OutOfHours - 1-347335038 Medvivo (22/01/2019) INS2-5528584911

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Outstanding –

Are services well-led? Outstanding –

MedvivoMedvivoInspection report

Greenways Business ParkChippenhamWiltshireSN15 1BNTel: 0800 6444 200www.medvivo.com

Date of inspection visit: 22 January - 24 january 2019Date of publication: 15/04/2019

1 Medvivo Inspection report 15/04/2019

This service is rated as Outstanding overall. (Previousinspection February 2017 – Outstanding)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Outstanding

Are services responsive? – Outstanding

Are services well-led? – Outstanding

We carried out an announced comprehensive inspection atMedvivo on 22-24 January as part of our inspectionprogramme.

At this inspection we found:

• The service had good systems to manage risk so thatsafety incidents were less likely to happen. When theydid happen, there was a focus on openness,transparency and the service learned from them andimproved their processes.

• The service routinely reviewed the effectiveness andappropriateness of the care it provided. Evidence baseguideline updates were regularly cascaded to staff.However we found in the sample of medical recordsreviewed that documentation was not always in linecurrent best practice and guidance. Staff involved andtreated people with compassion, kindness, dignity andrespect. Patients were valued as individuals and wereempowered to have a voice in their own care.

• Patients could access care and treatment from theservice within an appropriate timescale for their needs.Care was person centred and services were tailored anddelivered to meet the needs of an individual in a waythat ensured flexibility and choice.

• There was a strong focus on continuous learning andimprovement at all levels of the organisation and theculture ensured all staff were engaged to deliver highquality person centred care.

We saw several areas of outstanding practice:

• The provider worked collaboratively with externalstakeholders on a range of initiatives to improve accessto care and patient experience for those who werevulnerable, had a disability or were from a minoritygroup. An example of this was use of the Streetlinkhomelessness App and delivering care for refugeesbeing repatriated to the UK.

• There were innovative approaches to providingintegrated patient-centred care. For example, theprovider delivered an Urgent Care @Home service. Theservice ensured an integrated rapid health and socialcare response for service users in a health or social carecrisis in their own home to avoid inappropriateadmissions and expedite hospital discharges. This hadnot only improved patient outcomes but it has alsosupported the whole system in terms of increasedcapacity and financial savings.

• There was a strong emphasis on staff wellbeing. Theinterventions initiated by the provider had led to adecrease in turnover of over 6% in the last 12 months.Examples of initiatives taken were a Health andWellbeing Charter developed with staff, the introductionof Mental Health First Aiders, resilience workshops andself-awareness campaigns.

The area where the provider should make improvements:

• Improve and monitor documentation of consultations,to ensure they are consistently in line with best practiceand current guidance.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and IntegratedCare

Overall summary


Our inspection teamOur inspection team was led by a CQC Lead Inspector.The team included an urgent care GP specialist adviser, aCQC inspector and two CQC Inspection Managers.

Background to MedvivoMedvivo is the registered location for services provided byMedvivo Group Limited and is registered to provideservices from Fox Talbot House, Greenways BusinessPark, Bellinger Close

Chippenham, Wiltshire SN15 1BN The service covers apopulation of approximately 900,000 people across thecounties of Wiltshire, Bath and North East Somerset andSwindon. The service is a large employer, with between500 and 600 staff and 147 sessional GPs. Deprivationacross the area overall is lower than the national averageand it has relatively low numbers of patients fromdifferent cultural backgrounds. Medvivo provides anumber of services for patients in this area which include:

• NHS 111 service, delivered through a formalsubcontract arrangement with another provider. (NHS111is a telephone based service where people areassessed, given advice and directed to a local servicethat most appropriately meets their needs).

• Clinical Assessment Service in which healthcareprofessionals determine the most appropriatepathway that will best meet patient needs.

• The Access to Care service which provides a singlepoint of access, via a direct dial telephone number forhealth professionals and identified patients. Thisprovides a single point of access is to act as a referralmechanism into both the integrated community teamsand the community hospitals in Wiltshire.

• Urgent Care and at home response team (UC@H)provides rapid health and social care response forpeople experiencing a crisis in their own home inWiltshire.

• Urgent Care Clinic (SUCCESS) and Children’s & YoungPerson’s clinics (CYPC) in Swindon. These servicesprovide additional capacity for urgent demand forpatients accessing primary care within this area.

• GP resilience support, providing in hours support forpractices in Wiltshire where there is a need.

• GP Out of Hours (OOH) services across BaNES,Swindon and Wiltshire where care is delivered fromnine sites across the area:

• Chippenham Community Hospital, Rowden Hill,Chippenham, Wiltshire, SN15 2AJ (open 6.30pm until8am Monday to Friday and 24 hours over weekendsand bank holidays)

• Salisbury Hospital NHS Foundation Trust, OdstockRoad, Salisbury, Wiltshire SP2 8BJ EmergencyDepartment (open 6.30pm until 8am Monday to Fridayand 24 hours over weekends and bank holidays).

• Trowbridge Community Hospital, Adcroft Street,Trowbridge, BA14 8PH (open 6.30pm until 8amMonday to Friday and 24 hours over weekends andbank holidays)

• Savernake Community Hospital: Savernake,Marlborough, SN8 3HL. open from 7.30pm untilmidnight weekdays and 8am until midnight weekendsand Bank Holidays)

• Warminster Community Hospital, The Avenue,Warminster, BA12 8QS (open 7.30pm to midnightweekdays and 9am to 11pm at weekends and BankHolidays).

• Devizes Community Hospital, Family Health Centre,Couch Lane Devizes, SN10 1EF (open 12pm to 6pmSaturdays only)

• Royal United Hospital, Coombe Park, Bath BA1 3NG (open 6.30pm – 8am weekdays and 24hrs weekendsand bank holidays.

• Paulton Minor Injuries Unit, Salisbury Road, BristolBS39 7sb ( open weekends only 8am – midnight)

• Swindon NHS Health Centre, 1 Islington Street,Swindon, SN1 2DQ ( open 8am – 8pm daily)

• Moredon Medical centre, Moredon Road, Swindon SN22JG (open 8am – 8pm daily

We visited the sites at Royal United Hospital, Trowbridge,Chippenham, Savernake and Swindon (this included theOOH service and both the in hours SUCCESS and CPYCclinics) as part of this inspection.

Medvivo Group Limited is registered to provide thefollowing regulated activies:

• Treatment Disease, disorder and injury

Overall summary


• Personal Care • Transport services, triage and medical advice providedremotely

Overall summary


We rated the service as good for providing safeservices.

