Trust HQ

Letter from the Chief Inspector of General Practice

We carried out an announced inspection of the NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust (SWAST) on 17, 18 and 19 August 2016. This was to follow up on warning notices the Care Quality Commission served following an announced comprehensive inspection in March 2016.

The warning notice was served relating to regulation 12 Safe care and treatment and regulation 18 Staffing respectively of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notices was 8 July 2016. The Trust had kept us regularly informed on action being taken.

During the March 2016 inspection we visited both call centres and the SWASFT Headquarters. The March 2016 inspection highlighted several areas where the provider (SWAST) had not met the regulations. These included:

• Insufficient staff were employed and those employed were not deployed or supported effectively.
• NHS 111 calls were not responded to in a timely and effective manner. There was a lack of systems to ensure associated risks were mitigated for the safety of patient’s health and welfare.

At this inspection in August 2016 we found that positive steps had been taken to address the identified issues. We have focused on the warning notice findings in respect of the safe and effective domain and have not re-rated the Trusts provision of the NHS 111 service. The full report published on 16 June 2016 should be read in conjunction with this report.

Our key findings were as follows:

• The Trust had a clear vision that had improvement of service quality and safety as its top priority. The Trust had fully embraced the need to change and there was good evidence of team working. The Trust had actively sought to learn from the previous Care Quality Commission inspection, other NHS 111 providers, performance data, complaints, incidents and feedback.

• There were now systems in place to assess and monitor risks within the NHS 111 Service provided by SWAST and a number of steps had started to mitigate those risks. For example, recruitment and deployment of staff.

• The Trust had reviewed and subsequently de-established the role of Non Pathways Advisors (NPAs). Existing NPAs had been offered conversion training to become call advisors.

• The Trust had introduced systems to monitor and increase the number of appropriate and effective call audits performed to ensure all staff were following the NHS Pathways system and local standard operating procedures (SOPs). The Trust action plans intended to use completed call audits to identify individual and Trust wide areas of development and learning as the number of call audits increased.

• We saw evidence to show the Trust had started to introduce systems to ensure associated risks were mitigated for the safety of patient’s health and welfare. This included attempts to increase the number of staff within the NHS 111 call centres. NHS 111 calls were still not responded to in a timely and effective manner. The Trust was aware that it was too early to see systems fully embedded and to demonstrate that the new systems and processes were effective.

Overall there has been significant improvement in the approach of the Trust to the day to day and strategic running of the NHS 111 service that was not previously seen.

However the provider must:

• Ensure staff have further performance observation and support to ensure the needs of callers are correctly responded to.

• Reduce risks to callers by improving delays in call abandonment, initial answering of calls, warm transfer and returning calls by a clinician.

The NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust rating remains inadequate until a full comprehensive inspection of the Trusts NHS 111 service is carried out by the Care Quality Commission.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out a comprehensive inspection of the NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust (SWASFT) on 8, 9 and 12 March 2016.

Overall the Trust’s NHS 111 service is rated as inadequate.

There were two call centres, one at the Headquarters based in Exeter (referred to in the report as Devon), the other in St Leonards (referred to in the report as Dorset). We visited both call centres and the SWASFT Headquarters. SWASFT NHS 111 provides a telephone service to a diverse population for Dorset, Devon and Cornwall.

NHS 111 is a telephone-based service where callers were 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.

The Care Quality Commission bought forward this comprehensive inspection due to intelligence we received; this included information received from former and current staff as well as patients raising concerns about the way the NHS 111 service was operated by SWASFT. The concerns included alleged ineffective use of systems and processes, staff levels and recruitment processes, lack of staff training and support, and the way complaints and significant events were managed.

Our key findings were as follows:

• The Trust had limited systems in place to mitigate safety risks across the NHS 111 service. When incidents and significant events were identified, investigated and reported, due to factors such as substantial staffing shortages and limited forward planning to meet expected demand on the service, these factors often prevented systems being followed and lessons being learnt.

