Ambulance Station NewApproachComprehensive Report ......Nottingham Nottinghamshire NG15 8AA Tel:...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

AmbulancAmbulancee StStationationQuality Report

4 Robey CloseLinbyNottinghamNottinghamshireNG15 8AATel: 033300124018Website: www.centralmedicalservices.co.uk

Date of inspection visit: 18 and 26 February 2020Date of publication: 11/05/2020

1 Ambulance Station Quality Report 11/05/2020

Letter from the Chief Inspector of Hospitals

Ambulance Station is operated by Central Medical Services, East Midlands. The service provides emergency and urgentcare and a patient transport service.

We inspected this service using our comprehensive inspection methodology. We gave the service 48 hours’ notice of ourinspection to ensure everyone we needed to speak with was available. We carried out the inspection on 18 and 26February 2020.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

The services provided by this service patient transport services with emergency and urgent care transport from eventsand carrying out 999 calls for NHS trusts. On this inspection we inspected both core services.

Where our findings on patient transport services – for example, management arrangements – also apply to otherservices, we do not repeat the information but refer the reader to the patient transport core service.

We rated it as Good overall.

We found the following areas of good practice:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understoodhow to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staffassessed risks to patients, acted on them and kept good care records. They managed medicines well. The servicemanaged safety incidents well and learned lessons from them. Staff collected safety information and used it toimprove the service.

• Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored theeffectiveness of the service and made sure staff were competent. Staff worked well together for the benefit ofpatients, supported them to make decisions about their care, and had access to good information.

• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of theirindividual needs, and helped them understand their conditions. They provided emotional support to patients,families and carers.

• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made iteasy for people to give feedback. People could access the service when they needed it and did not have to wait toolong for treatment.

• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staffunderstood the service’s vision and values, and how to apply them in their work.Staff felt respected, supported andvalued. They were focused on the needs of patients receiving care. Staff were clear about their roles andaccountabilities. The service engaged well with patients and the community to plan and manage services and allstaff were committed to improving services continually.

However, we found the following issues that the service provider needs to improve:

• The service did not comply with Duty of Candour regulation.• Staff completion of information governance and prevent training was below 70%.• The safeguarding adults policy did not reference modern slavery.

Summary of findings


Following this inspection, we told the provider that it must and should make some improvements, even though aregulation had not been breached, to help the service improve. We also issued the provider with one requirementnotice that affected emergency and urgent care. Details are at the end of the report. Although a breach of a regulationnormally limits the rating of that key question to requires improvement as this breach relates to one incident, we haveover ruled that principle and the rating for safe for emergency and urgent care has therefore been rated as good.

Heidi SmoultDeputy Chief Inspector of Hospitals (Acute Hospitals South), on behalf of the Chief Inspector ofHospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Emergencyand urgentcare

Good –––

The main service provided was emergency and urgentcare. This included care at events and conveyingpatients to hospital services when required. Theservice transported high dependency patients for NHStrusts. The service carried out emergency ambulancework, for example, responding to 999 calls.We have rated safe, effective, caring, responsive andwell-led as good. We rated safe as requiresimprovement.Overall, we rated the service as good because it hadenough competent staff with the appropriate level ofqualifications and training. The service maintainedstandards of vehicles and equipment and followedinfection control practices. Staff followed best practiceand completed risk assessments and recordsappropriately. The service worked well with partnerorganisations and continuously tried to learn andinnovate. The service treated patients with kindnessand dignity at all times. However, the service did notfully comply with Duty of Candour regulation.

Patienttransportservices

Good –––

Patient transport services was a regulated activityprovided by the service. A different group of staffprovided this service to the staff that providedemergency and urgent care.We have rated safe, effective, responsive and well-ledas good. We did not see any patient care in patienttransport services, so we were unable to rate thecaring domain.Overall, we rated the service as good for the samereasons as emergency and urgent care. Staffresponded appropriately if a patient became unwellwhen being transported. staff stored patients ownmedication appropriately and staff monitored thearrival and departure times of patients.

Summary of findings


Contents

PageSummary of this inspectionBackground to Ambulance Station 7

Our inspection team 7

Information about Ambulance Station 7

Detailed findings from this inspectionOverview of ratings 9

Outstanding practice 32

Areas for improvement 32

Action we have told the provider to take 33

Summary of findings


Ambulance Station

Services we looked at:Emergency and urgent care; Patient transport services

AmbulanceStation

Good –––


Background to Ambulance Station

Ambulance Station is operated by Central MedicalServices, East Midlands. The service was registered at thislocation on 2 May 2017. It is an independent ambulanceservice based in Linby, Nottinghamshire. The serviceprimarily served the communities of the East Midlands.

The service has had a registered manager in post sincethe service registered.

The service provided pre-planned patient transportservices, for all age groups from birth. Journeys includeddischarges from hospitals, transfers for specialisttreatment, transport to and between care homes andrepatriation of patients from within the UK and Europe.

The main service provided was emergency and urgentcare. The service provided medical cover for events whichincluded conveyancing to hospitals. The eventsthemselves were not a regulated activity but the

conveyancing to hospital was. The service also providedemergency transfers to hospitals, including responding to999 calls. The service also transported high dependencypatients for NHS trusts.

The service had a total of 42 vehicles. The service had 27ambulances for the provision of urgent and emergencycare, five rapid response vehicles and a specialist quadbike for events. The service also had two ambulances forpatient transport use only. The service also had threesecure cell ambulances, a make ready van, a drivertraining ambulance and two other specialist vehicles.

The service was yet to be inspected at this location.

We inspected this service using our comprehensiveinspection methodology. We gave the service 48 hours’notice of our inspection to ensure everyone we needed tospeak with was available. We carried out the inspectionon 18 and 26 February 2020.

Our inspection team

The team that inspected the service comprised a CQClead inspector, one other CQC inspector, and a specialistadvisor with expertise in ambulance services. Theinspection team was overseen by Fiona Allinson, Head ofHospital Inspection.

Information about Ambulance Station

The service provides patient transport to NHS andprivately funded patients for admission to, or dischargefrom hospital, attending outpatient appointments andairport repatriations with medical escorts. The servicealso provides repatriation within the UK and Europe,events work with conveyancing to hospitals andemergency transfers including 999 calls. Staff carry outsome clinical interventions including administration ofoxygen and nitrous oxide, cardiac monitoring andsuction. The service offers transport and urgent andemergency services 24 hours a day, seven days a week.

Most of the work carried out by the service wascontracted by the local NHS trusts and some work wascarried out by private booking arrangements.

