This service is rated as Requires Improvement overall. The service had previously been inspected on between 25 March and 15 April 2021. That report rated the service as requires improvement overall and in the safe key question, inadequate for well led, and good for the effective, caring and responsive key questions. The service was found to be in breach of regulations 12 and 17 of HSCA (RA) 2014, and two warning notices were issued. The specific issues found which breached regulation 12 related to infection prevention and control procedures not being followed. The breaches of regulation 17 related to a lack of leadership and clear governance processes, and the culture within the organisation.
We carried out an announced comprehensive inspection of Queens Urgent Treatment Centre on 10, 11, 17, 18 and 25 November, and 8 December 2021. We are mindful of the impact of COVID-19 pandemic on our regulatory function. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We found that some of the breaches of regulation from the previous inspection had been addressed, but others had not been. We also found breaches in other areas. Following this inspection, the key questions are rated as:
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Requires improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
At this inspection we found:
- The service had good systems to manage risk in most areas so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes. However, incidents were not being processed within their own specified timelines.
- The organisations own audits showed that best infection prevention and control practice was not being consistently followed.
- The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. However, the service was not meeting the targets specified by its commissioners.
- The organisation did not have sufficient procedures in place to ensure that effective staffing was being provided.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Patients were able to access care and treatment from the service, although it was not routinely meeting the four-hour target for patient throughput.
- The leadership and governance functions at the organisation had been improved and were mostly in line with its constitution. However, some governance functions did not meet the needs of the organisation
- Staff that we spoke with stated that the culture of the organisation had improved since the previous inspection, although some staff said that they were not listened to.
- Communication procedures with the hospital provider who provided the co-located emergency department service were unclear.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure that care and treatment is provided in a safe way to patients. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good staffing. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The inspection of Queens Urgent Treatment Centre also formed part of a system review of urgent and emergency care provision in North-East London. The findings of this review relate to the overall system of care provision in this area, and are not all specific to this provider alone. The following details the findings of this system wide review:
A summary of CQC findings on urgent and emergency care services in North East London.
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. We have summarised our findings for North East London below:
North East London
Provision of urgent and emergency care in Northeast London was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area is complex, made up of a large number of health and social care providers. We did not inspect all providers within the system and did not inspect any GP services.
We undertook these inspections during the COVID-19 pandemic; the pandemic had put significant pressure on health and social care services and the staff working within them. Despite the challenging circumstances, we found examples of staff working in partnership. For example, there was good engagement between service leaders to understand the impact of demand on different services and to discuss opportunities to signpost patients to services under less pressure. However, system wide collaboration was needed to alleviate the pressure and risks to patient safety identified in the emergency department we inspected.
We were told there were capacity issues, especially in primary care, resulting in delays for patients trying to access urgent care or patients being signposted from 111 to acute services. We were told appointments for out of hours GPs were often unavailable. We observed patients queuing to access both the urgent treatment centre and emergency department and were told patients attended these services due to an inability to access their own GP. This put additional demand on the hospital and caused further delays in patients accessing treatment.
In addition, there had been an increase in the number of 111 calls from patients requiring dental treatment and patients reported a local reduction in dental providers accepting new patients.
There are opportunities for more effective integration between 999 and 111 services. Due to the way 111 and 999 services integrate nationally, the call system for the 999 service was unable to electronically send information to the 111 service if it was decided the caller did not meet the criteria for an ambulance. The caller was asked to redial 111. In contrast, 111 were able to communicate directly with 999 if they felt their caller required an ambulance. Ambulance service leaders in London were fully sighted on a national pilot to improve this issue and hoped this would improve people’s experience of urgent and emergency care, wherever they live.
We inspected one emergency department in North East London and found that local services did not always work together to reduce attendances or the length of stay in the emergency department. This resulted in situations of overcrowding, compromised infection control and extended waits for treatment which impacted on outcomes for patients. The ambulance service had commenced daily calls with system partners to try and reduce ambulance handover delays and to monitor demand across North East London. Leaders from services in North East London acknowledged their responsibility to support the emergency department and are working to implement improvement plans with colleagues from primary care and community services.
We identified an opportunity for more effective collaborative working and communication between an emergency department and the co-located urgent treatment centre resulting to improve people’s experience of accessing urgent and emergency care. Different digital operating systems within these services did not promote effective communication or integration between services and impacted on how services could work collaboratively to deliver safe, effective and timely patient care. These issues resulted in some people being sent from the urgent treatment centre to the emergency department without an effective referral mechanism and meant they experienced further delays whilst in another queue to be assessed. Leaders from a range of services were looking to further integrate services in the area and, in response to our findings, were collaborating to implement new and innovative ways of assessing patients safely and in a timely way.
We found examples of delays in discharge from acute medical care impacting on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews and prolonged waits in the Emergency Department due to the lack of bed capacity. We also found patients in the emergency department for whom a decision to admit had been made; however, they were still waiting in excess of 24 hours before being transferred to a bed on the ward. These delays exposed people to a risk of harm.
We identified a significant number of patients unable to leave hospital to return to their own home or move into community care. This was due to a number of complex reasons including delays in the provision of care packages due to lack of availability, a lack of residential and/or nursing care beds and because of a shortage of social care staff and the impact of vaccination as a condition of deployment. We were told that Local Authorities were working to increase capacity in social care and that they regularly met with system partners to discuss the provision of urgent and emergency care in London; however, the impact on patient flow through urgent and emergency care pathways remained a significant challenge across North East London. Increased collaboration and support from system partners was required to manage the risk being held in the emergency department we inspected.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care