Safety systems and processes

The service had clear systems to keep people safe andsafeguarded from abuse.

• The provider conducted safety risk assessments. It hadsafety policies, including Control of SubstancesHazardous to Health and Health & Safety policies, whichwere regularly reviewed and communicated to staff.Staff received safety information from the provider aspart of their induction and refresher training.

• The provider had comprehensive systems to safeguardchildren and vulnerable adults from abuse. Policieswere regularly reviewed and were accessible to all staff.They outlined clearly who to go to for further guidance.We saw examples where learning of safeguardingincidents was shared with Medvivo staff, via the weeklyclinical review bulletin and quarterly non clinical roundup e-magazine.

• All staff received up-to-date safeguarding and safetytraining appropriate to their role. They knew how toidentify and report concerns. In addition to on linetraining the safeguarding lead for Medvivo deliveredface to face safeguarding training for their staff. Thisbespoke training included utilisation of case studiesthat Medvivo had dealt with during the past 12 monthsto ensure staff were able to fully relate to the training.

The service worked with other agencies to support patientsand protect them from neglect and abuse. Examples of thiswere:

• Medvivo had been commissioned to be the PrimaryCare Liaison lead for the Multi-Agency Risk AssessmentConference (MARAC). The meetings facilitated thesharing of information of those at highest risk ofdomestic homicide between other agencies, including,the Police, child protection services, probation andother healthcare specialists. Following MARAC meetingsMedvivo shared information with the patients GPsurgery and communicated any requested actions thatneed to be taken by the GP. Data for meetings that tookplace during July – September 2018 showed that 776patients were discussed and 624 had special notesadded to their medical record ensuring clincians acrossprimary care ensuring that the potential to keep thesepatients safe was improved.

• Medvivo ensured that when a safeguarding matter wasraised the patients GP would be contacted and wherepossible, spoken to in person. This was in addition tothe standard post service messaging system to ensureany necessary actions were taken.

• To ensure oversight and consistency of safeguardingprocesses, all referrals made by the subcontracted NHS111 service, were monitored by Medvivo and followedup where necessary.

• Staff took steps to protect patients from abuse, neglect,harassment, discrimination and breaches of theirdignity and respect.

• The provider carried out staff checks at the time ofrecruitment and on an ongoing basis whereappropriate. Disclosure and Barring Service (DBS)checks were undertaken where required. (DBS checksidentify whether a person has a criminal record or is onan official list of people barred from working in roleswhere they may have contact with children or adultswho may be vulnerable).

• Staff who acted as chaperones were trained for the roleand had received a DBS check. We saw notices in thewaiting room of sites that we visited that advisedpatients that chaperones were available if required.

• There was an effective system to manage infectionprevention and control. Annual infection control auditswere undertaken including audits at each base site andhandwashing audits. We saw evidence that action wastaken to address any improvements identified as aresult.

• The provider ensured that facilities and equipment weresafe and that equipment was maintained according tomanufacturers’ instructions. There were systems forsafely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks topatient safety.

• There were arrangements for planning and monitoringthe number and mix of staff needed. Staff rotas weremapped against activity and demand profiles, includingseasonal variation. Live shift management was inoperation in order to monitor delivery and the impacton safety. They implemented additional resource

Are services safe?

Good –––


should it be required due to unexpected sickness orsurges in demand. For example, the ability for GPs noton rota, to carry out remote triage via secure computersystems, for short periods of time.

• There was an effective induction system for temporarystaff tailored to their role.

• Staff understood their responsibilities to manageemergencies and to recognise those in need of urgentmedical attention. They knew how to identify andmanage patients with severe infections, for examplesepsis. In line with available guidance, patients wereprioritised appropriately for care and treatment, inaccordance with their clinical need. Systems were inplace to manage people who experienced long waits.

• Staff told patients when to seek further help. Theyadvised patients what to do if their condition got worse.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe careand treatment to patients.

• The service had systems for sharing information acrossthe providers different services, with staff and otheragencies to enable them to deliver safe care andtreatment. Such as, sharing information aroundvulnerable patients, who would benefit from otherservices they delivered such as the at home responseservice.

• Clinicians made appropriate and timely referrals in linewith protocols and up to date evidence-based guidance.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safehandling of medicines.

• The systems and arrangements for managingmedicines, including medical gases, emergencymedicines and equipment, and controlled drugs andvaccines, minimised risks. The service kept prescriptionstationery securely and monitored its use.Arrangements were also in place to ensure medicinesand medical gas cylinders carried in vehicles werestored appropriately.

• The service carried out regular medicines audit toensure prescribing was in line with best practiceguidelines for safe prescribing. For example,

antimicrobial stewardship had been audited on aregular basis. Educational material on antimicrobialstewardship was available on the intranet site for staffand information for patients at the clinical sites.

• Staff prescribed, administered or supplied medicines topatients and gave advice on medicines in line with legalrequirements and current national guidance.

• Processes were in place for checking medicines andstaff kept accurate records of medicines.

• Patients’ health was monitored in relation to the use ofmedicines and followed up on appropriately.

• Palliative care patients were able to receive promptaccess to pain relief and other medication required tocontrol their symptoms. They were given a separatenumber to call so that they could have direct access tohealthcare professionals.

Track record on safety

The service had a good safety record.

• There were comprehensive risk assessments in relationto safety issues.

• The service monitored and reviewed activity. Thishelped it to understand risks and gave a clear, accurateand current picture that led to safety improvements.

• A weekly risk meeting provided a focus for riskmanagement throughout the organisation. This ensuredthat controls were in place to avoid or manage incidentsthat had occurred. The meeting consisted of reviewingrecently closed incidents, to ensure all actions had beencompleted, a review of outstanding incidents and areview and action plan for all newly raised incidents.Learning from incidents was shared via weeklye-newsletters with staff and with sub-contractedservices.

• There was a system for receiving and acting on safetyalerts. We saw that these had been cascaded to relevantstaff and actions were taken and fed back tomanagement when completed. Information to cliniciansregarding changes to practice was cascaded in theweekly clinical bulletin.

Lessons learned and improvements made

The service learned and made improvements when thingswent wrong.

Are services safe?

Good –––


• There was a system for recording and acting onsignificant events and incidents. Staff understood theirduty to raise concerns and report incidents and nearmisses. Leaders and managers supported them whenthey did so.