At the time of our inspection the service was registered toprovide the following regulated activities:

• Diagnostic and screening procedures

• Transport services, triage and medical adviceprovided remotely

• Treatment of disease, disorder or injury

During the inspection we spoke with nine members ofstaff including the registered manager, director of

Summaryofthisinspection

Summary of this inspection


operations, HR director, lead nurse, two paramedics, oneambulance technician and two emergency careassistants. We spoke with four patients and relativesduring our inspection. We also reviewed 10 patientfeedback cards and they were all complimentary aboutthe service the staff provided. During our inspection, wereviewed 20 sets of patient records. We reviewed vehiclechecklists and records. We reviewed eight staff files.

There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection. The service has not beeninspected previously.

The service had a total of 42 vehicles. The vehicles wereparked overnight on the site.

Activity (1 January 2019 to 31 December 2019)

In the reporting period there were 35 emergency andurgent care patient journeys undertaken from events,14500 high dependency transfers and 13085 emergencypatients attended to.

There were 8250 patient transport journeys undertakenfor the NHS, five private transfers and 88 were from airambulances to other departments.

The service held controlled drugs (CDs). Patients wouldalso carry their own medication in their personalbelongings on discharge.

Track record on safety

• No never events

• 35 incidents

• One serious injury

Summaryofthisinspection

Summary of this inspection


Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Emergency and urgentcare Good Good Good Good Good Good

Patient transportservices Good Good Not rated Good Good Good

Overall Good Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceThe service conveyed patients to hospital services fromevents which meant they were providing emergency andurgent care regulated activities. From 1 January 2019 to31 December 2019, the service transferred 35 patients tohospital from events. The service also transferred 14,500high dependency patients during this timeframe.

The service also carried out emergency ambulance callsfor NHS providers. From February 2019 to January 2020,the service carried out 13,085 patient transfers tohospital.

The service carried out 88 patient transfer journeys fromthe local air ambulance to another location.

The service provided emergency and urgent care atevents however, CQC does not currently have the powerto regulate this activity.

The service employed 210 members of staff, of which 199were frontline staff. All of the frontline these staff carriedout urgent and emergency work, patient transportjourneys and event work.

Summary of findingsWe found the following areas of good practice:

• The service provided mandatory training in key skillsto all staff mostly made sure everyone completed it.The service had enough staff with the rightqualifications skills training and experience to keeppatients safe from avoidable harm and provide theright care and treatment. The service made sure staffwere competent for their roles.

• Staff understood how to protect patients from abuse.Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.

• The service controlled infection risk well. They keptequipment, vehicles and premises visibly clean. Thedesign, maintenance and use of facilities, premises,vehicles and equipment kept people safe.

• The service used systems and processes to safelyprescribe, administer, record and store medicines.

• The service managed patient safety incidents well.Managers investigated incidents and shared lessonslearned with the whole team, the wider service andpartner organisations. When things went wrong, staffapologised and gave patients honest informationand suitable support.

• The service provided care and treatment based onnational guidance and evidence-based practice. Staffkept detailed records of patients’ care and treatment.Staff assessed and monitored patients’ pain.

Emergencyandurgentcare

Emergency and urgent care

Good –––


• The service monitored and met key performanceindicators so that they could facilitate goodoutcomes for patients. The service monitored theeffectiveness of care and treatment. They used thefindings to make improvements and achieved goodoutcomes for patients.

• All those responsible for delivering care workedtogether as a team to benefit patients. Staffsupported patients to make informed decisionsabout their care and treatment.

• Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs. Staff provided emotionalsupport and involved patients, families and carers.

• The service planned and provided care in a way thatmet the needs of local people and could access theservice when they needed it.

• The service was inclusive and took account ofpatients’ individual needs and preferences and it waseasy for people to give feedback and raise concernsabout care received.

• Leaders had the integrity, skills and abilities to runthe service. They were visible and approachable inthe service for patients and staff. Staff felt respected,supported and valued. They were focused on theneeds of patients receiving care

• The service had a vision for what it wanted toachieve. Leaders and staff understood and knew howto apply the vision.

• Leaders operated good governance processes,throughout the service. Leaders and teams usedsystems to manage performance effectively. Theyidentified and escalated relevant risks and issues andidentified actions to reduce their impact.

• The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats.

• Leaders and staff openly engaged with staff, patientsand the public to plan and manage services. All staffwere committed to continually learning andimproving services.

However, we found the following issues that theservice provider needs to improve:

• The service did not comply with Duty of Candourregulation.

• The mandatory training levels for informationgovernance and Prevent training were below 70%.

• The safeguarding policy did not reference modernslavery in line with best practice.



Good –––


Are emergency and urgent care servicessafe?

Good –––

We rated safe as good.

Mandatory training

The service provided mandatory training in keyskills to staff and mostly made sure everyonecompleted it.

The service had set guidelines on what mandatorytraining was required based on the clinical or non-clinicalgrade of staff members. The service provided training onrecruitment and then annually. Overall the compliancerate for mandatory training as of 31 December 2019 was82%. The service had planned mandatory training in forall staff who required it.

The service had two training modules where trainingcompletion was below 70%. Training levels forinformation governance was at 60% and trainings levelsfor PREVENT were at 59%. PREVENT training is meant toalert people to the possibilities of “non-violentextremism”.

All staff had training in basic life support (BLS) as aminimum level of life support training, although mosthad advanced life support training (ALS). Trainingcompletion rate for ALS was 96%.

Mandatory training modules included equality anddiversity, health and safety, conflict resolution, fire safety,infection prevention and control, moving and handling,safeguarding adults (including Mental Capacity Act 2005and Deprivation of Liberty Safeguards), safeguardingchildren, resuscitation of adults and children (matched toeach clinical grade appropriately – e.g. first aiders,cardiopulmonary resuscitation (CPR) and automatedexternal defibrillator (AED), paramedics completed fullALS training), information governance, PREVENT training,consent and capacity, learning disability awareness,mental health awareness, dementia awareness,medicines management and administration, customercare, professionalism, major incident and advanceddriving.

The service had a training manager and were clear whichstaff needed to complete training, this would be bookedand the staff would be contacted. The registeredmanager monitored this through the training matrixwhich indicated who needed to do which training. Theregistered manager showed us the training matrix whichindicated staff training levels.

Staff told us that they received emails that they were dueto renew training and could access this via online coursesas requested by the registered manager. The service alsoprovided several training courses face to face.

Staff who required advanced life support training to carryout urgent and emergency care work received theappropriate training.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise andreport abuse, and they knew how to apply it.

The service had a named safeguarding lead and asafeguarding adults and children policies that includedguidelines and training requirements for the staff. Thepolicy contained references to female genital mutilation(FGM) guidelines. The policy did not contain anyreference to modern slavery guidance in line with bestpractice.

The safeguarding lead had safeguarding level fourtraining. The service also had another staff member whohad level four safeguarding training who acted as thesafeguarding lead if the safeguarding lead was not atwork. Staff told us they were aware of the namedsafeguarding lead and would contact them with anyqueries.

