to meet demand. Staff rotas were well managed. We had been made aware that earlier in the year there had been a shortage of clinicians. However, at the time of the onsite assessment this had improved. Leaders told us they were providing 137% above commissioned clinical hours.

The service was able to demonstrate staff had the skills, knowledge, and experience to carry out their roles. An induction programme was in place to support all newly appointed staff. Recruitment checks in line with guidelines had been completed prior to staff commencing in their roles. Staff had completed mandatory training, and this was centrally monitored to ensure timely completion. Some staff had also completed specific training relevant to their specialist area. Clinical staff were supported to meet the requirements of professional revalidation. There was a system to ensure appointments were allocated to appropriate clinicians. The service had a demand management plan. This was a requirement to ensure the integrated urgent care service (IUCS) met the clinical needs of patients and that key performance indicators (KPIs) were met. The plan identified the minimum staffing levels (non-clinical and clinical) to ensure the safe running of the service. There were systems and processes to monitor the number and mix of staff needed. Systems and processes demonstrated the service had contingency plans for dealing with an increase in the patient population during summer/winter and bank holiday periods. We identified inconsistencies around the reviewing, monitoring and the providing of feedback to clinicians who delivered care and treatment. This was not consistent across all staff groups There was no audit trail to monitor this.

We received no specific feedback in this area.

Staff were aware of their infection prevention and control (IPC) responsibilities. For example, how to respond to an infectious disease outbreak. Staff told us they could raise IPC concerns in team meetings. Staff knew how to manage clinical waste safely.

Appropriate standards of cleanliness and hygiene were met. The premises were visually clean. There were arrangements for managing waste and clinical specimens. Staff had access to Personal Protective Equipment (PPE).

Staff had received training on infection prevention and control. Policies and procedures were available to staff including a plan to manage an infectious disease outbreak. An up-to-date infection prevention and control audit had been carried out. However, the actions identified on the audit were unclear regarding the person responsible for addressing the actions and a time frame for completion of the identified area of concern. A process was in place to record, and risk assess staff vaccinations in line with national guidance.

We received no specific feedback in this area.

Staff told us and we observed they involved people in decisions about their medicines, during telephone and video consultations. Prescribing was in line with best practice guidelines for medicines. Staff described the system used to audit prescribing practice through the use of telephone consultations and outcomes. Staff and leaders had a good knowledge of their patient population.

Clinical records were accurate and up to date. Blank prescriptions were stored securely, and their use was monitored. Appropriate authorisations for staff to administer medicines were in place. There were systems, processes, policies and procedures to manage Patient Group Directions (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition) or Patient Specific Directions (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient).

There were systems, policies and procedures for the appropriate and safe use of medicines, including medical gases, emergency medicines equipment and controlled drugs at treatment centres. The fleet of vehicles for transporting clinicians, complied with the company’s medicines management and controlled drugs policies for the safe storage of medicines and transporting of equipment. However, we identified concerns regarding medicines not being stored at the correct temperature during times of temperature variations such as the winter months. We also identified that labels on boxes stored within vehicles were visible. Following our assessment, the service was proactive in addressing these areas and ensured actions had been taken and new systems and processes implemented. We observed controlled drugs, when issued, were noted in the controlled drug logbook and signed by 2 people. Controlled drugs were stored and recorded in line with the requirements of the Medicines Act 1968. Regular stock checks of all medicines were carried out on a weekly basis and recorded via an electronic system. Medicines were removed from vehicles to a secure storage area when not in use. We observed effective systems and processes for the management of medicines at the medicines storage facility.