• In order to maintain oversight, the provider ensured thatthe provider of the NHS 111 subcontract reported allincidents to them. This meant they were able to monitorrisk to patients and ensure a consistent approach tosafety.

The provider took part in end to end reviews with otherorganisations. All incidents underwent a root causeanalysis and lessons learned used to make improvements.

For example, following an incident with the subcontractorwhen a call handler’s headset had not been turned off atthe end of the shift, a number of calls were lost. Contactwas established with all except five of the patients whosecall had not been answered. Following a root causeanalysis, actions were implemented to minimise the risk ofthe situation arising again, including a second check by theteam leader that all headsets are turned off. Medvivoensured further patient safety by ensuring these actionshad been implemented and asking their own IT team toreview telephony to ensure that calls would be diverted toanother call handler if unanswered after a number of rings.

Are services safe?

Good –––


We rated the service as Good for providing effectiveservices.

Effective needs assessment, care and treatment

• The provider had systems to keep clinicians up to datewith current evidence based practice. We saw evidencethat clinicians assessed needs and delivered care andtreatment in line with current legislation, standards andguidance supported by clear clinical pathways andprotocols. Clinical staff had access to guidelines fromthe National Institute for Health and Care Excellence(NICE) and used this information to help ensure thatpeople’s needs were met. NICE guidance updates, ineasy to read format were distributed electronically to allclinical staff on a quarterly basis. The latest clinicalroundup included updated guidance for ten diseaseareas, including Irritable Bowel Syndrome and UrinaryTract infections. Urgent updates were shared with staffvia the weekly clinical digest. The organisation was ableto monitor receipt and reading of thesecommunications by staff.

• The provider carried out clinical consultation auditsusing the clinical guardian software for the servicesoffered via the adastra platform, which comprised theircore work. Cases from the other two systems were notroutinely audited. However, GPs working on thesesystems also worked within Adastra where their clinicalconsultations were subject to regular audit. Wereviewed 30 patient medical records for the threesystems. Of the 11 we reviewed for the system used forthe practice resilience programme, which were notbeing specifically audited, we found that thedocumentation for six of records did not adhere toguidance and indicated that there was a potential to putpatients at risk. Following the inspection, the providerundertook an independant review of these whichdemonstrated that patients had received appropriatecare in line with guidelines. The provider told us thatthey had also spoken to GPs where documentation fellbelow expected standards, in order that this shouldimprove. We were also told that the provider hadinitiated a manual system of audits until the two clinicalsystems could be integrated with the clinical guardiansystem for auditing purposes.

Telephone assessments were carried out using a definedoperating model. Staff were aware of the operating modelwhich included live transfer of calls from call handler toclinician and the use of a structured NHS Pathwaysassessment tool.

• Clinical assessments were carried out using structuredassessment tools such as the National Early WarningScore (NEWS2) and the Paediatric Early Warning Score(PEWS) to identify those who were at risk of developingSepsis.

• Patients’ needs were fully assessed. This included theirclinical needs and their mental and physical wellbeing.

• Care and treatment was delivered in a coordinated waywhich took into account the needs of those whosecircumstances may make them vulnerable. For example,management plans for vulnerable people weredocumented within enhanced summary care recordsand IT systems were configured so that safeguardingalerts from the local authority were availiable toclinicians.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• Arrangements were in place to deal with repeat patients.For example, risk assessments were undertaken on eachoccasion, regarding the risk of repeat prescribing to apatient unknown to the clinician and the risk, if a patientwas not supplied with a prescription. Standardoperating procedures were in place to support clinicianswith this process.

• There was a system in place to identify frequent callersvia monthly high caller reports. Medvivo had workedwith the NHS 111 provider as part of their integratedurgent care service delivery, to support these patientsand reduce the number of calls received.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• When staff were not able to make a direct appointmenton behalf of the patient, clear referral processes were inplace. These were agreed with senior staff and clearexplanation was given to the patient or person callingon their behalf.

• Technology and equipment were used to improvetreatment and to support patients’ independence. Forexample, the MiDos App had been installed onto thedrivers’ mobile phones, so that they could easily accessinformation for patients, about when and which local

Are services effective?

Good –––


pharmacies were open. We also saw that due topotential difficulties obtaining mobile signals in therural part of the area each base car, carried two mobilephones which were on different networks.

• Staff assessed and managed patients’ pain whereappropriate using recognised pain assessment tools.

Monitoring care and treatment

The service had a programme of quality improvementactivity and routinely reviewed the effectiveness andappropriateness of the care provided. For example,responders were assessed during monthly joint visits withsupervisors and feedback was given where appropriate toimprove standards of care.

Providers are required to report monthly to their clinicalcommissioning group (CCG) on their performance againstthe standards which includes: audits; response times tophone calls: whether telephone and face to faceassessments happened within the required timescales:seeking patient feedback: and, actions taken to improvequality.

• The provider had subcontracted the NHS 111 service ofthe Integrated Urgent Care contract to Vocare, however,the provider maintained oversight and held the overallresponsibility and accountability and reporting to thecommissioners for performance delivery. Whereperformance was not in line with key performanceindicators (KPIs) the provider managed theseappropriately. For example, requesting hourly updatesfrom Vocare to the Medvivo management if callsanswered within 60 seconds fell below 70%. NHS 111data demonstrated:▪ Weekly performance data for calls answered within

60 seconds (for which the target is 95%) variedbetween 70% and 90%. Available data for December2018 and January 2019 showed improvement withthe mean average of 85% of calls answered within 60seconds. This was in line with national averages. Theaverage length of time for a call to be answeredwithin 30 seconds for quarter two 2018/19 was 41seconds which was an improvement from theprevious quarter of one minute and seven seconds.

▪ Weekly performance data for the number of callsabandoned (the national target is less than 5%)showed the service was mainly in line or performingbetter than the national target. (Abandonment ratesindicate the number of service users who abandoned

the call. This can indicate risk to patients with aserious illness being unable to access timelytreatment). The average number of calls abandonedfor a call to be answered for quarter two 2018/19 was3.5% which was an improvement from the previousquarter of 6%.

▪ Data for the disposition times for home visitsdemonstrated for the period May – October 2018 that57% of patients were seen within the urgent – 2hours category and 86% within the routine- 6 hourscategory. In recognition that this needed to beimproved the provider had audited, to highlightareas for improvement. It was identified that due topoor mobile reception clincians were not recordingthe visit on the system until they returned to basewhich affected the disposition times. They alsoidentified a training need regarding use of the systemby staff. We spoke with the commissioners who wereaware of these issues and who told us they wereassured that the data did not reflect the quality ofcare patients were receiving.