Safeguarding training provided by the service metnational guidance. All staff had training in level threesafeguarding children and level two safeguarding foradults as part of the mandatory training programme. Theservice provided online training as a refresher for staffwho had already undertook safeguarding traininghowever, if the staff member was new to healthcare theyhad face to face training.



Good –––


The registered manager told us the service identified anypotential safeguarding issues at the time of booking orfrom staff on collection or handover at the start or end ofjourneys.

The safeguarding lead reported they shared safeguardingincidents with the hospitals and ambulanceorganisations they provided a service to. The serviceworked with a variety of NHS trusts who had individualreporting systems, the service followed the appropriatepathway for reporting safeguarding depending on theNHS trust.

If a patient was identified as having a protection plan inplace it would be conveyed to the ambulance crew whowere carrying out the patient journey.

The service recognised and acted on safeguardingconcerns. The service had safeguarding folders for eachof the services. We reviewed the reported safeguardingincidents that staff had reported in one of the folders andsaw appropriate reporting based on concerns identifiedduring patient care. These included reporting for poorhome conditions, poor care of relatives and unstableliving situations.

Cleanliness, infection control and hygiene

The service controlled infection risk well. Staff usedequipment and control measures to protectpatients, themselves and others from infection.They kept equipment, vehicles and premises visiblyclean.

Staff had training in infection control procedures as partof the mandatory training programme. Records showed94% of staff had undertaken infection prevention controltraining. The service had an appropriate infection controlpolicy in place. The service had a lead nurse who alsoacted as the infection control lead for the service.

The service cleaned ambulances daily and between eachpatient. Staff recorded this on each of the patient transferrecords. We reviewed 10 records and the box whichshowed that the vehicle had been cleaned had beenchecked on 10 occasions. Whilst on inspection we sawthree patient journeys, the trolley was cleaned and thelinen was swapped on each occasion.

The registered manager told us that they completed adeep clean after transporting a patient with an infectious

condition or as a minimum, every six weeks. The servicehad a contract with a cleaning company that providedregular deep cleaning and was also available 24 hours aday seven days a week to provide emergency deepcleaning.

The registered manager told us if the service transporteda patient with a known infection this would be recordedon the booking sheet or confirmed on collection and thevehicle would then be removed from service to becleaned. The staff told us that where possible thatjourney would be booked as the last journey of that shiftto clean the equipment and not disrupt other bookings.Appropriate decontamination cleaning products wereavailable on all ambulances as part of the infectioncontrol pack.

We saw all sterile supplies including single use dressings,were stored correctly, packaging was intact, and theywere all in date.

All reusable equipment was visibly clean and storedsafely. We saw that the stretcher trolley, carry chair andseats were clean and surfaces intact. Blankets and pillowswere clean and stored tidily. Staff told us they wouldcollect a new blanket and pillowcase from the hospitalafter each journey if they were leaving one with thepatient.

On this inspection we saw staff in visibly clean uniforms.Staffs arms were bare below the elbows. Staff wereresponsible for cleaning their own uniforms. However, theservice had a contract with a laundry company whowould clean uniforms if required.

Gloves, personal protective equipment (PPE) and handcleansing gel were available for use in all vehicles. Duringobservation we saw staff use PPE and hand cleansing gelappropriately, staff also washed their hands in thehospitals in between patients.

The service carried regular infection control audits. Theservice audited the cleanliness of both its ambulancesand its base. Between October 2019 and December 2019the average monthly audit scores for the vehicles was96.5% and for the base room it was 100%.

Environment and equipment



Good –––


The design, maintenance and use of facilities,premises, vehicles and equipment kept people safe.Staff were trained to use them. Staff managedclinical waste well.

The service had their own workshops near to their office.The service had a team who looked after equipment andthe vehicles. All vehicles had valid insurance, road tax andannual safety checks. The registered manager told us thatall vehicles are serviced and have an annual safety checkat the same time and the company is signed up to theannual safety check alert service. All vehicles hadbreakdown cover with the same company.

The service had a paper-based system of vehicle foldersbut was moving over to an electronic system. Staffshowed us logs to report any defects or concerns with thevehicles. These were shared with the registered manager.The electronic system would track reported faults andprovide reminders for annual safety checks ahead oftime. The system would also track mileage so vehiclescould be serviced at the appropriate time.

The service had suitable equipment that was tested andready for use. Medical devices were calibrated andserviced by qualified staff and were accurate and safe foruse. This included stretchers, carry chairs, suction units,electrocardiogram (ECG) machines and automaticexternal defibrillator unit (AEDs). We inspected fivevehicles and they all had appropriate medical deviceswhich were serviced appropriately.

We saw an asset register for the equipment used by theservice. This included equipment that had been sold ordecommissioned but was kept on record to ensure therewas an audit trail of its disposal. We were told that anyequipment recorded as out of service would be servicedand used if required. Any equipment that was not in usewas clearly marked so that staff would not use it.

Staff t transferred patients in a safe and secure mannerusing seat belts, child car seats with belts or harnesses onthe stretcher.

Staff transferred some patients and only transferredpatients up to the weight limit of their equipment. If theywere unable to do so safely, they would decline thebooking or call for additional help if it was an emergency.The majority of stretchers at the service were bariatricstretchers.

There were seat belts for all seats and a two-pointharness on the stretcher.

Clinical waste bags and sharps bins were available on theambulance. Staff told us these were emptied after useand collected for disposal by a specialist company whichprovided a lockable yellow wheelie bin which wasemptied weekly. The sharps bin had just been removedand was being replaced. We were shown body fluidspillage kits.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.

Staff made clinical assessments of patients. The serviceused national early warning scores (NEWS2). We sawevidence that patients had primary and secondaryassessments completed. The individual clinician treatingthe patient was trained to make clinical decisions anddecided if the patient should be taken to hospital. Theregistered manager told us that if any drugs carried byparamedics or interventions had been carried out, theparamedic would also accompany the patient. All staffalways had access to senior paramedic clinical advice.

The service followed National Institute for Health andCare Excellence (NICE) guidelines. Staff followed NICEguideline NG51 the recognition, diagnosis and anymanagement of sepsis. Staff used a recognised sepsisscreening tool which provided a flowchart for staff toidentify and provide emergency treatment for patientswith sepsis. Staff we spoke with had a goodunderstanding of sepsis and knew how to use the sepsistool.

The service provided advanced resuscitation equipmentsuch as airway management equipment and this wouldbe used, if required, to provide clinical intervention forpatients who were being transferred.

Staff told us they were able to contact a senior clinicaladvisor from within the service for advice if it was notdeemed to be an emergency. The senior clinicalmanagers included the registered manager, director of



Good –––


operations and lead nurse. The service also had aconsultant doctor contact if it was needed. Staff told usthis would then be documented in the patient transportrecord.

The service prepared an event medical plan for all events.This included the location of emergency hospital servicesin case a patient needed conveying to hospital.

