An out-of-hours GP service at the centre of a scandal over patients waiting hours for calls must improve, the regulator has said.
The Care Quality Commission (CQC) said Integrated Care 24 (IC24), which runs non-emergency 111 and out-of-hours services in Norfolk and Wisbech and surrounding areas, needs to do more to recruit and retain GPs.
It also must ensure staff who are taking calls from the public are adequately trained to make clinical decisions by phone.
Inspectors who visited in March with 48 hours' notice found that patients were waiting too long to speak to or see GPs.
There was a also a lack of proof that call handlers had been properly trained for their job.
Some medicines were also found to be out of date, their report said.
It follows previous reports which found deficiencies in call handling and a shortage of GPs and staff saying they had been asked to alter records.
In February, a whistleblower told the Daily Mail that just one GP had provided emergency cover for more than 900,000 people on some nights.
Patients were also found to have waited more than 12 hours for return calls after contacting 111.
The new CQC report found that "some nurses triaging patients were found to have undertaken tasks without evidence of them having had the appropriate training".
It said: "Nurses in the out-of-hours service were also expected to have been trained in extended skills such as history taking and minor illness. We were not provided with evidence that this was always the case."
Inspectors said IC24 had provided evidence that new staff had extra skills but this was not the case for existing staff.
Data for the service covering September 2015 to January 2016 also showed long delays for patients.
Overall, data on making home visits within one hour showed the service performance ranged from 58.4% to 92.4%, against a national target of 95%.
For home visits within two hours, the range was 69% to 99% (against the national target of 95%), while there were wide variations in people seeing doctors face-to-face, from 89.5% in October 2015 in Cambridgeshire and Peterborough to 56.3% in December 2015 in South Norfolk (against a 95% target).
For a face-to-face appointment within six hours, performance fell to 84.9% in December 2015 in Norwich, against a 95% target.
For home visits within two hours, performance ranged from 33.3% in November 2015 in some areas to 91.3% in November 2015 in Cambridgeshire and Peterborough.
Inspectors also said: "On one occasion during a recent Saturday prior to our inspection there had been a shortage of GPs in the whole area over a 24-hour period, spread over several shifts.
"During this period a total of 50 GP shifts were planned and six had remained uncovered. This had resulted in potential difficulties in patients being able to access the services of a GP in certain areas."
IC24 said "recruitment had proven difficult, which was partly due to competing offers of shifts and benefits to GPs at other services".
An NHS England spokesman said: "IC24 is working to address the issues raised in the CQC report and we expect them to continue to improve their services so they are as robust as those provided across the rest of the country."
The latest available data shows that IC24 has shown considerable improvement in the past five months and is now performing well above average.
Janet Williamson, deputy chief inspector of general practice at CQC, said: "Our inspectors found that systems and processes to help prevent patients being put at risk of harm were not always in place.
"There were delays in patients accessing the 111 and the GP out-of-hours service, the systems to show that staff had been appropriately trained and security checked were ineffective and we found some medicines were out of date. We have told the service to take action to address these and other issues.
"However, we also found evidence that the new leadership had already taken action to address some areas of concern, indicating that they are capable of making these improvements.
"We will return to this service again soon to check it has taken action to ensure everyone who uses this service gets safe, high-quality care. If, when we return, we are not satisfied that this has happened we will consider taking further action."
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