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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 service Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Outstanding –

Are services well-led? Outstanding –

HilltHilltopop HeightsHeightsQuality Report

Hilltop HeightsLondon RoadCarlisleCumbriaCA1 2NSTel: 01228 608200Website: www.chocltd.co.uk

Date of inspection visit: 30 November 2016Date of publication: 13/04/2017

1 Hilltop Heights Quality Report 13/04/2017

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

What people who use the service say 8

Outstanding practice 8

Detailed findings from this inspectionOur inspection team 9

Background to Hilltop Heights 9

Why we carried out this inspection 9

How we carried out this inspection 9

Detailed findings 11

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Hilltop Heights (Cumbria Health on Call) on 30thNovember, 2016. Overall the service is rated asoutstanding.

Our key findings across all the areas we inspected were asfollows:

• There was an open and transparent approach to safetyand an effective system in place for recording,reporting and learning from significant events.

• Risks to patients were assessed and well managed.• Patients’ care needs were assessed and delivered in a

timely way according to need. The service met theNational Quality Requirements.

• Staff assessed patients’ needs and delivered care inline with current evidence based guidance. Staff hadbeen trained to provide them with the skills,knowledge and experience to deliver effective careand treatment.

• There was a system in place that enabled staff accessto patient records, and the out of hours staff providedother services, for example the local GP and hospital,with information following contact with patients aswas appropriate.

• The service managed patients’ care and treatment in atimely way.

• Information about services and how to complain wasavailable and easy to understand.

• Improvements were made to the quality of care as aresult of complaints and concerns.

• The service had good facilities and was well equippedto treat patients and meet their needs. The vehiclesused for home visits were clean and well equipped.

• There was a clear leadership structure and staff feltsupported by management. The service proactivelysought feedback from staff and patients, which it actedon.

• The provider was aware of and complied with therequirements of the duty of candour.

We saw some areas of outstanding service:

• The provider was highly responsive to the the needs ofthe predominantly rural population. For example, apilot for telehealth appointments had recently been

Summary of findings


completed. This had reduced the average time forpatients in rural areas to be seen for either a routinebase or home visit from 146 minutes to 32 minutes.They worked closely with other service providers, suchas North West Ambulance Service (NWAS), for whomthey provided GP-triage. NWAS told us the most recentdata showed that in 93% of cases when this servicewas used, a hospital admission was avoided for thepatient.

• The leadership, management and governance assuredthe delivery of high quality care, and supportedlearning and innovation throughout the organisation.

Leaders had an inspiring shared purpose andmotivated staff to succeed. Staff we spoke to told usthe executive team were highly approachable, andthat this had a positive effect on staff morale.

• Governance and strategy were proactive andinnovative. The provider had been proactive inaddressing the specific recruitment difficulties facedby the service in this geographical area. As a result of acollaborative recruitment drive six new salaried GPshad been employed. This in turn improved capacity tomeet demand and safety, as reliance on agency staffwas sometimes as low as 5% of shifts per week.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The service is rated as good for being safe.

• The service used every opportunity to learn from internal andexternal incidents, to support improvement. Learning wasbased on a thorough analysis and investigation.

• Information about safety was highly valued and was used topromote learning and improvement.

• Staff understood and fulfilled their responsibilities to raiseconcerns and report incidents and near misses.

• When things went wrong patients were informed in keepingwith the Duty of Candour. They were given an explanationbased on facts, an apology if appropriate and, whereverpossible, a summary of learning from the event in the preferredmethod of communication by the patient. They were toldabout any actions to improve processes to prevent the samething happening again.

• The out-of-hours service had clearly defined and embeddedsystem and processes in place to keep patients safe andsafeguarded from abuse.

• When patients could not be contacted at the time of their homevisit or if they did not attend for their appointment, there wereprocesses in place to follow up patients who were potentiallyvulnerable.

• There were systems in place to support staff undertaking homevisits. Staff had access to a range of communication equipmentto ensure they could contact each other.

• Staff were aware of their responsibilities regarding informationsharing, documentation of safeguarding concerns and how tocontact relevant agencies in normal working hours and out ofhours.

• Risks to patients were assessed and well managed.

Good –––

Are services effective?The service is rated as good for being effective.

• Our findings at inspection showed that systems were in place toensure that all clinicians were up to date with both NationalInstitute for Health and Care Excellence (NICE) guidelines andother locally agreed guidelines.

• We also saw evidence to confirm that the service used theseguidelines to positively influence and improve the service andoutcomes for patients.

Good –––

Summary of findings


• Clinical audits demonstrated quality improvement.• CHoC was a member of Urgent Health UK (UHUK), which

provided external audit of the service, and benchmarkedperformance against 23 other out of hours care providers inEngland. At the two most recent audits in 2015 and 2016, CHoCwas given a rating of “highly commendable”, which is thehighest of five ratings available. Only four providers currentlyhave this rating.

• Staff had the skills, knowledge and experience to delivereffective care and treatment.

• There was evidence of appraisals and personal developmentplans for all staff.

• Staff worked with other health care professionals to understandand meet the range and complexity of patients’ needs.

Are services caring?The service is rated as good for being caring.

• We observed a strong patient-centred culture.• CHoC commissioned Healthwatch Cumbria to carry out a

survey into patient satisfaction between September 2016 andNovember 2016. From 1,676 respondents they found that 91%of patients were either very satisfied or satisfied with theiroverall experience.

• CHoC ranked ninth highest out of all of the 211 clinicalcommissioning group (CCG) areas in England for patientsatisfaction with their overall experience of the service in 2014.

• Views of external stakeholders were very positive.• Feedback from the large majority of patients through our

comment cards and questionnaires, and collected by theprovider was very positive.

• Information for patients about the services available was easyto understand and accessible.

• We saw staff treated patients with kindness and respect, andmaintained patient and information confidentiality.

• There were systems in place to ensure that patients were keptinformed with regard to their care and treatment throughouttheir visit to the out-of-hours service.

Good –––

Are services responsive to people’s needs?The service is rated as outstanding for being responsive.

• Services were tailored to meet the needs of the localpopulation, and the involvement of other organisations and thelocal community was integral to how services were planned.