• The service had locally agreed key performanceindicators (KPI’s) as set by the commissioners. Thesewere agreed prior to the start of the Integrated UrgentCare (IUC) contract and national standards had notbeen set by NHS England at this time. Thecommissioners had decided not to set targets for thefirst nine months of the contract, other than thoseassociated with the NHS 111 service. Medvivo reportedmonthly to the commissioners and much of the datawas reported as numbers of patients, as agreed with thecommissioners in order to facilitate future resourcingmodelling. We spoke with the commissioners who toldus that the provider was performing well and meetingtheir expectations Following the recent publication ofNHS England standards, specific targets would be set atthe end of February 2019. The reporting format showedthat for the period July - September 2018:▪ The average time, for a patient receiving an urgent

clinical assessment was 17 mins. This figure hadremained stable throughout the period.

▪ The average time to a definitive clinical encounterwas 56 minutes. This figure had steadily decreasedfrom 1hour and 13mins over the reporting period.


Good –––


▪ The percentage of calls that were booked for a faceto face appointment with a clinician within a primarycare setting was 24%. This figure had remainedstable over the reporting period.

• Out of 15,240 patients triaged by the Clinical AssessmentService (CAS) September – November 2018 showed:▪ 58% of patients triaged by the CAS needed no further

follow up.▪ 29% were referred for a face to face consultation with

an out of hours GP.▪ 7% were referred to secondary care.▪ 2% were referred to the emergency services.▪ 1% were referred to other services such as the

mental health or palliative care services.▪ 2% of patients were recorded as a failed encounter.

These underwent a risk assessment by a member ofthe clinical team. If considered medium or high risk,allied services such as local hospitals were contactedand if required a welfare visit was arranged.

▪ Outcomes from referrals into the CAS from theambulance service demonstrated admissionavoidance. 71% of the cases were either closed withno follow up or referred to a primary care orcommunity service.

• The service made improvements through the use ofaudits. For example, cases where a broad spectrumantibiotic had been prescribed, (antibiotics which aremost likely to develop resistance if used inappropriately)were audited to ascertain if best practice was beingadhered to. The initial audit showed that of these cases,47% did not meet best practice. Individual cliniciansreceived feedback; they were asked to reflect on theirpractice and reminded of the antibiotic guidelines. Afollow up audit demonstrated that the interventionshad made a positive impact, as 90% of these antibioticshad been prescribed according to best practice.

Effective staffing

Staff had the skills, knowledge and experience to carry outtheir roles.

• All staff were appropriately qualified.• The provider had an induction programme for all newly

appointed staff. Induction for all staff consisted of a twoday corporate induction, which included, a strategicoverview, Medvivo’s vision and values, safeguarding andincident reporting, HR and IT and mandatory trainingmodules such as information governance. Additionally,

specific role specific inductions were mapped out for allnew starters. Staff we spoke with told us that theinduction they had received was comprehensive andrelevant to their roles.

• The provider ensured that all staff worked within theirscope of practice and had access to clinical supportwhen required.

• The provider understood the learning needs of staff andprovided protected time and training to meet them.Staff were encouraged and given opportunities todevelop. The continuing development of staff skills,competence and knowledge was recognised as integralto ensuring high quality care. Staff were proactivelysupported to acquire new skills and share best practice.For example, all responders (staff who deliver nonclinical interventions and support services) wereencouraged to undertake the Care Certificate,supported by the organisations trained assessors. Therewas a strategy to invest in two nurses per year todevelop them into Advanced Nurse Practitioners inorder to provide ongoing home-grown talent providingresilience for the future. Sessional GPs were given accessto the provider's e-learning data base and were offeredattendance, at available face to face learning.

• Recent interventions to strengthen leadershipcompetencies had included the introduction of abespoke management course developed by Medvivoand a competency framework for managers. A newmedical director was being mentored by herpredecessor.

• Study days for nurse practitioners, paramedics andpharmacists were held three times a year. We saw thatthese included, non medical prescribing, paediatricsand end of life care, however some staff reporteddifficulties attending these sessions due to clinicalcommitments

The provider provided staff with ongoing support. Thisincluded one-to-one meetings, appraisals, coaching andmentoring, clinical supervision and support forrevalidation. Nurses told us during the inspection, thatclinical supervision was not mandatory however theservice provided clinical supervision for staff who did nothave support elsewhere.

• The provider could demonstrate how it ensured thecompetence of staff employed in advanced roles byaudit of their clinical decision making, includingnon-medical prescribing.


Good –––


• There was a clear approach for supporting andmanaging staff when their performance was poor orvariable. For example, we saw from clinical call audits,clinicians were asked to reflect on patient managementif the care delivered was considered not to be in linewith best practice.

Coordinating care and treatment

Staff worked together, and worked well with otherorganisations to deliver effective care and treatment.

• We saw records that showed that all appropriate staff,including those in different teams, services andorganisations, were involved in assessing, planning anddelivering care and treatment.

• Patients received coordinated and person-centred care.This included when they moved between services, whenthey were referred, or after they were discharged fromhospital. Care and treatment for patients in vulnerablecircumstances was coordinated with other services. Forexample, Medvivo’s lead role for the area at theMulti-Agency Risk Assessment Conference (MARAC)meetings and the over 80 pathway for patients callingNHS 111. Staff communicated promptly with patient'sregistered GP’s so that the GP was aware of the need forfurther action. Staff also referred patients back to theirown GP to ensure continuity of care, where necessary.There were established pathways for staff to follow toensure callers were referred to other services for supportas required. The service worked with patients to developpersonal care plans that were shared with relevantagencies. For example, treatment escalation plans (TEP)and individual end of life pathways.

• Patient information was shared appropriately, and theinformation needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way. Prior to the mobilisation of theintegrated urgent care contract, across an area whichutilised a number of different clinical recording systems,Medvivo led discussions with stakeholders on thetechnological options regarding an urgent careclinician’s ability to access adequate information tosupport clinical decision making at the point of care.Technological solutions included, a system wherebyuploaded data was aligned to a patients TEP and asystem that enabled access to shared informationrelating to child welfare and safeguarding alerts heldwithin the local authority system.

• The service had formalised systems with thesubcontracted NHS 111 service with specific referralprotocols for patients referred to the service. Anelectronic record of all consultations was sent topatients’ own GPs.

• The service ensured that care was delivered in acoordinated way and took into account the needs ofdifferent patients, including those who may bevulnerable because of their circumstances. For example,bespoke pathways had been developed to enhancepatient care for the under five years, over eighty years,those at the end of their life and those experiencingmental health issues.

• There were clear and effective arrangements forbooking appointments, transfers to other services, anddispatching ambulances for people that require them.Staff were empowered to make direct referrals and/orappointments for patients with other services.

• Issues with the Directory of Services (DoS) were resolvedin a timely manner. Medvivo had worked with thecommissioners to ensure DoS profiles and DoS rankingswere set to channel activity to lower acuity services andaway from the Ambulance Service and EmergencyDepartments where appropriate.

Helping patients to live healthier lives

Staff were consistent and proactive in empoweringpatients, and supporting them to manage their own healthand maximise their independence.

• The service identified patients who may be in need ofextra support. For example, patients over 80 years old,where increased case complexity is common and knownto lead to difficulties for call handlers in completing theNHS Pathways assessment. As these could result ininappropriate referral to Ambulance and the Emergencydepartment, these were passed on for assessment by aclinician.

• Where appropriate, staff gave people advice so theycould self-care. Systems were available to facilitate this.

• Risk factors, where identified, were highlighted topatients and their normal care providers so additionalsupport could be given.

• Where patients needs could not be met by the service,staff redirected them to the appropriate service for theirneed.

Consent to care and treatment


Good –––


The service obtained consent to care and treatment in linewith legislation and guidance.

• Clinicians understood the requirements of legislationand guidance when considering consent and decisionmaking.

• Clinicians supported patients to make decisions. Whereappropriate, they assessed and recorded a patient’smental capacity to make a decision.

The provider monitored the process for seeking consentappropriately.


Good –––


We rated the service as outstanding for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect andcompassion. Patients were valued as individuals and wereempowered to have a voice in their own care.

• Staff understood patients’ personal, cultural, social andreligious needs. They displayed an understanding andnon-judgmental attitude to all patients.

• The service gave patients timely support andinformation. Call handlers gave people who phoned intothe service clear information. There were arrangementsand systems in place to support staff to respond topeople with specific health care needs such as end oflife care and those who had mental health needs.

• A sympathy card had been designed for urgent care athome responders (UC@H) to take to families who hadsuffered bereavement during the previous week.

• Following a Christmas box appeal, 35 boxes, containingfood and treats, were delivered to those service userswho had been identified by the UC@H, as being in needor those who would be alone over the Christmas period.

• Of the 58 patient Care Quality Commission commentcards we received 56 were wholly positive about theservice experienced. Comments included praise for theefficiency of the service from the initial call to NHS 111to being seen at one of the services sites and theprofessionalism of the staff.

Patient feedback that had been collected by the service forthe out of hours GP service from April – December 2018showed that patients were continually positive about theway staff treated people and reported positive outcomesfrom their care and experiences, for example of the 55respondents:

• 100% agreed or strongly agreed that they were treatedwith dignity and respect and

• 100% agreed or strongly agreed that they had receivedthe support required from the service.

• 98% agreed or strongly agreed that they felt involved indecisions about their care.

• 98% would recommend the service to their family andfriends.

•

Feedback collected by Medvivo for the Urgent Care atHome service from April - December 2018 showed that forthe 22 respondents:

• 100% agreed or strongly agreed that they had receivedthe support required from the service.

• 98% agreed or strongly agreed that they were treatedwith dignity and respect.

• 98% agreed or strongly agreed that they felt involved indecisions about their care.

• 100% would recommend the service to their family andfriends.

•

The service had recognised children and young peoplecould be high users of urgent care and had recentlyintroduced specially designed feedback cards specificallyfor this age group. Of the eighteight responses received atthe time of the inspection, all respondents said that theyfelt that it was a good service to look after friends andfamily if they needed similar care or treatment to them.Comments included how easy and nice the doctor or nursewas to speak to.

• Patients we spoke with during the inspection spokehighly of the service and reflected the comment cardsand survey results.

Involvement in decisions about care and treatment

Staff empowered patients be involved in decisions and bepartners in their care.

• The provider was aware of the Accessible InformationStandard (a requirement to make sure that patients andtheir carers can access and understand the informationthey are given).

• Interpretation services were available for patients whodid not have English as a first language. We saw noticesin the reception areas, including in languages other thanEnglish, informing patients this service was available.Patients were also told about multi-lingual staff whomight be able to support them. Information leafletswere available in easy read formats, to help patients beinvolved in decisions about their care. Makaton booklets(a language programme that gives everyone assistanceto speak with patients with communication difficulties)were kept in all cars and at bases.

• Patients told us through comment cards, that they feltlistened to and supported by staff and had sufficienttime during consultations to make an informed decisionabout the choice of treatment available to them.

The service recognised the totality of people’s needs. Forexample, patients with learning disabilities or complex

Are services caring?

Outstanding –


social needs, family, carers or social workers wereappropriately involved. Medvivo had workedcollaboratively with third sector groups to improve patientexperience for those in minority groups or with a disabilityand to ensure their input when developing their model ofcare. Working with a national association for peopleaffected by blindness had led to patient information beingcreated in braille and some patient groups having access tocare via a telephone number that bypassed the normalline.

• Parents attending the Children and Young Persons Clinichad suggested that the service stock copies of “MyHospital Passport” (a leaflet produced by the AutisticSociety) to facilitate coordinated care when childrenwith autism were moving between services. Thissuggestion was acted upon.

• Staff helped patients and their carers find furtherinformation and access community and advocacyservices. They helped them ask questions about theircare and treatment.

• Patients told the provider that it would be reassuring forthem to have information about the service following ahome visit OOH. An information card was produced

which the visiting clinician left with the patient. The cardenabled patients to provide feedback about the servicethey received but also told them the name of theclinician and how to contact the service, should theyneed to again. This was further improved recently byincluding an option to complete the feedback on lineand a new ‘wallet’ sized card which included a QR codefor easier access to the online survey. A similar feedbackcard was then produce for the UC@H service.

Privacy and dignity

The service respected and promoted patients’ privacy anddignity.

• Staff respected confidentiality at all times.• Staff understood the requirements of legislation and

guidance when considering consent and decisionmaking.

• Staff supported patients to make decisions. Whereappropriate, they assessed and recorded a patient’smental capacity to make a decision.

The service monitored the process for seeking consentappropriately.

Are services caring?

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We rated the service as outstanding for providingresponsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meetpatients’ needs. Services were tailored to the needs ofindividual people and were delivered in a way to ensureflexibility, choice and continuity of care.

