Archived: Cambridgeshire Community Services NHS Trust Out of Hours Services at City Care Centre

We carried out an announced comprehensive inspection at Cambridgeshire Community Services NHS Trust GP Out-of-Hours Service on 3 and 4 November 2015. Overall the service is rated as inadequate. Specifically, we found the out-of-hours service inadequate for providing safe and effective services and being well led. It required improvement for providing responsive services but was good in providing a caring service. Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not always in place to keep them safe. For example, the triage process was unsafe because nurses were undertaking tasks without the support of triage protocols and guidance or evidence of appropriate training.

• Staff were clear about reporting incidents, near misses and concerns. However scope for on-going learning and improvement from incidents was limited.

• The system for assessing the competency of staff who were administering medicines under a PGD was not effective.

• Staff files and recruitment procedures were not documented or governed thoroughly.

• There was insufficient assurance to demonstrate people received effective, timely care and treatment. For example, response times for call backs to patients.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Consumable clinical equipment was found to be out of date in some areas, for example gauzes in the storage cupboards and cars.

• Safeguarding referral processes were not audited and there was no process in place to ensure that safeguarding referrals had been tracked and effectively followed up.

• Leadership arrangements were ineffective due to a lack of understanding between the Board and frontline delivery of the out-of-hours service.

• Governance arrangements were fragmented and ineffective with clinical and managerial leaders having limited oversight of the risks to patients and to staff.

The areas where the service must make improvements are:

• Ensure that all staff who triage patients have been adequately trained to make clinical decisions by telephone and have been assessed as competent to do so. In addition, protocols and guidelines must be implemented in order to guide staff to make safe and appropriate triage decisions.

• Ensure medication administration protocol competency assessments are recorded and kept up to date

• Ensure that the length of time patients wait for definitive clinical assessment is robustly monitored and managed to ensure patient care does not suffer.

• Implement effective safeguarding referral procedures and ensure that all referrals are followed up and that this is documented.

• There must be a robust process for monitoring clinical equipment, to ensure that it is fit for purpose and that consumable items are in date.

• Governance around staff files and recruitment procedures must be implemented and recorded effectively.

• The service must ensure there are sufficient and appropriately trained staff on site in order to keep patients safe. Contingency arrangements must be agreed for staff to follow when last minute gaps in GP cover arise.

• Clear governance and leadership arrangements must be implemented to ensure that clinical and managerial leaders understand and can mitigate risks to patients and staff and have an effective oversight of the performance of the out-of-hours service at all times.

The areas where the service should make improvements are:

• Records should be kept of all clinical supervision for both doctors and nurses.

• Provide communication with all staff regarding service changes taking place.

• Ensure that National Quality Requirement (NQR) key performance indicators are met each month in respect of definitive clinical assessments, face to face consultations and call backs from a health care professional.

• Appropriate and effective clinical audits should be implemented to ensure that the service can identify areas for development and learning.

• Learning relating to incidents should be shared with all relevant staff in order to facilitate a culture of on-going improvement.

 On the basis of the ratings given to this service at this inspection, I am placing the service into special measures. This will be for a period of six months. We will inspect the service again in six months to consider whether sufficient improvements have been made. If we find that the service is still providing inadequate care we will seek to de-register the location and not the provider.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice