This service is rated as Good overall (Previous inspection April 2018 – Inadequate).

We carried out an announced comprehensive, follow up inspection at King George’s Emergency Urgent Care Centre (EUCC) on 14 March 2019.

CQC previously inspected the service on 5 April 2018 and asked the provider to make improvements because although the care being provided was responsive, it was not being provided in accordance with the relevant regulations relating to safe, effective, caring and well led care. Specifically, we found the provider had breached Regulation 12 (1) (Safe care and treatment) and Regulation 17 (1) (Good governance) of the Health and Social Care Act 2008. This was because of an absence of appropriate clinical equipment and systems to safely assess and monitor patients. We also noted a lack of appropriate systems for sharing learning from safety incidents and for ensuring governance arrangements operated effectively.

Two Warning Notices were served and the service was placed into Special Measures. Shortly thereafter the service wrote to us to tell us what they would do to make improvements. We undertook this comprehensive inspection to check the service had followed their plan and to confirm they had met the legal requirements.

At this inspection, the key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Good

At this inspection we found:

•Action had been taken since our last inspection such that leadership and governance arrangements now supported the delivery of high-quality and person-centred care.

•Action had been taken since our last inspection to ensure that when safety incidents happened, learning was shared internally with relevant people. For example, a monthly Governance Committee had been established to learn from safety incidents and improve safety; and a staff bulletin established to share this learning.

•Action had been taken since our last inspection to improve how the service assessed and monitored patients. This included availability of appropriate clinical equipment and introduction of new protocols and training to support how clinicians ‘streamed’ or assessed patients. However, we noted the new protocols did not record how long patients waited in the queue or include formal arrangements for prioritising patients who were frail or acutely ill.

•Action had been taken since our last inspection to improve the service’s physical layout and make it more conducive to maintaining patients’ privacy, although we noted conversations in the service’s new initial assessment room could be overheard. We saw that staff involved and treated people with compassion, kindness, dignity and respect.

•There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

•Continue to liaise with it’s NHS Trust Landlord to further improve how the physical layout ensures patients’ privacy.

• Continue to further develop queue management arrangements, so as to more precisely measure how long patients wait in the queue.

•Take action to ensure electronic patient feedback terminals are available in languages other than English.

•Take action to ensure appropriate filing systems are in place for staff pre-employment checks and training records.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This service is rated as Inadequate overall (Previous inspection 30 March 2017– Requires Improvement).

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at King George’s Emergency Urgent Care Centre (EUCC) on 5 April 2018. The service is co-located with the Emergency Department of King George’s Hospital and is open 24/7. Patients are initially assessed by a nurse and then “streamed” or directed for treatment by the most appropriate clinician: for example at the hospital’s Emergency Department or at the EUCC.

This inspection was to confirm that the provider had carried out their plan to meet the legal requirements in relation to breaches in regulations that we identified in our previous inspection on 30 March 2017. At that time the service was rated as requires improvement for effective, caring and well led services; and rated overall as requires improvement. This report covers our findings in relation to those requirements and also in relation to additional findings made since our last inspection.

At this inspection we found:

• The provider’s clinical streaming process did not safely assess, monitor or manage risks to patients.

• Although we saw evidence that the provider learned from safety incidents and improved its processes, we could not be assured that learning included all relevant people.

• The delivery of high quality care was not assured by the governance arrangements in place. For example, nursing staff induction documents were not readily available and medicines audits lacked a clear process for managing clinicians who persistently breached local prescribing expectations.
• We also noted that clinical meetings were informal and infrequent.

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

• Action had been taken since our last inspection such that clinical audit was now being used to drive quality improvements.

• Staff treated patients with compassion, kindness, dignity and respect. However, there was no system to seek patient’s feedback. Three of the eight CQC comment cards completed by patients in the weeks leading up to the inspection indicated patients did not always feel they were treated with respect upon arrival at the centre.

• Records confirmed that the provider’s NHS Trust landlord was shortly due to commence reception area building improvement works in response to privacy and confidentiality concerns highlighted at our last inspection. Shortly after our inspection we were sent evidence confirming that the works had commenced.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review its medicines management protocols relating to checking expiry dates, prompt access to emergency medicines and also relating to clinicians who breach local prescribing expectations.
• Review the training needs of non clinical staff in response to patient feedback.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at King George’s emergency urgent care centre (EUCC) on 30 March 2017. The service is operated by the Partnership Of East London Cooperative Ltd (PELC) and based at King George’s Hospital in Goodmayes, Essex.

Patients are assessed upon arrival by a “streaming nurse” who determines the urgency of the presentation and the service best placed to provide care and treatment. Overall, the service is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• We looked at the personnel records of five clinical streaming staff but could not find confirmation that staff had completed the provider’s prerequisite streaming training. We also noted other gaps in training and that some staff had not had annual appraisals.

• The premises were accessible but due to a lack of space, when patients arrived at reception, privacy and confidentiality were not maintained. The premises were also inappropriate for streaming in that they lacked sufficient space to enable initial patient assessments to be conducted in private.
• Governance arrangements did not always work effectively in that infection risks to patients were not well managed and we saw limited evidence that clinical and internal audit was being used to drive quality improvements.

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

• Data indicated that patients’ care needs were assessed and delivered in a timely way according to need. The service met most targets which were specific to the urgent care centre.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Staff demonstrated that they understood their responsibilities and had received training on safeguarding children and vulnerable adults relevant to their role.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• We saw that reception staff were kind and compassionate.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The provider was aware of and complied with the requirements of the duty of candour.
• We noted that the provider had recently come through a period of organisational change; resulting in the Medical Director currently also serving as interim Chief Executive. Staff spoke positively about how the interim Chief Executive provided visible leadership and promoted a culture of collective responsibility.

The areas where the provider must make improvement are:

• Ensure that there are appropriate arrangements in place to assess, monitor and improve the quality and safety of the services provided (including two cycle audits and internal audits), so as to drive improvements in patient outcomes.

• Introduce reliable systems to ensure that staff are appropriately trained in line with its protocols and ensure that all staff receive an annual appraisal.

• Develop effective systems and processes to ensure that the dignity and respect of patients is maintained, by ensuring that all stages of the consultation process take place in a confidential setting.

The area where the provider should make an improvement is:

• Consider undertaking refresher infection prevention and control refresher staff training.

• Introduce reliable systems to ensure that staff are appropriately trained in line with its protocols and ensure that all staff receive an annual appraisal.

• Review the layout of its reception and waiting areas, to see where improvements can be made to arrangements for maintaining patients’ privacy, confidentiality and dignity.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice