We carried out an announced comprehensive inspection at The Health Exchange in July 2018 as part of our inspection programme where the service was rated as inadequate overall. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements. The full comprehensive report of our previous inspection can be found by selecting the ‘all reports’ link for Trust Headquarters on our website at

This inspection was an announced comprehensive inspection carried out on 1 April 2019 to check whether the provider had taken action to meet the legal requirements as set out in the requirement notices. The report covers our findings in relation to all five key questions and related population groups.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall due to concerns in providing safe, effective and well-led services.

We rated the practice as requires improvement for providing safe services because:

• The service had clear systems to manage risk so that safety incidents were less likely to happen. However, the service was not always maximising learning opportunities.
• Records we viewed did not provide assurance that information needed to deliver safe care and treatment to patients was routinely available.
• The service was not actively accessing or collecting data to monitor or ensure appropriate antimicrobial prescribing.
• Non-clinical staff had been given guidance on identifying deteriorating or acutely unwell patients. They were aware of actions to take in respect of such patients.
• The practice proactively worked with other agencies to support patients and protect them from neglect and abuse.

We rated the practice as requires improvement for providing effective services because:

• The service had reviewed their quality improvement activities. We found that whilst some improvements were evident there were areas where the quality improvement development was ongoing.
• The service was able to show that staff had the skills, knowledge and experience to carry out their roles. However, the provider did not routinely carry out audits to monitor the prescribing activities of non-medical prescribers.
• The service used Quality Outcome Framework (QOF) as a monitoring tool to measure clinical performance. The service recognised the characteristics of the patient population impacted on QOF data; therefore, there were ongoing discussions regarding key performance indicators and set targets.
• Staff were receiving ongoing support from the provider as well as local clinical commissioning group regarding the use of QOF to improve outcomes for patients.

We rated the practice as requires improvement for providing well-led services because:

• While the service had made some improvements since our inspection in July 2018, improvements were ongoing, and some changes were in their infancy.
• The service reviewed and improved their governance arrangements in most areas; however, there were processes which had not yet been established or fully embedded. For example, the service did not always effectively use the patient record system and therefore positive outcomes were not routinely captured.
• The service were not always maximising learning opportunities following incidents.
• The service was not routinely maintaining up to date records and were at an early stage in improvement of Quality Outcome Framework indicators.

These areas affected all population groups relevant to this service, so we rated the population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it. Survey results showed patients satisfaction rates were above local and national averages in several areas. The service was aware of issues related to waiting times and were acting to improve patient satisfaction.
• There was a focus on continuous learning and improvement at all levels of the organisation following complaints.
• Service user engagement workers encouraged patients to attend a recovery college where patients were able to access courses such as mental Health first aid, communicating confidently and caring in crisis.

Staff demonstrated a wealth of knowledge, passion and commitment to working with people whose circumstances make them vulnerable. We saw several areas of outstanding features including:

• The team attending secondary care appointments with patients to ensure attendance as well as offer support in environments which may be overwhelming and intimidating. The service also provided clothes to boost patient’s confidence when attending external appointments.
• The service funded travel for patients who found it difficult to attend appointments or pay for public transport.
• The nursing team went above and beyond in their outreach roles. The team supported migrant patients to complete application forms to enable them to access free medicine, optical and dental care.
• Staff employed by the service attended funerals and held memorials for patients who may have lost contact with family members or loved ones.

The areas where the provider must make improvements 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Explore ways of capturing and documenting support provided in order to measure as well as monitor positive outcomes.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This service is rated as Inadequate overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at The Health Exchange on 25 July 2018, in response to concerns received.

At this inspection we found a lack of a coherent plan for developing and monitoring the service and its contract:

• The service did not operate an effective programme of quality improvement activities to measure performance or clinical effectiveness and were unable to demonstrate how they accessed national available data.
• The service had oversight of some governance arrangements and used them to drive service delivery. However, we found that cohesive working between the service, Trust and commissioners as well as a clear understanding of the service was limited and this impacted on the services ability to develop effective governance arrangements. For example, management of staffing levels; clinical support as well as effective IT systems.
• The service was unable to demonstrate awareness of the day to day management of infection control as well as an established programme of ongoing or periodic infection control audits. The service did not have a system for monitoring or checking whether general cleaning was being carried out in line with the Trust’s cleaning policy.
• The service had some arrangements in place to enable appropriate actions in the event of a medical emergency. However, not all potential medical emergency situations were considered and a risk assessment to mitigate potential risks had not been carried out.
• There were areas of environmental safety where the service did not carry out risk assessment to mitigate risk. For example, the service were unable to provide assurance that a legionella risk assessment had been carried out as well as fire drills. Following our inspection, the provider sent evidence of a legionella risk assessment carried out in February 2016 and explained that an annual review had been carried out following our inspection.
• The service had clear systems to report and investigate safety incidents so that they were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
• Clinical staff ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Although the service operated an appointment system which allowed easy and flexible access to appointments during opening hours, the July 2017 national GP patient survey results were mainly below local and national averages for questions relating to access to care and treatment and the service had not analysed the results.
• There was a focus on continuous learning from incidents at all levels of the service.

The areas where the provider must make improvements 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:

• Take action to ensure advance training carried out by clinical staff is recognised and staff complete training recognised by the service as mandatory in a timely manner.
• Take action to gain patient feedback and explore effective ways to act on feedback in order to improve patient satisfaction.

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

Please refer to the detailed report and the evidence tables for further information.