• The NHS 111 service was monitored against the national Minimum Data Set for NHS 111 services and adapted National Quality Requirements. SWASFT were not consistently meeting these targets in most areas. Performance against some indicators such as calls being answered in 60 seconds were regularly at unacceptable levels. Necessary action to identify and improve callers’ outcomes was not taken.

• There was also insufficient assurance to demonstrate callers received effective or responsive care and treatment. For example we saw evidence of urgent callers waiting for long periods to receive a call back from a clinical advisor. Despite being aware of issues, the Trust had not reviewed the calls in detail to identify the root cause.

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example emergency and urgent callers were not being assessed in relation to their medical needs in a timely manner.
• SWASFT NHS 111 worked closely with all the Clinical Commissioning Groups who commissioned the service. NHS Dorset Clinical Commissioning Group, NHS Kernow Clinical Commissioning Group and NHS Northern, Eastern and Western Devon Clinical Commissioning Group.
• Staff were trained to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a Department of Health approved computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call). However, once trained there were limited systems in place to monitor staff usage of NHS Pathways, for example inadequate levels of call audits were conducted by the Trust meaning that poor performance could not effectively be identified and managed in a timely way. Also, serious incidents and opportunities for learning could have been missed.
• The Trust did not develop staff knowledge, skills or experience to enable them to deliver good quality care and treatment. Staff did not always receive appraisals, supervision, support or sufficient training to perform their roles.
• There were low levels of staff satisfaction and high levels of stress. There had been a high turnover of staff and significant sickness levels impacting on the service. Some staff were declined their annual leave requests as a result.
• Staff were supported to report issues and concerns but said often nothing was done by the Trust and no action was taken to change the factors that created the issues and concerns.
• Generic work station risk assessments were in place. However we saw examples of workstations (desks, computers and chairs) in both centres which were not appropriate for long periods of work or adjustable for individual members of staff. Staff told us safety in regard of workstations was not routinely monitored.
• The leadership within the organisation was variable and staff were confused on the leadership structure including who their line managers were. Staff told the inspection team the two call centres mostly worked separately to each other.
• There was eagerness by operational staff for continuous improvement and development of the service, but a lack of resources meant that improvements were not always implemented.
• We did not receive assurance from the leadership or governance processes in place that high quality care was being provided by the service. Senior staff did not demonstrate an extensive understanding of governance and its importance for the effective running of the service. This meant that they were unable to identify and mitigate risks effectively.
• During our inspection we found sections of staff, notably advisors and first line managers to be highly dedicated to and proud of the important work they were undertaking. However, they were also open and honest about the challenges they were facing on a daily basis. They were largely supportive of their immediate managers but found some senior managers and Board members to be remote and lacking an understanding of the issues they were experiencing.

There were areas of practice where the provider MUST make improvements.

The provider must:

• Continue to review staff numbers ensuring patients can access timely care and treatment when first accessing the service and when receiving a call back.

• Review the roles and responsibilities of Non Pathway Advisors ensuring callers consistently receive the correct level of advice when accessing the service.

• Ensure that the call queues, awaiting initial assessment and a clinical advisor call back are robustly monitored and managed by staff with clinical authority to intervene and allocate resources. This will ensure patients are being assessed and receive consultations within recommended timescales.
• Implement a consistent performance monitoring system for staff across both sites to identify and investigate poor performance.

• Identify individual and personal development needs of all staff including an appraisal programme.

• Increase the number of appropriate and effective call audits to ensure all staff are following the NHS Pathways system and local standard operating procedures (SOPs) allowing the service to identify areas of development and learning.

• Ensure all employees work at desks which have been suitably assessed for safety and ensure any work station risk assessments are followed up.

• Implement a clear leadership structure and staff made aware of their lines of management.

• P rofessor Steve Field CBE FRCP FFPH FRCGP

  Chief Inspector of General Practice