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Cambridgeshire Community Services NHS Trust Out of Hours Services at City Care Centre

Provider Cambridgeshire Community Services NHS Trust Type NHS Healthcare Organisation Region East Last inspected 4 Nov 2015

Overall rating: Inadequate  View full CQC report

Domain ratings

Five CQC key questions
Safe
Inadequate
Effective
Inadequate
Caring
Good
Responsive
Requires Improvement
Well-led
Inadequate

Earlier inspection findings

pre-2024 framework · 8 must-do 5 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8
Must do
Safe
Ensure that all staff who triage patients have been adequately trained to make clinical decisions by telephone and have been assessed as competent to do so. In addition, protocols and guidelines must be implemented in order to guide staff to make safe and appropriate triage decisions.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ We found that the registered person was not protecting service users against the risks associated with unsafe triage. Protocols, guidelines and appropriate training had not been provided to support and guide staff who make clinical decisions by telephone.
Must-do action 2 of 8
Must do
Safe
Ensure medication administration protocol competency assessments are recorded and kept up to date
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ We found that the registered person was not protecting service users against the risks associated with the need to ensure safe prescribing through effective PGD competency checks and authorisations.
Must-do action 3 of 8
Must do
Well-led
Ensure that the length of time patients wait for definitive clinical assessment is robustly monitored and managed to ensure patient care does not suffer.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ We found that the registered person was not protecting service users against the risks associated with the need for having effective governance systems in place to enable service leaders to maintain an accurate and up to date view of risks within the service.
Must-do action 4 of 8
Must do
Safe
Implement effective safeguarding referral procedures and ensure that all referrals are followed up and that this is documented.
Regulation: Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
⚠ We found that the registered person was not protecting service users against the risks associated with safeguarding referral procedures and to ensure these were followed up and recorded.
Must-do action 5 of 8
Must do
Safe
There must be a robust process for monitoring clinical equipment, to ensure that it is fit for purpose and that consumable items are in date.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ We found that the registered person was not protecting service users against the risks associated with the need to ensure equipment is checked and fit for purpose.
Must-do action 6 of 8
Must do
Well-led
Governance around staff files and recruitment procedures must be implemented and recorded effectively.
Regulation: Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed
⚠ We found that the registered person was not protecting service users against the risks associated with ineffectively operated recruitment procedure to ensure that the persons employed meet the conditions set out in Regulation 19. We also found that the registered person was not protecting service users against the risks associated …
Must-do action 7 of 8
Must do
Safe
Ensure there are sufficient and appropriately trained staff on site in order to keep patients safe. Contingency arrangements must be agreed for staff to follow when last minute gaps in GP cover arise.
Regulation: Regulation 18 HSCA (RA) Regulations 2014 Staffing
⚠ We found that the registered person was not protecting service users against the risks associated with maintaining sufficient numbers of qualified, competent, skilled and experienced staff.
Must-do action 8 of 8
Must do
Well-led
Clear governance and leadership arrangements must be implemented to ensure that clinical and managerial leaders understand and can mitigate risks to patients and staff and have an effective oversight of the performance of the out-of-hours service at all times.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ We found that the registered person was not protecting service users against the risks associated with the need for having effective governance systems in place to enable service leaders to maintain an accurate and up to date view of risks within the service.

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Effective
Records should be kept of all clinical supervision for both doctors and nurses.
Should-do action 2 of 5
Should do
Well-led
Provide communication with all staff regarding service changes taking place.
Should-do action 3 of 5
Should do
Effective
Ensure that National Quality Requirement (NQR) key performance indicators are met each month in respect of definitive clinical assessments, face to face consultations and callbacks from a healthcare professional.
Should-do action 4 of 5
Should do
Well-led
Appropriate and effective clinical audits should be implemented to ensure that the service can identify areas for development and learning.
Should-do action 5 of 5
Should do
Safe
Learning relating to incidents should be shared with all relevant staff in order to facilitate a culture of on-going improvement.

Location details

CQC ID: RYVY2
Local authority: Peterborough
Region: East

Inspection report

Type: Comprehensive inspection
Date: 4 November 2015
Rating: Inadequate
Actions: 8 must-do 5 should-do
AI-extracted 3 Jun 2026