Outstanding –

Summary of findings


• A number of services were in place to meet the needs of thepredominantly rural population. For example, a pilot fortelehealth appointments had reduced the average time forpatients in rural areas to be seen for either a routine base orhome visit from 146 minutes to 32 minutes. This pilot was nowbeing rolled out to other areas.

• The provider offered GP-led triage for paramedics, to allowthem to receive advice from CHoC GPs if they were unsurewhether or not to admit a patient to hospital. During thein-hours period, the CHoC control room also acted as a singlepoint of access for paramedics to contact GPs. Hospitaladmission had been avoided in 93% of cases whereparamedics had used this service, reducing unnecessaryhospital stays for patients.

• In 2014, CHoC ranked second highest across all of the 211clinical commissioning group (CCG) areas in England for thenumber of patients who responded that they knew how tocontact the out of hours service.

• The service had good facilities and was well equipped to treatpatients and meet their needs.

• The service had systems in place to ensure patients receivedcare and treatment in a timely way and according to theurgency of need.

• Information about how to complain was available and easy tounderstand and evidence showed the service respondedquickly to issues raised. Learning from complaints was sharedwith staff and other stakeholders. Complaints were investigatedby the member of the executive and/or management team whowas deemed most appropriate for the case, such as themedical director, senior clinical nurse lead, or the chiefexecutive.

Are services well-led?The service is rated as outstanding for being well-led.

• The service had a clear vision with quality and safety as its toppriority.

• High standards were promoted and owned by all service staffand teams worked together across all roles.

• Leaders had an inspiring shared purpose, strove to deliver andmotivated staff to succeed. For example, staff told us that themedical director was involved in supporting staff and offeringlearning opportunities, and would suggest cases for nursepractitioners to treat, under their supervision, to increase theirknowledge base.

Outstanding –

Summary of findings


• There was a high level of constructive engagement with staffand a high level of staff satisfaction. In response to a staffsurvey, the provider was actively pursuing ways to improve staffwell-being and encourage staff retention. For example, a salarysacrifice scheme which was set up with a medical indemnityprovider in an attempt to reduce the cost to clinicians of payingfor cover.

• In response to difficulties recruiting GPs to out of hoursservices, the provider had become a Tier 2 sponsor, whichallowed them to recruit medical staff who had trained in the UKbut who required a visa to work here. The provider believedthey were the only out of hours service in England to havebecome a Tier 2 sponsor.

• The provider was aware of and complied with the requirementsof the duty of candour, encouraging a culture of openness andhonesty. The service had systems in place for notifiable safetyincidents and ensured this information was shared with staff toensure appropriate action was taken

• The provider used innovative approaches to gather feedbackfrom people who used services and the public. They hadcommissioned Healthwatch Cumbria to conduct a surveywhich gathered the views of 1,676 patients. They also used thewebsite I Want Great Care (www.iwantgreatcare.org) to gatherfeedback from patients.

• The leadership drove continuous improvement and staff wereaccountable for delivering change. Safe innovation wascelebrated. There was a clear and proactive approach toseeking out and embedding new ways of providing care andtreatment, and we saw multiple examples of this during theinspection, such as the telehealth pilot, the pharmacy triagepilot, and working with the ambulance service to reducedemand.

Summary of findings


What people who use the service sayWe looked at various sources of feedback received frompatients about the out-of-hours service they received.The National GP Patient Survey asks patients about theirsatisfaction with the out-of-hours service. Data from theGP national patient survey published in July 2016 found:

• 71% of patients felt they had received care quicklyfrom the service, compared to the national average of62%

• 76% of patients felt their overall experience of theservice was good, compared to the national average of70%

• 91% of patients said they had confidence and trust inthe people seen or spoken to, compared to thenational average of 90%

An analysis of National GP Patient Survey data from 2014showed that Cumbria Health on Call (CHoC) ranked in thetop ten of all out of hours providers in England for patientsatisfaction for each of the five questions asked. Forexample, 69% of patients responded that they knew howto contact the out of hours service. This was the secondhighest number across all of the 211 clinicalcommissioning group (CCG) areas in England. CHoC wasalso rated highest for patient satisfaction with out ofhours provision across the eight CCGs which form part oftheir local area team.

CHoC commissioned Healthwatch Cumbria to carry out asurvey into patient satisfaction between September 2016and November 2016. From 1,676 respondents they foundthat:

• 91% of patients were either very satisfied or satisfiedwith their overall experience of CHoC

• 88% of patients at base visits, and 83% of patients athome visits, thought the wait was as expected orshorter.

• 94% of patients at base visits, and 93% of patients athome visits, felt reassured by the doctor or nurse theywere seen by.

• 92% of patients felt involved in decisions made abouttheir treatment.

CHoC used the website I Want Great Care(www.iwantgreatcare.org) to gather feedback frompatients. At the time of inspection, of the six sites wherepatients were seen, four had overall ratings of five stars(out of five) and two had overall ratings of 4.5 stars from atotal of 744 reviews.

We also gathered patient feedback at the seven sites wevisited during our inspection of CHoC. We spoke to 21patients in total, all of whom were satisfied with theservice provided.

Outstanding practice• The provider was highly responsive to the the needs of

the predominantly rural population. For example, apilot for telehealth appointments had recently beencompleted. This had reduced the average time forpatients in rural areas to be seen for either a routinebase or home visit from 146 minutes to 32 minutes.They worked closely with other service providers, suchas North West Ambulance Service (NWAS), for whomthey provided GP-triage. NWAS told us the most recentdata showed that in 93% of cases when this servicewas used, a hospital admission was avoided for thepatient.

• The leadership, management and governance assuredthe delivery of high quality care, and supported

learning and innovation throughout the organisation.Leaders had an inspiring shared purpose andmotivated staff to succeed. Staff we spoke to told usthe executive team were highly approachable, andthat this had a positive effect on staff morale.

• Governance and strategy were proactive andinnovative. The provider had been proactive inaddressing the specific recruitment difficulties facedby the service in this geographical area. As a result of acollaborative recruitment drive six new salaried GPshad been employed. This in turn improved capacity tomeet demand and safety, as reliance on agency staffwas sometimes as low as 5% of shifts per week.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC LeadInspector.The team included a second CQC Inspector, aGP specialist advisor and a Practice Nurse specialistadvisor.