• The provider used innovative ways to look at the rangeof services they were offering and tailored them to bestmeet the needs of the patients. The provider deliveredan Urgent Care at Home service, which had been jointlycommissioned by NHS Wiltshire Clinical CommissioningGroup and Wiltshire County Council. The serviceensured an integrated rapid health and social careresponse for service users in a health or social care crisisin their own home. The Single Point of Access (SPA)assessed and coordinated support for service users anddeployed the Mobile Response Service, within one hourfrom receipt of referral, who actively supported patientsin the short term (up to 72 hours) whilst the SPAarranged any on-going support required in order toavoid inappropriate admissions and expedite hospitaldischarges. The service was supporting over 250 peopleeach month, to remain at home or to return home fromhospital as soon as possible. This had not onlyimproved patient outcomes but it has also supportedthe whole system in terms of delays to transfers of care,increased capacity and financial savings. This servicehas been published on the Kings Fund website as a bestpractice case study, shortlisted for the LocalGovernment Chronicle awards and had won a Successin Partnership award from Wiltshire County Council.

• The provider engaged with commissioners to secureimprovements to services where these were identified.For example, the provider worked with GP urgent careleads and clinical commissioning quality leads acrossthe area to review and redesign case flow to ascertainwhich patients would benefit from an NHS Pathwaysassessment and which should go directly to the ClinicalAssessment Service or another service. This led to theimplementation of specific pathways for specificpatients. For example, patients under five years of age, acohort that can deteriorate quickly, were automaticallyoffered an assessment with a clinician. This hadexpedited face to face assessment, for a patient group

that can deteriorate very quickly, and preventedconsultations being sought elsewhere such asemergency departments. Similar pathways for patientsaged over 80 years had also been implemented.

• The provider improved services where possible inresponse to unmet needs. For example, bespoketemplates were designed in order to capture referralinformation from healthcare professionals calling theservice to refer palliative care patients. These weredesigned in partnership with the community palliativecare clinical teams including representatives from eachlocal hospice in order to be sure all patient needs weremet. Palliative care patients were also given telephoneaccess directly into the provider rather than having to gothrough NHS 111.

• The provider recognised the need to ensure sufficientcover for the services during periods of peak demand ofthe GP out of hours (OOH) cover.This had been achievedby employing and utilising paramedics to carry out aproportion of appropriate domiciliary visits on behalf ofthe clinical team, therefore enabling a higher number ofvisits to be made. Trial periods demonstrated improvedpatient outcomes from the increased clinical resourcewhich had led to more efficient and effective home visitsduring busy periods. A decision has been made for thisservice to operate over Christmas, Easter and bankholidays. Paramedics had undertaken accreditedtraining with the Royal College of Paramedics to ensurecompetencies for this role.

• The provider had been commissioned to deliver the GPResilience Support programme which supplied in hoursclinical triage support for GP practices that wereexperiencing short term staffing gaps.

• The service had a system in place that alerted staff toany specific safety or clinical needs of a person using theservice. For example, frequent callers. It was recognisedby the provider that many frequent callers weresuffering with long term medical or social problems.Systems were in place to identify them and they hadworked with the NHS 111 as part of their integratedurgent care service delivery, to support these patientsand reduce the number of calls received. By workingcollaboratively with the local hospitals, the ambulanceservice, mental health teams and the patient’s own GP,high intensity user plans were implemented whereappropriate. There was evidence that these had made apositive impact. For example, In December 2018, 30 callsa day were being received from one patient. A high

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intensity user plan was implemented and by the thirdweek of January only five calls had been received fromthis patient and none had been received in the two daysprior to the inspection.

• The facilities and premises we visited during theinspection were appropriate for the services delivered.

• The service made reasonable adjustments when peoplefound it hard to access the service. An example of thiswas the promotion to staff of the StreetlinkHomelessness App, which as well as providing a meansfor homeless people to source services close to them,enabled staff to send an alert if a homeless person wasseen and there was a concern for their welfare.

The service was responsive to the needs of people invulnerable circumstances. Examples of this were:

• The provider had recognised that 1% of the populationin the Bath and North East Somerset area were Chineseand a high proportion did not speak English. Links hadbeen established with the Lantern project and meetingshad taken place to inform this group how to accessservices.

• Relationships had been established with the LearningDisability forum in Swindon. At an event attended, theprovider was able to help the audience understand howthe out of hours service worked and how to access theNHS 111 service. Easy read leaflets and visual aids wereused to demonstrate the hours in which each servicecould be contacted.

• Medvivo provided care to refugees being repatriated tothe UK. Working with other agencies, refugees were metat the airport where a medical assessment wasundertaken. Following transfer to their accommodationstaff ensured that they were clear on how to access theservices, to meet their health care needs.

Timely access to the service

Patients were able to access care and treatment from theservice within an appropriate timescale for their needs.

• Patients were able to access care and treatment at atime to suit them. The service operated for 24 hours7days a week.

• Patients could access the service via the NHS 111service or by referral from a healthcare professional.Appointments at the out of hours (OOH) sites werebooked by the service. The service did not see walk-inpatients and a ‘Walk-in’ policy was in place which clearly

outlined what approach should be taken when patientsarrived without having first made an appointment, forexample patients were told to call NHS 111 or referredonwards if they needed urgent care. All staff were awareof the policy and understood their role with regards to it,including ensuring that patient safety was a priority.

• In the case of the Success clinic in Swindon,appointments were made by the patient’s own GPpractice. Appointments for the Children and Youngperson clinic could be made directly with the clinic bypatients.

• Workload was reviewed by the hour and staffingadjustments made as necessary. This modelling meantthat the provider could respond to emerging trends andhad resulted in an additional clinical assessment shiftbeing added due to high level of demand on Fridayevenings.

• Patients were generally seen on a first come first servedbasis, although the service had a system in place tofacilitate prioritisation according to clinical need wheremore serious cases or young children could beprioritised as they arrived. The reception staff wereaware of emergency criteria to use to alert the clinicalstaff if a patient had an urgent need. The criteriaincluded guidance on sepsis and the symptoms thatwould prompt an urgent response. The receptionistsinformed patients about anticipated waiting times.

• Waiting times, delays and cancellations managedappropriately. Where people were waiting a long timefor an assessment or treatment there werearrangements in place to manage the waiting list and tosupport people while they waited. For example, theClinical Assessment Service (CAS) and the NHS 111handlers were co-located. The provider monitored thequeue of callers into NHS111 and were able toreallocate calls to the CAS if the queue became long andwhere appropriate to ensure patients got the mostappropriate treatment in a timely manner.