The staff had a clear criteria of who they could transfer aspart of a high dependency transfer. High dependencypatients required a higher level of input and had morepotential issues than a standard patient transfer.

Staffing

The service had enough staff with the rightqualifications skills training and experience to keeppatients safe from avoidable harm and provide theright care and treatment.

The service had 210 members of staff, of which 199 werefrontline staff. The service had 69 paramedics, 54ambulance technicians, 36 emergency care assistants, 32first aid trained staff and eight registered nurses. Thesefrontline staff provided may be required to convey apatient off-site from events, provide the high dependencypatient transfers and undertake emergency medical care,including responding to 999 calls.

The service had a rota system for its regular staff. Staffwould also be contacted to cover any absences throughsickness. The service had both full-time staff and staffwho were independent contractors. They service had twostaff members on each ambulance and operated as manyas ambulance as were required based on the needs of theservice. Staff would not be expected to take on additionalwork they could not carry out.

Staff had the appropriate training and qualifications forthe roles they undertook. This included mandatorytraining on the training matrix. We also saw evidence ofqualifications reflecting the job role they carried out inplace in all eight staff files we reviewed whilst on site.

All patient transport staff had recruitment checksincluding a passport check, the right to work in the UK,employment histories, references and a disclosure andbarring service (DBS) checks in line with nationalregulations. We saw evidence of this in employee files wereviewed on site.

The service had 2% staff turnover and 1.25% staffsickness in the last 12 months. If staff were sick theregistered manager told us they would rearrange theshifts or bookings.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up to date and easilyavailable to all staff providing care.

The service had a variety of booking forms and systemswhich were used for emergency and urgent care. Whentransferring high dependency patients within the NHSservice they would receive a reference number whentransferring patients and would make records during thepatient journey. When responding to 999 calls the servicereceived information from the call centre and keptrecords during patient treatment.

Staff used a patient report form to document the careand treatment of patients conveyed off-site during anevent and for patients who were treated on site.

Whilst undertaking emergency call work patient reportforms (PRFs) were filled in by the crew to record anydetails of the journey. This included a description of themanual handling required or incidents. Forms were thensent to the appropriate NHS trust to which the work wassubcontracted after they were reviewed by the leadnurse.

We reviewed 20 PRFs whilst on inspection, 10 of whichwere for patients who required care after an emergencycall out work and 10 for patients who required care whilstat events. We found all the required information hadbeen completed and all the text boxes were filledappropriately. We saw the primary and secondaryassessment was completed on all patients if required. Allthe patient records we reviewed were clear and fullycomplete with a signature of the staff member. Recordsalso indicated if a patient had the presence of a do notattempt cardio-pulmonary resuscitation order (DNACPR).

The lead nurse audited every tenth record and used anonline auditing tool to monitor the results. The auditchecked records included appropriate recording ofmedicines, safeguarding, consent and capacity, patienttreatment and patient assessment. In the three monthsprior to inspection the service averaged 98.69%compliance.



Good –––


Staff ensured patient records were available to hospitalstaff. The registered manager told us that patient recordswere photocopied if the patient was taken to hospital, sostaff had a record of care and treatment provided.

Staff reported that they could store paperwork securelyon the ambulances. Records were stored in a lockableglovebox of the ambulance and handed in at the end ofeach shift before being sent to the appropriate NHS trustor stored on a weekly basis.

All computers at the service were secure and needed apassword to logon. The service ensured staff changedtheir logins on a regular basis in line with informationsecurity standards.

The service had recently gained compliance with the dataspace transfer governance (DSTP) informationgovernance for the NHS and were permitted to use NHSlogins for their emails.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

The service had a medicines management policy inplace. The policy contained information on storage ofmedicines, controlled drugs and administeringmedication.

The service stored medicines centrally and the lead nursewas responsible for this process. Medicines bags wereprepared for staff to take to events or when carrying outemergency medical care. Staff picked up a medicine bagsbefore each shift.

Medicines used for conveying patients from events andwhen attending emergency calls were taken from themedication storage on the site prior to staff attending theevent. The registered manager told us medicines wereheld in medicine bags with the clinician when in use.Individual paramedics were responsible for the storageand control of the medicines allocated to them for theevent or when on emergency calls. The registeredmanager told us the contents and quantities ofmedicines for each paramedic were listed and amendedas they were used. All medicines administered was alsorecorded on the patient treatment form. The followingtheir shift, staff would then store medicines and theywould be checked into the medicines storage room onsite.

The service used controlled drugs and had the requiredcontrolled drugs licence. Whilst on inspection wechecked the controlled drugs book and found that therecords were accurate.

Staff at the service carried out room temperature andfridge temperature check we saw the checks had beencarried out daily.

Medical gases including nitrous oxide and oxygen werealways stored securely on the ambulance. Medical gaseswere secured to the vehicle wall and were in date. Stafftold us the vehicle was kept locked when not in use.

The service had a formal contract with an externalprovider for oxygen and nitrous oxide cylinder supply andremoval.

Staff had training in the use of medical gases.Competence had been assessed on different courses andthe registered manger shared the syllabus with us toshow the topics included.

Staff told us they referred to Joint Royal CollegesAmbulance Liaison Committee (JRCALC) guidelines whenthey required further guidance on the use of medicationand medical gases. These were updated as new advice orguidance was published and were available on allvehicles.

The service had resuscitation policy which clearly statedthe procedure for administering emergency medicinessuch as oxygen and intravenous fluids. This was line withJoint Royal Colleges Ambulance Liaison Committee(JRCALC) guidelines.

Incidents

The service did not fully comply with Duty ofCandour legislation. However, the service managedpatient safety incidents well. Staff recognisedincidents and near misses and reported themappropriately. Managers investigated incidents andshared lessons learned with the whole team, thewider service and partner organisations. Managersensured that actions from patient safety alerts wereimplemented and monitored.

The service reviewed and followed up incidents. Theservice reported 35 incidents from January 2019 toDecember 2019. Of these incidents none were neverevents and one was a serious incident. Never events are



Good –––


defined as ‘adverse events that are serious, largelypreventable, and of concern to both the public andhealth care providers for the purpose of publicaccountability’. The service had a policy document thatincluded how and when to report incidents. This includednear misses, moderate harm and informationgovernance.

The records showed that incidents were reviewed andacted on. The registered manager gathered witnessstatements from staff to investigate the incident and stafftold us learning was shared with them. The service hadseparate incident files for serious incidents, each NHSprovider and for other incidents.

The service learned lessons and made changes followingincidents. The service had a serious incident whichresulted in harm to a patient due to staff not following thecorrect procedure when clamping a wheelchair into theback of an ambulance resulting in a patient falling. Whilston inspection we saw that the service had notices on staffboards reminding staff if the correct procedure.