Background to Hilltop HeightsHilltop Heights Cumbria Health on Call (CHoC) provides outof hours GP services from:

• Hilltop Heights, London Road, Carlisle, Cumbria, CA12NS.

We visited this site during our inspection. These premisesare operated and managed by CHoC and consisted of theservice’s call centre and head offices.The service operates24 hours a day, seven days a wekk. The service givestelephone advice and books appointments and home visitsfor patients. The service employs GPs, nurse practitionersand nurses.

Hilltop Heights is one of seven locations registered by CHoCto provide out of hours services in Cumbria. On average,2653 patients use the service each week across the sixlocations where patients are seen. CHoC provides care,treatment and support from Monday to Friday from 18:30to 08:00, and on Saturday and Sunday from 08:00 to 08:00for some 499,000 people over a land mass of 2,613 squaremiles. Cumbria is the second largest county in England andrepresents 48% of the land mass of the North West. AcrossCumbria 51% of the population live in rural areas. There are73 people per square kilometre on average.

In terms of patient population, there are above averagenumbers for all age groups over 50 and below average for

all groups below 45. Average life expectancy for both malesand females is close to the national average (males 78.6years, females 82.2, compared to the national average of78.9 and 82.8 respectively) however this does not reflect thelarge variation within Cumbria itself, where the lifeexpectancy in the most deprived areas for men is 13 yearslower, and for women eight years lower, than people in theleast deprived areas. 56.3% of the population reportshaving a long-standing health condition (national average54%). In terms of ethnicity, the population is 98.5% white(national average 85.4%) with the lowest percentages ofany CCG area in England of patients from black/blackBritish, mixed, or other ethnic groups (0.1%, 0.5% and 0.1%respectively).

We previously inspected Hilltop Heights CHoC in July 2013.We were not rating services at that time, however we foundCHOC to be compliant with all regulations.

Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. The inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

HilltHilltopop HeightsHeightsDetailed findings


How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the service and asked other organisations to sharewhat they knew. We carried out an announced visit on 30November.

During our visit we:

• Spoke with a range of staff including a GP, advancednurse practitioner, nurse practitioner, reception, driversand team leaders.

• Inspected the out of hours premises, looked atcleanliness and the arrangements in place to managethe risks associated with healthcare related infections.

• Looked at the vehicles used to take clinicians toconsultations in patients’ homes, and we reviewed thearrangements for the safe storage and management ofmedicines and emergency medical equipment.

• Reviewed comment cards where patients and membersof the public shared their views and experiences of theservice.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Please note that when referring to information throughoutthis report, for example any reference to the NationalQuality Requirements data, this relates to the most recentinformation available to the CQC at that time.

Detailed findings


Our findingsSafe track record and learning

People were protected by a strong comprehensive safetysystem, and a focus on openness, transparency andlearning when things went wrong.

• Staff told us they would inform the service manager ofany incidents and there was a recording form availableon the service’s computer system. The incidentrecording form supported the recording of notifiableincidents under the duty of candour. (The duty ofcandour is a set of specific legal requirements thatproviders of services must follow when things go wrongwith care and treatment). We saw evidence that whenthings went wrong with care and treatment, patientswere informed of the incident, received support, anexplanation based on facts, an apology whereappropriate and were told about any actions to improveprocesses to prevent the same thing happening again.Often this was done by the chief executive, or anothermember of the executive team.

• The service carried out a thorough analysis of thesignificant events and ensured that learning from themwas disseminated to staff and embedded in policy andprocesses. This was done directly with staff involved viatelephone calls, meetings or emails, and more broadlythough team manager meetings and organisationalnewsletters.

We reviewed safety records, incident reports, patient safetyalerts and minutes of meetings where these werediscussed. We saw evidence that lessons were shared andaction was taken to improve safety in the service. Forexample, following a road traffic incident it was identifiedthat one or two items of equipment moved around in thecars. Processes were put in place to ensure all cars werepacked in a standard way and all equipment was secured.

Overview of safety systems and processes

The service had clearly defined and embedded systems,processes and services in place to keep patients safe andsafeguarded from abuse, which included:

• Arrangements were in place to safeguard children andvulnerable adults from abuse. These arrangementsreflected relevant legislation and local requirements.Policies were accessible to all staff. The policies clearly

outlined who to contact for further guidance if staff hadconcerns about a patient’s welfare. There was a leadmember of staff for safeguarding. Staff demonstratedthey understood their responsibilities and all hadreceived training on safeguarding children andvulnerable adults relevant to their role. GPs were trainedto child safeguarding level three. The whole team wasengaged in reviewing and improving safety andsafeguarding systems. The service’s computer systemensured that all cases where safeguarding concernswere suspected would be reviewed by a lead member ofstaff for safeguarding. After each patient contact, thepatient record could not be completed without asafeguarding question being answered, to ensure thiswas at the forefront of clinicians’ minds.

• All staff who acted as chaperones had received aDisclosure and Barring Service (DBS) check. (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). Training had recently beenrolled out to staff and a new chaperone policy had beenput in place to ensure staff fully understood their role.

• The service maintained appropriate standards ofcleanliness and hygiene. We observed the premises tobe clean and tidy. The service shared the accident andemergency premises at the hospital. All cleaning andinfection control arrangements were carried out by theNorth Cumbria University Hospitals NHS Trust. Theprovider had systems in place to ensure appropriatestandards were maintained and to regularly review thearrangements with the trust.

• There was a system in place to ensure equipment wasmaintained to an appropriate standard and in line withmanufacturers’ guidance.

• We reviewed four personnel files and found appropriaterecruitment checks had been undertaken prior toemployment. For example, proof of identification,references, qualifications, registration with theappropriate professional body, appropriate indemnityand the appropriate checks through the Disclosure andBarring Service. The provider employed an officemanager who put in place systems to check that all newemployed and sessional staff had the relevantdocuments and training in place.

Medicines Management

Are services safe?