• Patients with the most urgent needs had their care andtreatment prioritised.

• Where patient’s needs could not be met by the service,staff redirected them to the appropriate service for theirneeds.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously andresponded to them appropriately to improve the quality ofcare.


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• Information about how to make a complaint or raiseconcerns was available and it was easy to do. Stafftreated patients who made complaintscompassionately. The complainant was contacted bytelephone on the day the complaint was received todiscuss the concerns. The provider had found this to bevery effective in de-escalating and resolving issuesquickly to the complainant’s satisfaction

• The complaint policy and procedures were in line withrecognised guidance. Seventy two complaints werereceived in the last year. This included complaintsreceived by the NHS 111 service. We reviewed a sampleof these complaints and found that they weresatisfactorily handled in a timely way.

• Issues were investigated across relevant providers anddiscussed at the weekly risk meeting. Staff were able tofeedback to other parts of the patient pathway whererelevant.

The provider undertook a comprehensive quarterly reviewof complaints to identify trends and themes. Lessonslearned were shared widely throughout the organisation inthe form of e-bulletins, printed newsletters and theintranet. Actions were taken to improve the quality of carereceived. For example, training had been undertaken toimprove communication skills for patient facing staff.


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We rated the service as outstanding for leadershipbecause the leadership governance and culture wereused to drive and improve the delivery of high-qualityperson centred care.

Leadership capacity and capability

The service used a systematic approach to working withother organisations and wider health economy to improvecare outcomes, tackle health inequalities and ensure thedelivery of high quality person centred care.

• Leaders had the experience, capacity and skills todeliver the service strategy and address risks to it. Theyunderstood local health needs and worked to designservices to reduce demand on other health and socialcare services. Arrangements were in place to mentor thenewly appointed medical director who did not haveprevious experience in a senior leadership role. Therewas also a team of 3 clinical directors supporting theservice. They were knowledgeable about issues andpriorities relating to the quality and future of services.They understood the challenges and were addressingthem.

• Leaders at all levels were visible and approachable.They worked closely with staff and others to make surethey prioritised compassionate and inclusive leadership.Leaders had an inspired shared purpose and strived todeliver and motivate staff to succeed.

• The leadership and culture of the provider was used todrive improvements and deliver high quality personcentred care. The provider worked effectively as a wholeteam, involved the patients and the community andother organisations to deliver the best outcomes anddeliver the care within the community whereverpossible.

• Senior management was accessible throughout theoperational period, with an effective on-call system thatstaff were able to use.

• The provider had effective processes to developleadership capacity and skills, including planning for thefuture leadership of the service.

Vision and strategy

The strategy and supporting objectives were stretching,challenging and innovative, while remaining achievable.

• There was a clear vision and set of values. The servicehad a realistic strategy and supporting business plans toachieve priorities.

• The service developed its vision, values and strategyjointly with patients, staff and external partners.

• The provider valued staff engagement and staff wereaware of and understood the vision, values and strategyand their role in achieving them.

• The strategy was in line with health and social prioritiesacross the region. The provider planned the service tomeet the needs of the local population.

• The provider monitored progress against delivery of thestrategy.

• The provider ensured that staff who worked away fromthe main base felt engaged in the delivery of theprovider’s vision and values.

• Quality improvement projects were regularlyundertaken to continually improve the services offeredto patients. For example, developing the skills of theresponders to be able to undertake patientobservations where the additional skills in assessmentand communication enabled responders to escalateconcerns more effectively.

Culture

The service had a culture of high-quality sustainable care.

• There was a clear leadership structure in place and stafffelt supported by management. Staff we spoke to wereproud of the organisation and spoke highly of theculture. We saw high levels of staff engagement and acommon focus on improving the quality of patientexperience.

• Skill mix within the service was continually assessed, inorder to address the challenges faced by delivering anintegrated urgent care (IUC) service to meet the needs ofthe community. For example, the development ofprescribing pharmacists to conduct telephone triage formedicine related issues and the employment ofparamedics to provide additional home visiting capacityduring holiday periods.

• Leaders and managers acted on behaviour andperformance inconsistent with the vision and values.

• Openness, honesty and transparency weredemonstrated when responding to incidents andcomplaints. The provider was aware of and had systemsto ensure compliance with the requirements of the dutyof candour.

• Staff we spoke with told us they were able to raiseconcerns and were encouraged to do so. They hadconfidence that these would be addressed.

Are services well-led?

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• There were processes for providing all staff with thedevelopment they need. This included appraisal andcareer development conversations. For example,Medvivo’s bespoke leadership development programmeand apprenticeships for responders to enableaccredited qualifications. A training profile had beencreated for every role in line with the NHS Englandblueprint and a competency matrix had beendeveloped for operational roles which gave clearpathways for staff to develop skills and competenicesfor team leader roles.

• All staff received regular annual appraisals in the lastyear. Staff were supported to meet the requirements ofprofessional revalidation where necessary.

• Clinical staff, including nurses, were considered valuedmembers of the team. There were opportunities forprofessional development and evaluation of theirclinical work. Clinical education events were organisedfor staff to attend. These were also advertised on theservices website and clinicians working outside of theorganisation were able to book places. Additionally, twonurses each year were supported to gain the accreditedqualifications necessary to become Advanced NursePractitioners.

• The service actively promoted equality and diversity. Itidentified and addressed the causes of any workforceinequality. Staff had received equality and diversitytraining. Staff felt they were treated equally.

• There were positive relationships between staff andteams.

There was a strong emphasis on the safety and well-beingof all staff. In the most recent staff survey, 93% respondedpositively to the question, is positive action taken on healthand wellbeing. The interventions initiated by the providerhad led to a decrease in turnover of over 6% in the last 12months. Examples of these were:

• A Health and Wellbeing Charter had been developedwith staff which had led to, an improved workingenvironment, including sit/stand desks, resources andsignposting information on the intranet, peer to peerrecognition awards, a celebrating success fund wheremanagers are able to pay for an event to celebrate thesuccesses of a team and incentives to encourage staff toproactively look after their own health with, for examplediscounted gym memberships, dental and eye care.

• Building a resilient workforce was a priority for themanagement team and a range of interventions hadbeen initiated to support this. For example, MentalHealth First Aiders, resilience workshops, self-awarenesscampaigns such as desk yoga and mindfulness, accessto free counselling, well being incorporated into regularone to ones.

