This service is rated as Requires Improvement overall.
We carried out an announced comprehensive inspection of Primary Care 24 (Merseyside) Limited on 9, 10, 11, 12 and 13 May 2022.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Requires Improvement
Are services well-led? – Requires Improvement
We had an additional focus on the urgent and emergency care pathway and carried out several inspections of services across a few weeks in the Merseyside area. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.
A summary of CQC findings on urgent and emergency care services in Cheshire and Merseyside (Liverpool, Knowsley and South Sefton).
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 Liverpool, Knowsley and South Sefton within the Cheshire and Merseyside ICS below:
Cheshire and Merseyside (Liverpool, Knowsley and South Sefton)
Provision of urgent and emergency care in Cheshire and Merseyside was supported by services, stakeholders, commissioners and the local authority.
We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff had continued to work hard under sustained pressure across health and social care services. Services had put systems in place to support staff with their wellbeing, recognising the pressure they continued to work under, in particular for front line ambulance crews and 111 call handlers.
Staff and patients across primary care reported a preference for face to face appointments. Some people reported difficulties when trying to see their GP and preferred not to have telephone appointments. They told us that due to difficulties in making appointments, particularly face to face, they preferred to access urgent care services or go to their nearest Emergency Department. However, appointment availability in Cheshire and Merseyside was in line with national averages. We identified capacity in extended hours GP services which wasn’t being utilised and could be used to reduce the pressure on other services. People and staff also told us of a significant shortage of dental provision, especially for urgent treatment, which resulted in people attending Emergency Departments.
Urgent care services, including walk-in centres were very busy and services struggled to assess people in a timely way. Some people using these services told us they accessed these services as they couldn’t get a same day, face to face GP appointment. We found some services went into escalation. Whilst system partners met with providers to understand service pressures, we did not always see appropriate action taken to alleviate pressure on services already over capacity.
The NHS 111 service, which covered all of the North West area including Cheshire and Merseyside, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours (OOH) provider.
We found some telephone consultation processes were duplicated and could be streamlined. At peak times, people were waiting 24-48 hours for a call back from the clinical assessment and out of hours services. We identified an opportunity to increase the skill mix in clinicians for both the NHS 111 and the clinical assessment service. For example, pharmacists could support people who need advice on medicines. Following our inspections, out of hours and NHS 111 providers have actively engaged and worked collaboratively to find ways of improving people’s experience by providing enhanced triage and signposting.
People who called 999 for an ambulance experienced significant delays. Whilst ambulance crews experienced some long handover delays at the Emergency Departments we inspected, data indicated these departments were performing better than the England average for handovers, although significantly below the national targets. However, crews found it challenging managing different handover arrangements at different hospitals and reported long delays.
Service leaders were working with system partners to identify ways of improving performance and to ensure people could access appropriate care in a timely way. For example, the service worked with mental health services to signpost people directly to receive the right care, as quickly as possible. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.
We saw significant levels of demand on emergency departments which, exacerbated by staffing issues, resulted in long delays for patients. People attending these departments reported being signposted by other services, a lack of confidence in GP telephone appointments and a shortage of dental appointments. We inspected some mental health services in Emergency Departments which worked well with system partners to meet people’s needs.
We found there was poor patient flow across acute services into community and social care services. Discharge planning should be improved to ensure people are discharged in a timely way. Staff working in care homes (services inspected were located in Liverpool and South Sefton) reported poor communication about discharge arrangements which impacted on their ability to meet people’s needs.
The provision of primary care to social care, including GP and dental services, should be improved to support people to stay in their own homes. Training was being rolled out to support care home staff in managing deteriorating patients to avoid the need to access emergency services. We found some examples of effective community nursing services, but these were not consistently embedded across social care. Staffing across social care services remains a significant challenge and we found a high use of agency staff. For example, in one nursing home, concerns about staff competencies and training impacted on the service’s ability to accept and provide care for people who had increased needs.
We found some care homes felt pressure to admit people from hospital. Ongoing engagement between healthcare leaders and Local Authorities would be beneficial to improve transfers of care between hospitals and social care services. In addition, increased collaborative working is needed between service leaders. We found senior leaders from different services sometimes only communicated during times of escalation.
This report covers the inspection of Primary Care 24 (Merseyside) Limited. The reports of previous inspections can be found by selecting the ‘all reports’ link for Primary Care 24 (Merseyside) Limited on our website at www.cqc.org.uk.
This report comprises information from a combination of:
- What we found when we inspected the service.
- Information from our ongoing monitoring of data about the provider and information from the provider, patients, staff, the public and other organisations.
At this inspection we found:
- The service had systems in place to report significant events and incidents.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
The service is rated as requires improvement for being safe because:
- Not all staff had received up-to-date safeguarding training for their role.
- There were periods of understaffing which were not addressed in a way that ensured peoples safety was always protected. For example, there were shortfalls in clinicians available on some weekends and bank holidays.
The service is rated as requires improvement for being effective because:
- The provider continually did not meet some of the integrated urgent care indicators due to the demand for the service and the way it was delivered.
- There were missed opportunities for working with other services to improve the patient journey and feed back to commissioners. For example, working with NHS 111 to identify those patient pathways who could be booked into a face to face appointment with a clinician rather than receive a telephone consultation prior to an appointment.
The service is rated as requires improvement for being responsive because:
- Patients were not always able to access care and treatment from the service within an appropriate timescale for their needs.
The service is rated as requires improvement for being well-led because:
- Staff satisfaction about working at the service was mixed. Staff did not always feel actively engaged with or empowered by the leadership team.
- The approach to service delivery and improvement was reactive and focused on short-term issues. For example, providing clinical resources on Monday mornings to contact patients who contacted the service over the weekend.
The areas where the provider must make improvements as they are in breach of regulations are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
The areas where the provider should make improvements are:
- The organisation should continue to work closely with all system partners to tackle the capacity pressures on urgent and emergency care in the health and social care system in Liverpool.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care