The service completed incident forms for otherorganisations when they were not responsible for theissue. For example, when they were not given correctinformation about the patient and this affected thetransport or delivery of service.

The registered manager monitored incident themes andtrends, however there weren’t any identified themes.

The registered manager shared learning with the staffmembers involved as part of the investigation process.Any learning that was identified was shared with staff onstaff boards. We saw an example of this where there waslearning related to wheelchair clamps highlighted on thestaff board after a serious incident had occurred.

The service had a Duty of Candour Policy in place. Duty ofcandour requires providers of health and social careservices to notify patients (or other relevant persons) ofcertain ‘notifiable safety incidents’ and provide supportto that person. The policy contained suitable referencesto regulations and highlighted the steps that needed tobe undertaken following a serious incident. However,some actions were attributed to specific roles which werenot relevant in the organisation for example, a seniorclinical counsellor so we were not assured the policy wastailored to the organisational structure. The policy wasdue for review at the time of our inspection.

Where serious incidents had occurred, there was a robustapproach taken to investigation and actions were fullyimplemented. Staff had suitably followed some aspectsof the duty of candour however did not follow the Duty ofCandour policy fully to comply with all the Duty ofCandour regulations. Staff had notified relevant personspromptly were open and honest when an incidentoccurred and demonstrated they apologised and madeinitial contact with the relevant person over email.However, they did not offer or send copies of the incidentreports and actions to the relevant person and meetingsto discuss incidents were not routinely offered. Theservice also did not provide appropriate feedback andoutlined the measures taken to prevent re-occurrencewith the relevant person following on from a seriousincident. The service’s Duty of Candour policy in sectionexplained the necessary steps which should beundertaken in notifying the relevant person following aserious incident, but these were not always followed.

Are emergency and urgent care serviceseffective?(for example, treatment is effective)

Good –––

We rated effective as good.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and evidence-based practice.Managers checked to make sure staff followedguidance.

Staff had used updated and new guidance as it was madeavailable to them. New medical guidance was shared bythe service and then shared with staff. Staff told us theyhad access to Joint Royal Colleges Ambulance LiaisonCommittee (JRCALC) guidelines. The registered managertold us staff had access to sepsis and Advanced LifeSupport flowcharts as in the National Institute for Healthand Care Excellence (NICE) guidelines.



Good –––


All staff could access the on-line staff portal where theycould read policies. We were told that any alert tochanges to policies or urgent information sharing wasdone through a staff bulletin or staff electroniccommunication application.

Policies and procedures reflected national guidelines. Forexample, the resuscitation policy included clear guidancefor staff from the United Kingdom Resuscitation Council(UKRC) and Joint Royal Colleges Ambulance LiaisonCommittee (JRCALC). This included guidelines on how tomanage a cardiac arrest, post resuscitation care andhypothermia.

The registered manager told us the service followed theunified do not attempt cardio-pulmonary resuscitationorders (DNACPR) from the hospital wards. The serviceonly used original copies of DNACPR paperwork whentransporting patients who had them in place.

Staff told us if a patient dies whilst on board theambulance and the team were aware of a do not attemptcardio-pulmonary resuscitation order (DNACPR) or thepatient was nearing the end of their life, they told us theywould continue to the destination and inform theappropriate authorities.

At the time of inspection staff did not undertake securemental health transfers. Staff had training in mentalhealth awareness as part of the mandatory trainingprogramme.

Pain relief

Staff assessed and monitored patients’ pain.

Staff assessed patients pain using a verbal 0-10 pain scoreand recorded this on the patient treatment record. Therewas also a visual pain scale for children or adults whowere unable to communicate their pain verbally.

Whilst on inspection we saw staff ask about pain levels ofpatients and record the pain score.

Staff had access to pain relief medication if it wasrequired. All staff were able to administer pain relief.

Response times

The service monitored and met key performanceindicators so that they could facilitate goodoutcomes for patients. They used the findings tomake improvements.

The service monitored key performance indicators (KPIs)against targets set by the three NHS organisations theyhad urgent and emergency contracts with. Responsetimes overall were monitored by the trusts that theservice had contracts with. The performance of thisservice would form part of that, so there is not a specificresponse time which was monitored.

The service was performing well with the majority of itsKPIs. We reviewed the KPIs of the NHS contracts andcould see that the service was performing well withinwhat it could control. When the service operated onbehalf of NHS trusts they had a number of KPI’s inrelation to service provision; including areas such asshifts cancelled after being confirmed, booking on theshift within five minutes of start time, post hospital turnaround and hospital handover. In the last ten months theservice had achieved amber (on target) times and green(exceeding target) five times.

The service looked into poor performance areas withinthe KPIs to see if it could improve. For example, sinceJune 2019 the services performance in clinical handovertimes had dropped. This was due to the serviceexpanding the emergency departments it serviced. Theservice had delays in clinical handovers at someemergency departments due to the high levels ofcapacity of those emergency departments.

The service was performing well with its air ambulancetargets. The service had a 100% response rate within twohours to emergency air ambulance patient transfer tohospital requests for the trust it had a contract with.

Patient outcomes

The service monitored the effectiveness of care andtreatment.

In the 20 patient records that we reviewed showed staffhad administered timely treatment and had a clearexplanation for why patients were transferred to hospital.

The lead nurse audited every tenth patient treatmentrecord in order to check the effectiveness of the care andtreatment provided and ensured that they had positiveoutcomes where possible. The audit checked recordsincluded appropriate recording of medicines,safeguarding, consent and capacity, patient treatmentand patient assessment. In the three months prior toinspection the service averaged 98.69% compliance.



Good –––


The service did not necessarily identify any overallchanges that needed making but it did highlightindividual practice mistakes which were correctedthrough conversation and supervision of staff.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held meetings with them to provide support anddevelopment.

The service had an appraisal system that met the needsof the staff and the business. Team leaders carriedappraisals for the staff in their teams. The registeredmanager and staff told us these identified staff membersspecialist strengths, development or training needs andhow they would be achieved. As of December 2019. theappraisal rate was 98%.

We saw evidence of staff appraisals in all the records wereviewed, and staff told us they had annual appraisals.

The service had an induction policy in place to ensurethat all new staff received consistent and appropriateintroduction. This policy applied to all permanent ortemporary staff. The service had an induction checklistwhich staff would complete. The induction checklistincluded; infection prevention, safeguarding,resuscitation, vehicles and equipment, healthcarepathways, medicines management, uniform andpersonal protective equipment, risk, event medicine,clinical assessment, major incidents and duty of candour.

The service had an online system that automaticallychecked staffs driving licences on a six- monthly basis.The system sends automatic alerts if it finds issues. Staffmembers have their driving license physically checked onrecruitment prior to employment. We saw in all staffrecords we reviewed that staff had driving licence checksupon recruitment.