Good –––


• The arrangements for managing medicines at theservice, including emergency medicines and vaccines,kept patients safe (including obtaining, prescribing,recording, handling, storing, security and disposal). Theservice carried out regular medicines audits, with thesupport of the local CCG medicines management team,to ensure prescribing was in accordance with bestpractice guidelines for safe prescribing. Blankprescription forms and pads were securely stored andthere were systems in place to monitor their use.

• The service held stocks of controlled drugs (medicinesthat require extra checks and special storage because oftheir potential misuse) and had standard operatingprocedures in place that set out how controlled drugswere managed in accordance with the law and NHSEngland regulations. These included auditing andmonitoring arrangements, and mechanisms forreporting and investigating discrepancies. The providerheld a Home Office licence to permit the possession ofcontrolled drugs within the service. There were alsoappropriate arrangements in place for the destruction ofcontrolled drugs.

• Processes were in place for checking medicines,including those held at the service and also medicinesbags for the out of hours vehicles.

• Arrangements were in place to ensure medicines andmedical gas cylinders carried in the out of hoursvehicles were stored appropriately. Medicines were notstored in the cars unless they were in use.

Monitoring risks to patients

Risks to patients were assessed and well managed.

• There were procedures in place for monitoring andmanaging risks to patient and staff safety. There was ahealth and safety policy available. The service had up todate fire risk assessments and carried out regular firedrills. All electrical equipment was checked to ensurethe equipment was safe to use and clinical equipmentwas checked to ensure it was working properly. Clinicalequipment that required calibration was calibratedaccording to the manufacturer’s guidance.

• There were systems in place to ensure the safety of theout of hours vehicles. Checks were undertaken at thebeginning of each shift. These checks included theequipment on board, the lights and indicators of thevehicle and the communication systems within it. Thedriver told us the vehicles were fitted with tyre sensors

to alert if there was a problem with tyre pressure andthere was an agreement with a local tyre firm for swiftreplacement. All of the vehicles used were ‘all wheeldrive’ to cope with the rural area. Records were kept ofMOT and servicing requirements. We checked two of thevehicles with the drivers and found they complied withtheir safety tests. The vehicles were fitted with GPS sothat their speed and location could be tracked. Thisimproved safety for drivers and clinicians, as the controlroom always knew where the cars were located.

• Arrangements were in place for planning andmonitoring the number of staff and mix of staff neededto meet patients’ needs. There was a rota system inplace for all the different staffing groups to ensureenough staff were on duty. The inspection team sawevidence that the rota system was effective in ensuringthat there were enough staff on duty to meet expecteddemand. The provider had become a Tier 2 sponsor,which meant they were allowed to recruit from a widerpool of medical staff by being eligible to employ doctorswho trained in the UK but who needed a visa in order togain employment. In 2016, this meant the provider wasable to employ six new salaried GPs, doubling thenumber of salaried GPs employed by the provider,which in turn reduced their reliance on agency staff. Theprovider set a limit of 15% of shifts per week beingcarried out by agency doctors. We saw evidence that notonly did the provider mostly remain within this limit, butthat on occasion the number of agency doctors used ina week was as low as 5%. The provider employed nursepractitioners, and did not use agency nursing staff. Theprovider believed they were the only out of hoursservice in England to have become a Tier 2 sponsor.

Arrangements to deal with emergencies and majorincidents

The service had adequate arrangements in place torespond to emergencies and major incidents.

• There was an effective system to alert staff to anyemergency.

• All staff received annual basic life support training,including use of an automated external defibrillator.

• The service had a defibrillator available on the premisesand oxygen with adult and children’s masks.

• Emergency medicines were easily accessible and allstaff knew of their location. All the medicines wechecked were in date and stored securely.

Are services safe?

Good –––


• The service had a comprehensive business continuityplan in place for major incidents such as power failureor building damage. The plan included emergencycontact numbers for staff. This plan had proved effectiveduring the severe flooding suffered in Cumbria in

December 2015. The service was able to continueoperating, and to support other services in the area. Wesaw that the plan had been reviewed thoroughlyfollowing this event to look for further improvements.

Are services safe?

Good –––


Our findingsEffective needs assessment

The service assessed needs and delivered care in line withrelevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) best service guidelines.

• The service had systems in place to keep all clinical staffup to date. Staff had access to guidelines from NICE andused this information to deliver care and treatment thatmet patients’ needs.

• The service monitored that these guidelines werefollowed.

Management, monitoring and improving outcomes forpeople

From 1 January 2005, all providers of out-of-hours serviceswere required to comply with the National QualityRequirements (NQR) for out-of-hours providers. The NQRare used to show the service is safe, clinically effective andresponsive. Providers are required to report monthly to theclinical commissioning group on their performance againststandards which includes audits, response times to phonecalls, whether telephone and face to face assessmentshappened within the required timescales, seeking patientfeedback and actions taken to improve quality.

We saw that the most recent results (July-September 2016)which showed the provider was meeting theserequirements overall. There were two areas where theprovider was outside of the target range for part of thatrequirement. However, they were aware of these and wesaw evidence that attempts were being made to addressthese:

• NQR 8: Initial telephone calls.

On the initial telephone call to the service, no more than0.1% of calls should be engaged, and no more than 5%calls abandoned - Pass.

In terms of time taken for the call to be answered by aperson, all calls must be answered within 60 seconds of theend of the introductory message which should normally beno more than 30 seconds long. Where there is nointroductory message, all calls must be answered within 30seconds – 92% of all calls in this period (target 95%).

We saw that this figure was improving month on month,and could also be explained by the number of peopleincorrectly contacting the service using a phone line otherthan 111. This number was being given to some patients inerror, and the provider was carrying out work at the time ofinspection to reduce the number of people who used thenumber.

• NQR 12: Face-to-face consultations (whether in a centreor in the patient’s place of residence) must be startedwithin the following timescales, after the definitiveclinical assessment has been completed:

Emergency: Within 1 hour – Over the course of 2016 theprovider had achieved 89% (target 95%) of baseappointments within one hour, and 82% (target 95%) ofhome visits.

Urgent: Within 2 hours - Over the course of 2016 theprovider had achieved 95% (target 95%) of baseappointments, and 91% (target 95%) of home visits.