Governance arrangements

There were clear responsibilities, roles and systems ofaccountability to support good governance andmanagement.

• Structures, processes and systems to support goodgovernance and management were clearly set out,understood and effective. The governance andmanagement of partnerships, joint workingarrangements and shared services promoted interactiveand co-ordinated person-centred care.

• Staff were clear on their roles and accountabilitiesincluding in respect of safeguarding and infectionprevention and control. There were local leads whomonitored and supported specialties such assafeguarding and led the Multi-Agency Risk AssessmentConference (MARAC) Primary Care Liaison service for thearea to ensure a joined-up approach to patient carewith local agencies and providers such as GPs,secondary care, the Police and social services.

• Leaders had established proper policies, proceduresand activities to ensure safety and assured themselvesthat they were operating as intended. We looked at anumber of these policies and found them to be regularlyreviewed. For example, infection prevention control,consent and duty of candour.

Managing risks, issues and performance

There were clear and effective processes for managingrisks, issues and performance.

• There was an effective process to identify, understand,monitor and address current and future risks includingrisks to patient safety which included monitoring andmanaging risk within sub-contracted services.

• The provider had processes to manage current andfuture performance of the service. Performance ofemployed clinical staff could be demonstrated throughaudit of their consultations, prescribing and referraldecisions. However, we found in the sample of medicalrecords reviewed that documentation was not always in


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line current best practice and guidance.Following theinspection the provider told us that actions had beentaken to improve this with the relevant clincians.Leaders had oversight of MHRA alerts, incidents, andcomplaints. Leaders also had a good understanding ofservice performance against the national and local keyperformance indicators. Performance was regularlydiscussed at senior management and board level.Performance was shared with staff and the local CCG aspart of contract monitoring arrangements.

• Clinical audit had a positive impact on quality of careand outcomes for patients. There was clear evidence ofaction to resolve concerns and improve quality. Forexample, in relation to the use of nationally recognisedassessment tools, National Early Warning Score (NEWS2)and the Paediatric Early Warning Score (PEWS) toidentify those patients who were most unwell andrequired prioritising for treatment.

• The providers had plans in place and had trained stafffor major incidents.

• The provider implemented service developments andwhere efficiency changes were made this was with inputfrom clinicians to understand their impact on the qualityof care.

Appropriate and accurate information

The service acted on appropriate and accurateinformation.

• Quality and operational information was used to ensureand improve performance. Performance informationwas combined with the views of patients.

• Quality and sustainability were discussed in relevantmeetings where all staff had sufficient access toinformation.

• The service used performance information which wasreported and monitored, and management and staffwere held to account.

• The information used to monitor performance and thedelivery of quality care was accurate and useful. Therewere plans to address any identified weaknesses. Forexample, Medvivo told us that they were not alwayssatisfied with the performance being delivered by theNHS 111 service which was subcontracted to anotherprovider. Actions were in place to address this, includinghourly reporting to Medvivo when performance levelshad fallen below set targets and reporting to Medvivo on

patient safety investigations following breaches withinthe NHS 111 service. We saw that performance of theNHS 111 service against targets had improved at the endof quarter two compared to quarter one.

• The service used information technology systems tomonitor and improve the quality of care.

• The service submitted data or notifications to externalorganisations as required.

• There were robust arrangements in line with datasecurity standards for the availability, integrity andconfidentiality of patient identifiable data, records anddata management systems.

Engagement with patients, the public, staff andexternal partners

The service involved patients, the public, staff and externalpartners to support high-quality sustainable services.

• A full and diverse range of patients’, staff and externalpartners’ views and concerns were encouraged, heardand acted on to shape services and culture. Forexample, patient engagement events were held withpatient participation groups. Leaders also collaboratedwith multiple providers to ensure that their views wereheard and used to shape the mobilisation of theIntegrated Urgent Care service.

• The provider implemented innovative approaches togather feedback from people who use services,including from those in different equality groups suchas; a feedback card designed specifically for childrenand meeting with the local Chinese community toimprove the understanding of their needs.

• Staff were able to describe to us the systems in place togive feedback. For example, through the employeeforum, via the intranet and staff survey. The most recentstaff survey demonstrated that 84% of respondentswere happy and engaged.

• The service was transparent, collaborative and openwith stakeholders about performance. For example, wesaw that the provider had made available on its website,the previous year’s quality report for the service.

• We spoke with commissioners of the services who toldus that the provider was transparent and easy to workwith in very collaborative way and had worked hard todeliver on performance. Local GPs also respondedpositively to the service being provided for theirpatients.

Continuous improvement and innovation


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The leadership drove continuous improvement and staffinnovation was recognised.

• There was a focus on continuous learning andimprovement at all levels within the service. Forexample, the provider was keen to understand how wellthe newly mobilised Integrated Urgent Care service wasperforming and commissioned the Primary CareFoundation to review the model that had beenimplemented. The provider was using the findings tofurther improve the services being delivered forpatients.

• The service made use of internal and external reviews ofincidents and complaints. Learning was shared andused to make improvements.

• Leaders and managers encouraged staff to take time outto review individual and team objectives, processes andperformance.

•

There were clear proactive approaches to piloting andembedding new ways of providing care and treatmentExamples of this were:

• To meet the challenges faced by out of hours (OOH)services the provider had successfully bid for funding

from the Pharmacy Integration Fund to pilot thedevelopment of prescribing pharmacists. This has beendone in conjunction with the provider of thesubcontracted NHS 111 service and two universities.

• The provider was working with the local mental healthprovider to design an improved pathway for patients. Aproject was being scoped to include mental healthsupport to be included within the Clinical AssessmentService (CAS), with the aim to improve patientexperience and reduce the need for crisis intervention.

• Following collaboration with Improved Access toPsychological Therapies (IAPT) the service was now inthe position to include IAPT services within the Directoryof Services, making these services available to morepatients who called NHS 111.

• The provider was in the process of trialling the additionof a greater range of disciplines within the CAS, theseincluded district nurses and paramedics.

• A project was in progress to improve patient flow fromSalisbury Hospitals NHS Foundation Trust usingtechnology. Patients were identified where part or all oftheir care could be met using a technological devicethat tracked patients on discharge. The objective of thissystem was to reduce the numbers of delayeddischarges, facilitate fewer care visits and lead toimproved patient safety.


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Documents

OutOfHours - 1-347335038 Medvivo (22/01/2019) INS2-5528584911