All members of staff that carried out driving dutiesincluding emergency driving had evidence of additionaldriver training. The service had emergency drivinginstructors who held an advanced driving qualificationand assessed all new staff members. Drivers werere-assessed every three years if they drove regularly andyearly if they weren’t regular drivers. We also sawevidence of drivers being re-assessed appropriatelyfollowing incidents.

The registered manager told us they checked theparamedic registration details on the Health and CareProfessions Council (HCPC) website. This registrationrequired paramedics to demonstrate every yearly theyare trained and competent to work as a paramedic.

The service employed eight nurses in total. The serviceensured nurses had undergone re-validation.

Staff worked in a crew of two or more and there was nolone working.

Multi-disciplinary working

All those responsible for delivering care workedtogether as a team to benefit patients. Theysupported each other to provide good care andcommunicated effectively with other agencies.

The service worked with other organisations andprofessionals to ensure the safety of patients. The servicehad contract with three NHS providers and the registeredmanager attended regular meetings with theseorganisations.

The staff told us they had regular contact with medicalstaff at hospitals and other units when carrying outurgent and emergency work and patient transports. Theservice had several examples of positive feedback fromother organisations.

Staff worked with the local authority and NHSorganisations when raising safeguarding concerns aboutpatients.

Staff liaised with the local emergency departments andhospital wards about specific patients’ care. When theyconveyed an acutely unwell patient to an emergencydepartment or hospital ward, they alerted the hospital toensure the department was ready to receive the patient.

Consent, Mental Capacity Act

Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent. Theyknew how to support patients who lacked capacityto make their own decisions or were experiencingmental ill health.

All staff had received training in consent. If the patientlacked capacity or was confused staff demonstrated agood understanding and reported, they would remain



Good –––


calm and compassionate. If the patient had capacity butwas unable to talk, staff told us they would try to obtainconsent non-verbally. The service had a consent andcapacity policy in place. The Mental Health and MentalCapacity policy on the staff portal provided guidance onconsent, how to establish capacity and how to record it inthe patient record.

Staff had training in mental health awareness. The servicecould transport patients with mental health conditionswith or without escorts as part of the urgent andemergency work. At the time of inspection, the servicedid not transport patients who were sectioned under theMental Health Act.

The service did not use restraint methods for patienttransfers. Staff told us they did not use restraint if apatient had challenging behaviour. Staff would try tode-escalate the situation, talk to health care professionalswho knew the patient and call the police if the situationwas not manageable. Some staff had training in conflictmanagement.

Staff told us when a patient declined to be transported itwas documented on the patient transport form (PTR).The registered manager told us that some staff hadconflict resolution training and skills, but that staff wereable to risk assess the situation at the time. Staff wereable to refuse to take a patient if they deemed the patientor staff would be unsafe. For example, if a patient wasaggressive or at risk of harming themselves or others.

Staff told us they would always seek consent from thepatient to transfer them to hospital and this would berecorded in the comment box of the patient treatmentrecord. On all patient treatment records we reviewed theconsent section was filled in appropriately. If the patientdeclined transfer, staff recorded this on the record andthe patient was asked to sign. We did not see any recordswhere the patient had declined transfer to hospital.

Staff demonstrated they had a good understanding of theMental Capacity Act. Staff were able to recognisesituations where consent was impaired, for example if thepatient was unconscious or confused. If a patient wasunconscious and needed emergency medical treatmentat the hospital, staff told us they would work in thepatient’s best interests and transfer to hospital.

Staff told us if a patient was confused, they would carryout a capacity assessment. If the assessment showed thepatient lacked capacity to make the decision, they woulddiscuss it with the police, explain the rationale for thedecision and request assistance.

Are emergency and urgent care servicescaring?

Good –––


Compassionate care

Staff treated patients with compassion andkindness, respected their privacy and dignity, andtook account of their individual needs.

During the inspection we observed three patientjourneys. We observed one high dependency transfer andtwo emergency calls, Staff always treated patients withkindness and compassion during these journeys.

Staff always respected patients’ privacy and dignity.During the patient journeys we observed staff werealways conscious of patients’ privacy and dignity. Staffensured that curtains were closed in patients’ homeswhen carrying out examinations on them. Staff ensuredthat curtains were drawn in hospitals when transferringpatients from the bed to the stretcher.

Staff took account of patients’ individual needs. Stafftried to follow patient’s wishes on where they wouldreceive treatment on the patient journeys we observed.

We looked at ten patient feedback cards during theinspection. Patient feedback cards were all positive.Patients said, “staff were comforting and attentive” and“staff were extremely friendly, professional and made mefeel at ease.”

Emotional support

Staff provided emotional support to patients,families and carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.



Good –––


Staff showed emotional support to patients. We saw staffhave conversations with their patients about theirwellbeing and regularly checked on them. Staff alsospoke with the relatives of two patients to see how theywere doing.

We looked at several patient feedback cards during theinspection. Patients provided feedback on emotionalsupport. One patient said, “staff made sure I was OKwhen I was upset and couldn’t do anymore for me.”

Understanding and involvement of patients andthose close to them

Staff supported and involved patients, families andcarers to understand their condition and makedecisions about their care and treatment.

Staff showed understanding to patients and to thoseclose to them. We saw staff explain the situation topatients and try and carry out the treatment the patientrequired. Staff phoned the hospital ward directly toattempt to get the patient immediate access which theyasked for to reduce the patients anxiety of having to wait.Staff also spoke to those close to the patients to see ifthey wanted to accompany the patient in the ambulance.

We looked at several patient feedback cards during theinspection. Patients provided feedback on understandingand being involved in patient care. One patient said, “thecrew always explained everything to me as they wentalong.”

Are emergency and urgent care servicesresponsive to people’s needs?(for example, to feedback?)

Good –––

We rated responsive as good.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved.

The service had contracts with three NHS providers. Theservice responded to urgent emergencies for two of the

providers and carried out high dependency patienttransfers for the other service. The emergency and urgentcare service provided emergency care and treatment forpatient who required it.

The emergency and urgent care service providedtransport to hospital for patients from events, providingprompt access to treatment was needed.

The service provided free support to assist vulnerablepatients repatriate. Staff had transported a victim of aterrorist attack. The service transferred a patient back toanother country following an attack in the UK. Staff alsotransferred a patient for free who called for a transfer butcouldn’t afford the fees.

The service covered events and only worked at eventswhere they conveyed patients who needed it to hospital.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Theservice made reasonable adjustments to helppatients access services.

The staff told us they rarely transported patients whorequired an interpreter, but they would ask about anyrequirements at the point of booking if the journey waspre planned. If the patient was accompanied by a familymember or carer, they would ask for their assistance intranslating. Staff would only use family members inemergency situations until an appropriate translatorcould be arranged. Staff understood the risks involvedwith having family members translate for patients. Staffalso had emergency communication booklets withcommon emergency phrases in 18 different languages.Staff told us there was a telephone translator service theycould call on their mobile phones if required. The servicealso had posters in the six most common languages. Theservice had communication aids if they were required forpatients with learning disabilities.