Less urgent: Within 6 hours - Over the course of 2016 theprovider had achieved 100% (target 95%) of baseappointments, and 99% (target 95%) of home visits.

We looked at performance against the one-hour target andfound that it was a relatively small sample of patients eachmonth who required these appointments (compared tothose making up the other targets). This meant thatmissing the one-hour deadline on only one or twooccasions each month had a greater impact on thepercentages recorded against this target. For example, inFebruary 2016, 21 patients were triaged as requiring aone-hour appointment; three of these were missed,meaning the provider achieved 85% against this target. InApril 2016, 22 patients were triaged for one-hourappointments and one missed the target. This difference oftwo patients increased performance to 95% and put themjust within target for that month. In some months, due tothe low numbers, the provider would have to see everypatient within the timeframe to avoid dropping below thetarget set.

Over the course of 2016, 380 patients were offered aone-hour home appointment, of which 67 missed thetarget. We looked at a sample of 12 of these misses, andfound that on average the target was missed by 18 minutes(nearest miss was five minutes, longest was 41 minutes).

Are services effective?(for example, treatment is effective)

Good –––


The provider told us that the geography of the area hadimpacted on their ability to meet the one-hour target. Aswell as being predominately rural, the mountains and lakesmeant that journeys between destinations often tooklonger by road than they might in other parts of thecountry. They felt that tourism in the Lake District in thesummer months had an impact, and we saw thatperformance dipped for the months of July and August. Wealso saw from the data that the areas where the target wasbeing missed most often coincided with the most rural andmountainous parts of the county. This had impacted on theprovider’s ability to meet the target for base appointmentsalso, as we saw evidence that base visits within theone-hour timeframe had been offered but declined bypatients who felt they were unable to make the journey tothe base within that time. We saw minutes of meetings withthe local clinical commissioning group (CCG), whoacknowledged the difficulty of meeting these targets inCumbria. The CCG told us that they asked CHoC to reporton the one-hour target, but did not performance managethem against it due to the geographical challenges and theimpact that the small number of patients had on theoverall target.

The provider had been pro-active in attempting to improveon performance against these targets by increasing staffing,which they had done by employing six additional salariedGPs who were now in post. They had made changes to staffrotas to meet demand. They had also recentlyimplemented improved technology which helped them tomonitor demand in real time. This meant work could beshared more effectively between clinicians. We sawexamples of this during the inspection, when one servicewas able to triage calls for another area which wasexperiencing increased demand. They had also invested insystems which allowed them to correlate the times enteredby clinicians with the arrival time recorded by the vehicles’satellite navigation systems, to ensure that figures obtainedwere accurate.

There was evidence of quality improvement includingclinical audit.

• Since 2011, CHoC had been a member of Urgent HealthUK (UHUK), which provided external audit of the service,and benchmarked performance against 23 other out ofhours care providers in England. At the two most recent

audits in 2015 and 2016, CHoC was given a rating of“highly commendable”, which is the highest of fiveratings available. Only four providers currently have thisrating.

• The performance of each clinician was audited monthly,and results were displayed in a clinician dashboardonline tool. The medical and nursing staff reviewedthese dashboards with the medical director/clinicalnursing lead and used them to aid their learning.

• We looked at a sample of seven clinical auditscompleted in the last two years and found these had ledto improvements. For example, audits into abdominalpain and headaches in OOH patients had led toadditional training for clinicians to improve diagnosisand treatment. Also, an audit of antibiotic prescribinghad led to an overall reduction in prescribing thesemedications, including a 29% reduction in a type ofantibiotic commonly associated with causing vomitingand diarrhoea.

• GPs who worked for the service and completed clinicalaudits at their usual practices as part of theirrevalidation could, where relevant, share these withother clinicians at the quarterly CHoC clinical meetings.

• Findings were used by the service to improve services.For example, recent action taken as a result includedimproving the systems for checking stocks ofmedication to ensure that it was within its use-by date.

Effective staffing

Staff had the skills, knowledge and experience to delivereffective care and treatment.

• The service had an induction programme for all newlyappointed staff. This covered such topics assafeguarding, infection prevention and control, firesafety, health and safety and confidentiality. New staffwere also supported to work alongside other staff andtheir performance was regularly reviewed during theirinduction period. GP registrars who trained at practicesin Cumbria and did shifts with CHoC as part of thattraining received five days additional training from theprovider which was specific to out of hours care. Theseregistrars also had a trainer present with them duringshifts to support them.

• Training was provided in conjunction with relevantexternal services. For example, the provider worked withthe North West Ambulance Service to offer training tostaff around patient triaging.


Good –––


• The service could demonstrate how they ensuredrole-specific training and updating for relevant staff.Nurses told us they felt very supported, had enoughtraining opportunities to maintain and progress theirskills and were supported in reflective practice. Staff toldus that the medical director was involved in supportingstaff and offering learning opportunities. We were toldby several members of the nursing staff that the medicaldirector often worked shifts on the out of hours serviceand would suggest cases for nurse practitioners to treat,under their supervision, to increase their knowledgebase.

• The learning needs of staff were identified through asystem of appraisals, meetings and reviews of servicedevelopment needs. Staff had access to appropriatetraining to meet their learning needs and to cover thescope of their work. This included ongoing support,one-to-one meetings, coaching and mentoring, andclinical supervision. All staff had received a recentappraisal or had one booked to be completed within thenext few weeks.

• Staff received training that included: safeguarding, firesafety awareness, basic life support and informationgovernance. Staff had access to and made use ofe-learning training modules and in-house training. Theprovider also had plans to open their own trainingacademy for their staff and external agencies. We sawwork on the academy taking place during theinspection.

• Staff involved in handling medicines received trainingappropriate to their role.

Coordinating patient care and information sharing

The information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the service’s patient record systemand their intranet system.

• This included access to as required ‘specialnotes’/summary care records, which detailedinformation provided by the person’s GP. This helpedthe out of hours staff in understanding a person’s need.

• The service shared relevant information with otherservices in a timely way, for example when referringpatients to other services.

• The provider worked collaboratively with other services.Patients who could be more appropriately seen orfollowed up by their registered GP or an emergencydepartment were referred on.

• The service worked closely with staff in the hospital A&Edepartment. Across the whole service, CHoC hadreceived 3099 referrals from A&E in the past year, helpingto lower the demand on emergency care.

• A clinical co-ordinator was based at the providerheadquarters. This person had full access to thecomputer system used by the GP practices in thecounty, and therefore could access full patient records. Ifclinicians needed to check patient records, they couldcontact the clinical co-ordinator, who could pass theinformation securely to the clinician.

• There was a direct telephone line which patients whohad a special note on their records (such as patients atthe end of life) could call to contact the service withoutthe need to contact NHS 111.

• The provider offered GP-led triage for paramedics duringthe out-of-hours period, as well as being a single pointof contact for paramedics to contact the patient’s ownGP in-hours. This service allowed paramedics to receiveadvice from a GP if they were unsure whether or not toadmit a patient to hospital. The most recent resultsprovided by NWAS showed that in 93% of cases whereparamedics had used this service, patients had not beenadmitted. This resulted in a reduction of unnecessaryadmissions to hospital for patients, and reduced strainon secondary care services in the area. We were told byNWAS that the average rate of admission avoidanceproduced by all providers across the region wasapproximately 87%. The use of the service hadincreased significantly since its introduction in February2014, from 81 cases per month to 705 cases in January2017.

The service worked with other service providers to meetpatients’ needs and manage patients with complex needs.They sent out-of-hours notes to the registered GP serviceselectronically by 8am the next morning.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in linewith legislation and guidance.

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005.


Good –––


• When providing care and treatment for children andyoung people, staff carried out assessments of capacityto consent in line with relevant guidance.

• Where a patient’s mental capacity to consent to care ortreatment was unclear clinical staff assessed thepatient’s capacity and, recorded the outcome of theassessment.


Good –––


Our findingsKindness, dignity, respect and compassion

We observed members of staff were courteous and veryhelpful to patients and treated them with dignity andrespect.

• Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments.

• We noted that consultation and treatment room doorswere closed during consultations; conversations takingplace in these rooms could not be overheard.

• Reception staff knew when patients wanted to discusssensitive issues or appeared distressed they could offerthem a private room to discuss their needs.

CHoC commissioned Healthwatch Cumbria to carry out asurvey into patient satisfaction between September 2016and November 2016. This was in response to difficulties inobtaining feedback from a broad population. From 1,676respondents they found that:

• 91% of patients were either very satisfied or satisfiedwith their overall experience of CHoC

• 94% of patients at base visits, and 93% of patients athome visits, felt reassured by the doctor or nurse theywere seen by.

• 93% of patients were very satisfied or satisfied with thewelcome received upon attending for an appointmentat a base site.

The National GP Patient Survey asks patients about theirsatisfaction with the out-of-hours service. An analysis ofNational GP Patient Survey data from 2014 by NHS Englandshowed that Cumbria Health on Call (CHoC) ranked in thetop ten of all out of hours providers in England for patientsatisfaction for each of the five questions asked. Forexample:

The study found that CHoC ranked ninth highest out of allof the 211 clinical commissioning group (CCG) areas inEngland for patient satisfaction with their overallexperience of the service.

CHoC was also rated highest for patient satisfaction without of hours provision across the eight CCGs which formpart of the local area team.

Data from the most recent National GP Patient Survey,published in July 2016, showed the service continued toperform above national averages. For example:

• 76% of patients felt their overall experience of theservice was good, compared to the national average of70%

• 91% of patients said they had confidence and trust inthe people seen or spoken to, compared to the nationalaverage of 90%

CHoC used the website I Want Great Care(www.iwantgreatcare.org) to gather feedback frompatients. At the time of inspection, of the six sites wherepatients were seen, four had overall ratings of five stars (outof five) and two had overall ratings of 4.5 stars from a totalof 744 reviews.

Commonly used words by patients in the reviews included‘excellent’, ‘kind’, ‘caring’, ‘reassuring’ and ‘brilliant care’.

We gathered patient feedback at the seven sites we visitedduring our inspection of CHoC. We spoke to 21 patients intotal, all of whom were happy with the service provided.

Care planning and involvement in decisions aboutcare and treatment

Patients told us through their comment cards they feltinvolved in decision making about the care and treatmentthey received. They also told us they felt listened to andsupported by staff and had sufficient time duringconsultations to make an informed decision about thechoice of treatment available to them.

The service provided facilities to help patients be involvedin decisions about their care:

• Staff told us that translation services were available forpatients who did not have English as a first language.This was accessed by staff contacting the headquartersof the service.

• Information leaflets were available in easy read format.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

Services were tailored to meet the needs of the localpopulation, and the involvement of other organisationsand the local community was integral to how services wereplanned. The provider engaged with commissioners tosecure improvements to services where these wereidentified.

• A number of services were in place to meet the needs ofthe predominantly rural population. For example,telehealth appointments had recently been introducedfollowing a successful pilot of the service, meaningpatients could have video consultations with cliniciansat other sites from a venue closer to their home. Thishad reduced the distance patients needed to travel forappointments, giving the patients additional choice inwhere they could be seen. Previously, the average timefor patients in rural areas to be seen for either a routinebase or home visit was 146 minutes. During thetelehealth pilot, patients could be seen by a doctor in anaverage of 32 minutes. This service was offered incollaboration with a local NHS trust.

• The provider offered GP-led triage for paramedics duringthe out-of-hours period, as well as being a single pointof contact for paramedics to contact the patient’s ownGP in-hours. This service allowed paramedics to receiveadvice from a GP if they were unsure whether or not toadmit a patient to hospital. The most recent resultsprovided by the North West Ambulance Service (NWAS)showed that in 93% of cases where paramedics hadused this service, patients had not been admitted. Thisresulted in a reduction of unnecessary admissions tohospital for patients, and reduced strain on secondarycare services in the area. We were told by NWAS that useof the CHoC service by paramedics had increased from81 cases in February 2014 to 705 cases in January 2017,and that the average rate of admission avoidanceproduced by all providers across the region wasapproximately 87%.

• Clinicians at the service provided physical care topatients staying in community mental health wardsovernight.