Staff had mental health awareness training. Mental healthawareness also formed part of the induction process.

The registered manager told us that booking informationwas taken that reflected the cultural, religious orpreference needs of the patient. For example, female onlycrews were available if requested. This would not alwaysbe possible in an urgent or emergency situation.



Good –––


Staff had training in dementia awareness, and it formedpart of the staff induction process. The registeredmanager told us that staff used their training orexperience of working with patients. The service haddementia friendly distraction aids which could be used tocomfort patients living with dementia.

All ambulances were equipped to transport patients whorequired assistance with getting in and out of theambulance or who used wheelchairs or other walkingaids. There was a child harness available for use with thestretcher on the ambulance.

Access and flow

People could access the service when they needed it,in line with national standards, and received theright care in a timely way.

The service operated 24 hours a day, seven days a week.

Patients accessed the service via emergency calls toreceive emergency care when it was required. The servicealso provided high dependency transfers for patients.

Patients accessed the service for transfer to hospital fromevents by presenting at the onsite medical centre andbeing assessed by staff.

At events that required patients being transferred tohospital the registered manager told us there was alwaysa vehicle available for this.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff,including those in partner organisations.

The service had a complaints policy which told patients,their family, carers and other professionals how to make acomplaint. Staff told us they were aware of thecomplaints process. The policy stated that complaintswere accepted verbally or in writing. The complaint wasconsidered formal if the person making the complaintrequested it and the details of the complaint wereprovided. The policy outlined the responsibilities, duty ofcandour and the complaints process.

Complaints were acknowledged within three workingdays and a complete written response sent within 25

working days. If the complaint was more complex andtook longer to investigate, the policy stated that thecomplainant would be kept informed. If the complaintinvolved other providers, the service shared thecomplaint, with consent, and requested they respondedseparately.

In 2019 the service had eight patient complaints allrelated to the urgent and emergency care service. Threewere due to clinical disagreements, two complaints weredue to lost/broken property, one was the crew attendingan incorrect address, one was for faulty equipment andone was due to poor staff attitude.

We reviewed three patient complaints and found that theservice had responded appropriately and in a timelymanner on each of the occasions.

The registered manager did not identify any particularthemes of trends from their complaints.

The registered manager used team meetings and the staffmessage board to share any lessons learnt fromcomplaints if it was needed.

Are emergency and urgent care serviceswell-led?

Good –––

We rated well-led as good.

Leadership of service

Leaders had the skills and abilities to run theservice. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. They supported staff to develop their skillsand take on more senior roles.

The senior management team comprised of; theregistered manager, head of operations, clinical director,lead nurse, head of human resources, finance manager,training and compliance manager and the head of eventsand business development.



Good –––


The registered manager had overall responsibility for therunning of the company. The registered manager alsoworked alongside the staff on patient transport journeyswhen needed. They carried out appraisals and providedtraining as required.

The organisation was a nationally recognised accreditedteacher of first aid. The service was also accredited toteach advanced ambulance practitioner and emergencyblue light ambulance driving both of which werenationally accredited and used by the NHS ambulancetrusts as recognised courses.

The senior management team was also responsible forthe management of risk, complaints and incidentinvestigation and governance of the service. They haddeveloped new processes and use of electronic systemsto provide clear oversight of the service.

The clinical director acted as senior clinical advisor andwas available for staff to contact for clinical advice. Theywere responsible for updating staff on clinical guidelinesand overseeing the clinical support of the team. Theregistered manager told us they would meet with theclinical director regularly or when needed.

Staff told us that managers were visible andapproachable.

Staff told us that communication with the leadershipteam was very good. We saw evidence of thiscommunication on communication boards on theinspection site.

We found the leadership team were very responsive. Theregistered manager provided us with informationpromptly.

Vision and strategy for this service

The service had a vision for what it wanted toachieve. Leaders and staff understood and knewhow to apply the vision.

The service had a vision that stated it, ‘aims to be theoutstanding provider of quality ambulance provision withthe highest level of trained staff from our own in-housetraining academy supporting a vibrant and growingeconomy’. Its mission was to, ‘Work with employers and

employees to deliver high quality patient care and offerlife changing employment opportunities whilst providingoutstanding teaching and learning’. Staff were aware ofthe services vision and mission.

The registered manager told us his continuing vision andstrategy would be to focus on growth whilst maintainingquality.

Staff and registered manager told us there were plans todevelop the business and expand to do more eventswork.

The service was also developing its training facilities andhad recently purchased a new building with a focus onpolicies and training for in house staff and staff fromoutside the company.

Culture within the service

Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The service provided opportunities for careerdevelopment. The service had an open culturewhere staff could raise concerns without fear.

Staff demonstrated throughout the inspection that theyplaced a high priority on ensuring a good standard ofpatient centred care. Staff said they were proud of theircommitment to patient care.

Staff told us they were proud to treat patients and carerswith compassion and kindness. They aimed to provideemotional support to patients, families and carers.

Staff told us they felt respected, supported and valued bythe leadership of the service.

Staff told us the registered manager was visible andapproachable for all staff and staff could raise concernswithout fear.

Staff told us they were able to raise concerns without fearof victimisation. The service had a recognised personresponsible for staff feedback, including whistleblowingand complaints. Staff were actively encouraged to giveboth positive and negative feedback.

Staff were able to access training online or face to face.Staff told us if there was other training, they wished to do



Good –––


they could discuss this with the registered manager. Theservice had good training facilities on site. The servicehad developed a team leader role for staff members whowanted to advance.

Managers took account of staff members emotionalwell-being. A senior member of staff held debriefs withstaff members if there was a traumatic incident. A seniormember of staff held a debrief after each event whichincluded reflecting on any patient care.

Governance

Leaders operated good governance processes,throughout the service. Staff at all levels were clearabout their roles and accountabilities and hadopportunities learn from the performance of theservice.

The registered manager was responsible for allgovernance arrangements. The senior management teamincluded the registered manager, head of operations,clinical director, lead nurse, head of human resources,finance manager, training and compliance manager andthe head of events and business development. There wasa clear organisational and reporting structure which staffwere aware of and understood what they wereresponsible for.

Staff at the service had a regular weekly team meetingwhere staff were updated. If staff could not attend thismeeting they could be updated on incidents, complaintsand other feedback using either the staff communicationboard, and electronic app or via email. These meetingwere minuted so staff could access the information ifneeded.

The service held regular meetings whenever they wererequired for incidents or any other issues. These meetingwere always minuted. We reviewed four sets of meetingminutes which included meetings for; scope of practicefor staff, contact meetings, employee relations andrecruitment. The minutes for the meetings were clear andconcise. There were clear actions and responsible staffmembers with timeframes for each of the actions.