• All of the vehicles used were ‘all wheel drive’ to copewith the rural area. They were also fitted with GPS so

that their speed and location could be tracked. Thisimproved safety for drivers and clinicians, as the controlroom always knew where the cars were located. Thiscould also be used to manage demand when required.

• During the widespread flooding in Cumbria duringDecember 2015, CHoC worked closely with other localservices, such as the mountain rescue service, to ensurepatients could still be reached by clinicians. The firebrigade helped to take doctors by boat to parts of thecounty which were cut off by water.

• In response to a high volume of calls to the service frompatients with queries about their medication, theprovider had started a pilot scheme of having clinicalpharmacists on hand to answer calls. This freed up timefor doctors on shift to continue seeing patients. As thepilot had only recently begun, there were no resultsavailable at the time of inspection.

• To tackle high demand, the provider had recentlyimplemented improved technology which helped themto monitor demand in real time. This meant work couldbe shared more effectively between clinicians, reducingwaiting times for patients. We saw examples of thisduring the inspection, when one service was able totriage calls for another area which was experiencingincreased demand.

• There was a direct telephone line which patients whohad a special note on their records (such as patients atthe end of life) could call to contact the service withoutthe need to contact NHS 111.

• Home visits were available for patients whose clinicalneeds which resulted in difficulty attending the service.

• There were accessible facilities, a hearing loop andtranslation services available.

• Staff confirmed that the service did not discriminateregarding patients age, disability, gender, genderreassignment, pregnancy and maternity status, race,religion or belief. The facilities were suitable to meet theneeds of patients with impaired physical ability.

Access to the service

On average, 2653 patients use the service each week acrossthe six locations where patients are seen, and it operatedfrom Monday to Friday from 18:30 to 08:00, and onSaturday and Sunday from 08:00 to 08:00. The call centreoperated 24 hours a day, seven days a week.

Patients could access the service via NHS 111. The servicedid not see ‘walk in’ patients and those that came in were

Are services responsive to people’s needs?(for example, to feedback?)

Outstanding –


told to ring NHS 111 unless they needed urgent care inwhich case they would be stabilised before referring on.There was a ‘walk in’ policy which clearly outlined whatstaff should do when patients arrived without having firstmade an appointment, and made patient safety thepriority. Staff were aware of the policy and understood theirrole. There were arrangements in place for people at theend of their life so they could contact the service directly,without the need to call NHS 111 first.

Feedback received from patients from the CQC commentcards and from the National Quality Requirements scoresindicated that in most cases patients were seen in a timelyway.

Data from the National GP Patient Survey published in July2016 showed the service was performing above nationalaverages. For example:

• 71% of patients felt they had received care quickly fromthe service, compared to the national average of 62%

An analysis of National GP Patient Survey data from 2014showed that Cumbria Health on Call (CHoC) ranked in thetop ten of all out of hours providers in England for patientsatisfaction for each of the five questions asked. Forexample, 69% of patients responded that they knew how tocontact the out of hours service. This was the secondhighest number across all of the 211 clinicalcommissioning group (CCG) areas in England.

A patient satisfaction study commissioned by CHoC andcompleted by Healthwatch found that patients were happywith access to the service. From 1,676 responses betweenSeptember 2016 and November 2016 they found that:

• 88% of patients at base visits, and 83% of patients athome visits, thought the wait for appointments was asexpected or shorter.

The service had a system in place to assess:

• whether a home visit was clinically necessary; and

• the urgency of the need for medical attention.

This was done by telephoning the patient or carer inadvance to gather information to allow for an informeddecision to be made on prioritisation according to clinicalneed.

Listening and learning from concerns and complaints

There was an active review of complaints and concerns, aswell as how these are managed and responded to. Peoplewho used services were involved in the review of theircomplaint.

• The complaints policy and procedures were in line withthe NHS England guidance and their contractualobligations.

• There was a designated responsible person whoco-ordinated the handling of all complaints in theservice.

• We saw that information was available to help patientsunderstand the complaints system.

We looked at a range of complaints received in the last 12months and found these were dealt with in a timely way.There was openness and transparency when dealing withthe complaint, for example patients were contacted by themember of the executive team investigating the complaintto discuss the outcome. Both formal and informalcomplaints were logged and reviewed every two weeks bythe medical director, senior clinical nurse lead and thechief executive. They were then investigated by themember of the executive and/or management team whowas deemed most appropriate for the case. Lessons werelearnt from individual concerns and complaints and alsofrom analysis of trends. Action was taken to as a result toimprove the quality of care. All complaints were presentedat the bi-monthly clinical governance meeting so thatlessons learned could be shared. Staff fully understood thecomplaints procedure and their role in this.

Are services responsive to people’s needs?(for example, to feedback?)

Outstanding –


Our findingsVision and strategy

The leadership, governance and culture were used to driveand improve the delivery of high-quality, person-centredcare. The service had a clear vision to achieve this and topromote good outcomes for patients.

The provider had four core values, these were:

• Clinically focused - Everything every one of us does is forthe patient

• Responsive - We listen and we respond quickly in apatient focussed way

• One Team - We work together to provide a high qualityservice which is organised and consistent, and inpartnership with both the local Acute and CommunityTrusts

• High Standards - We provide skilled professionalsworking to the highest standards who are passionateabout improving patient care

Staff we spoke to were extremely positive about theirexperience of working for CHoC and knew and understoodthe values.The service had a comprehensive strategy andsupporting business plans that reflected the vision andvalues and were regularly monitored. The strategy hadbeen devised with staff at a company away day and hadmeeting the needs of patients in a rural, sparsely populatedcommunity as their main aim. Working in partnership withother services, developing staff and increased use oftechnology were also key aims of the strategy, and we sawevidence that this was being put into practice during ourinspection.

We also saw evidence that the provider was keen to sharepractice with other providers. For example, members of theleadership team had given a presentation about theirlearning from the telehealth pilot to other providers of outof hours care who were members of Urgent Health UK.

Governance arrangements

The service had an overarching governance framework thatsupported the delivery of the strategy and good qualitycare. This outlined the structures and procedures in placeand ensured that:

• There was a clear staffing structure and that staff wereaware of their own roles and responsibilities.

• Service specific policies were implemented and wereavailable to all staff.

• The provider had a good understanding of theirperformance against National Quality Requirements.They had invested in new technology that allowed forthe development and use of real-time performancemonitoring to improve capacity to meet demand.Performance was regularly discussed at seniormanagement and board level. Performance was sharedwith staff and the local clinical commissioning group(CCG) as part of contract monitoring arrangements.

• A programme of continuous clinical and internal auditwas used to monitor quality and to makeimprovements.

• There were effective arrangements for identifying,recording and managing risks, issues and implementingmitigating actions.

Leadership and culture

The provider demonstrated they had the experience,capacity and capability to run the service and ensure highquality care. There was strong collaboration and supportacross all staff and a common focus on improving safety,quality of care, and people’s experiences. Staff told us themanagers were approachable and always took the time tolisten to all members of staff. Staff reported they felt theywere part of a family, and were respected and valued bymanagers.

There was a proactive approach to meeting therecruitment problems experienced by services in the area.The provider was a member of the CCG-led CollaborativeRecruitment Hub, which worked to encourage recruitmentof clinical staff in Cumbria. The provider was active inattending conferences and events nationwide to encouragerecruitment to the area. In 2016, the provider was able toemploy six new salaried GPs, which in turn meant theyreduced reliance on agency staff, as a result of successfullyapplying to be a Tier 2 sponsor. On occasion the number ofagency doctors used in a week was as low as 5%. Theprovider believed they were the only out of hours service inEngland to have become a Tier 2 sponsor.

The provider was aware of and had systems in place toensure compliance with the requirements of the duty ofcandour. (The duty of candour is a set of specific legalrequirements that providers of services must follow whenthings go wrong with care and treatment).This includedsupport training for all staff on communicating with

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Outstanding –


patients about notifiable safety incidents. The providerencouraged a culture of openness and honesty. The servicehad systems in place to ensure that when things wentwrong with care and treatment:

• The service gave affected people an explanation basedon facts and an apology where appropriate, incompliance with the NHS England guidance onhandling complaints.

• The service kept written records of verbal interactions aswell as written correspondence.

There was a clear leadership structure in place and staff feltsupported by management.

• There were arrangements in place to ensure the staffwere kept informed and up-to-date. This includedfeedback on incidents, complaints or safeguarding thatstaff had reported. Nurses confirmed these were used tosupport reflective learning. There was a staff newsletter.

• We saw evidence that the medical director was heavilyinvolved in supporting staff and offering learningopportunities. We were told by several members of thenursing staff that the medical director often workedshifts on the out of hours service and would suggestcases for nurse practitioners to treat, under theirsupervision, to increase their knowledge base.

• There were high levels of staff satisfaction. Staff wereproud of the organisation as a place to work and spokehighly of the culture. There were consistently high levelsof staff engagement. Staff at all levels were activelyencouraged to raise concerns. They had opportunitiesto meet regularly and share learning.

• Staff said they felt respected, valued and supported,particularly by the managers at the service. Staff had theopportunity to contribute to the development of theservice.

• A salary sacrifice scheme was set up with a medicalindemnity provider in an attempt to reduce the cost toclinicians of paying for cover. This was an effort toimprove staff well-being and to encourage new staff tojoin the organisation.

Seeking and acting on feedback from patients, thepublic and staff

Rigorous and constructive challenge from people who useservices, the public and stakeholders was welcomed and

seen as a vital way of holding the service to account. Theservice encouraged and valued feedback from patients, thepublic and staff. They proactively sought patients’ feedbackand engaged patients in the delivery of the service.

• The provider used innovative approaches to gatherfeedback from people who use services and the public.They used the website I Want Great Care(www.iwantgreatcare.org) to gather feedback frompatients. At the time of inspection, of the six sites wherepatients were seen, four had overall ratings of five stars(out of five) and two had overall ratings of 4.5 stars froma total of 744 reviews. Commonly used words bypatients in the reviews included ‘excellent’, ‘kind’,‘caring’, ‘reassuring’ and ‘brilliant care’.

• CHoC approached Healthwatch to commission a reportgathering broader feedback from patients, in responseto difficulties obtaining feedback from a widepopulation. Between September 2016 and November2016, Healthwatch spoke to 1,676 patients and foundthat 91% of patients were either very satisfied orsatisfied with their overall experience of CHoC.

• The service had gathered feedback from staff throughmeetings and one to one discussions, as well as a staffsurvey. Staff told us they would not hesitate to givefeedback and discuss any concerns or issues withcolleagues and management. Staff told us they feltinvolved and engaged to improve how the service wasrun.

• Several initiatives had been put in place in response tothe staff survey, including “20 days of 20” where staffwere encouraged to take part in activities, and socialevents and award ceremonies. These events wereintended to improve staff morale and well-being.

• The provider used social media platforms, such asTwitter, to communicate with patients and gatherfeedback.

Continuous improvement

The leadership drove continuous improvement and staffwere accountable for delivering change. Safe innovationwas celebrated. There was a clear and proactive approachto seeking out and embedding new ways of providing careand treatment, and we saw multiple examples of thisduring the inspection.

• The provider looked to benchmark their performancenationally to drive improvement. Since 2011, CHoC hadbeen a member of Urgent Health UK (UHUK), which


Outstanding –


provided external audit of the service, andbenchmarked against 23 other out of hours careproviders in England. At the most recent audit in 2016,CHoC was given a rating of “highly commendable”,which is the highest of five ratings available. Only fourproviders currently have this rating.

• There was a strong culture of innovation evidenced bythe number of pilot schemes the provider was involvedin. These included a telehealth service which hadreduced the average time for patients in rural areas tobe seen for either a routine base or home visit from 146to 32 minutes, and a telephone service staffed by

pharmacists to answer patients’ medicationqueries.Steps had been taken to increase capacity andmeet high demand, including investing in newtechnology to monitor demand in real time, and takinga proactive and innovative approach to recruitment.

• The provider had recently opened their own trainingacademy. We saw plans for the provider to offer trainingto external agencies, such as GP practices.

• The provider had met with the “frequent flyer team”from the North West Ambulance Service to explore waysto collaborate on reducing demand on services.


Outstanding –


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