Management of risk, issues and performance

Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact.

The service had a risk management framework in place.The policy outlined the responsibilities of different staffand staff in terms of risk management. It also highlightedthe management of the risk register and explained therisk management training on offer to the relevant staffmembers.

The service had a risk register in place. At the time ofinspection, the risk register was being reviewed by anexternal contractor. The service sent us the risk registerfollowing the inspection. The risks on the register wasrated, ‘low, moderate and high’, using a scale on bothlikelihood of the risk occurring and the severity of theconsequences if it did. The risk register stated who hadownership of the risks so it was clear who wasresponsible and the assurance plans in place.

The service had several ‘high’ risks on the risk register,which had current positions and assurance plans inplace. One example was the risk, ‘Harm to staff or visitorsand negative impact on company reputation due to poorhealth & safety or unkempt premises. To counter this riskstaff did regular health and safety checks of the premisesand had a single point of contact for maintenance andsecurity issues. The service also did a report of premisesto board meetings and monitored incidents daily usingan incidents log.

The registered manager told us one of the main risks atthe time of inspection was non-payment for servicesdelivered within a reasonable time frame. The registeredmanager had bought in a finance director who hadimproved the timeliness of payment.

Information Management

The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats. The information systems wereintegrated and secure. Data or notifications wereconsistently submitted to external organisations asrequired.

Staff had access to a password protected electronic staffapplication where they could read policies and accessother forms.



Good –––


Staff could access and provide a variety of performancedata relating to their urgent and emergency care workbroken down by each provider.

Confidential information was stored on secure electronicsystems. Paperwork with confidential patient informationwas stored in a locked cupboard and shredded when notneeded.

The registered manager submitted notifications to theCQC following safeguarding alerts or serious incidents.They had also completed safeguarding alerts to the localauthorities and hospitals.

The registered manager was responsive to requests fordata and additional information as requested followingthis inspection.

Public and staff engagement

Leaders and staff openly engaged with staff,patients and the public to plan and manage services.

Leaders encouraged staff engagement and ensured theywere available to staff. Staff were able to comment onpolicies and procedures through staff meetings or talkingdirectly to one of the senior management team. All staffwere members of a closed staff electroniccommunication group that was also used to sharefeedback and other information. Staff can also leavefeedback through an online questionnaire.

Patients were able to leave feedback easily. We saw afeedback poster and cards on the ambulance. Thesecould be completed by patients, families and carers andplaced in a secure post box fixed to the internal wall ofthe vehicle. The service also used information frominternet-based feedback, complaints and compliments.The service told us, and from what we saw, patientfeedback was generally positive but there was a lowresponse.

The service engaged with its partners and the widerhealthcare economy. The service provided a link on theinvoices it sent to private companies. The service hadregular meetings with the NHS trusts it worked with andwere inspected by these trusts on a regular basis.

Innovation, improvement and sustainability

All staff were committed to continually learning andimproving services.

The service was investing in new facilities in order toimprove learning opportunities for its own staff andhealthcare staff from other organisations. The service wasincreasing the training facilities it had in order expandthat side of its business as well as improve the training onoffer for its own staff.

The service worked prior to some events to researchrecovery from potential drug related illness. This helpedthe service make clinical decisions about whether or nota patient who came in whilst unwell needed conveying tohospital. The service looked on internet forums prior toevents to research the drugs that were commonly incirculation and look at side effects. Staff then looked atdrug amnesty bins and at drugs taken by patients duringevents in order to help staff working at events have aknowledge of the strength and side effects of the drugs atthe festival. This was also used to help staff at futureevents.

The service worked with local schools in order to try andprevent injuries to children. The service sent a paramedicto a school following an incident when a child wasinjured during a fight. The paramedic explained theimpact the injuries could have on the person involved inorder to try and prevent this from happening again.



Good –––


Safe Good –––

Effective Good –––

Caring Not sufficient evidence to rate –––

Responsive Good –––

Well-led Good –––

Information about the serviceAmbulance Station is operated by Central Medical Services,East Midlands. The service was registered at thislocation on 5 May 2017. It is an independent ambulanceservice in Linby, Nottinghamshire. The service primarilyserves the communities of the East Midlands.

The service had two patient transfer specific ambulances.The vehicles were parked on site overnight.

Activity (1 January 2019 to 31 December 2019)

There were 8,250 patient transfers for NHS trusts. Theservice carried out five private patient transfer journeys.The service carried out 88 patient transfer journeys from airambulance to another location.

The service employed 210 members of staff, of which 199were frontline staff. All of the frontline these staff couldwork in patient transport services.

Where our findings on patient transport services – forexample, management arrangements – also apply to otherservices, we do not repeat the information but cross-referto the emergency and urgent care section above.

Summary of findingsWe found the following areas of good practice:

• The service maintained its vehicles used in patienttransport services.

• Staff responded appropriately if a patient becameunwell when being transported.

• The service staffed patient transport journeysappropriately.

• Staff kept detailed records of patients’ care andtreatment during patient transports.

• The service stored patients own medicationappropriately.

• The service monitored arrival and departure timesfor journeys.

• The service planned and provided care in a way thatmet the needs of local people and the communitiesserved.

• People could access the service when they needed it,in line with national standards, and received the rightcare in a timely way.


Patient transport services

Good –––


Are patient transport services safe?

Good –––


Mandatory training

The management and completion of mandatory trainingacross the service was the same for both the emergencyand urgent care service and the patient transport service.The evidence detailed in the emergency and urgent caresection of this report is also relevant to the emergency andurgent care service and therefore we have used this to ratethis service.

Safeguarding

The management of safeguarding across the service wasthe same for both the emergency and urgent care serviceand the patient transport service. The evidence detailed inthe emergency and urgent care section of this report is alsorelevant to the patient transfer services and therefore hasbeen used to rate the service.

Cleanliness, infection control and hygiene

The management of cleanliness, infection control andhygiene across the service was the same for both theemergency and urgent care service and the patienttransport service. The evidence detailed in the emergencyand urgent care service section of this report is alsorelevant to the patient transport service and therefore hasbeen used to rate the service.

Environment and equipment

The service maintained its vehicles used in patienttransport services.

We reviewed one of the two patient transport vehicleswhilst on inspection. The vehicle was in good conditionand contained appropriate serviced and calibratedequipment.

The rest of the management of the environment andequipment across the service was the same for both theemergency and urgent care service and the patient

transport service. The evidence detailed in the emergencyand urgent care service section of this report is alsorelevant to the patient transport service and therefore hasbeen used to rate the service.

Assessing and responding to patient risk

Staff responded appropriately if a patient becameunwell when being transported.

Staff responded to patients who became unwell while withthe service. The registered manager and staff told us that ifa patient’s health deteriorated while being transported theteam would review their condition and drive to the nearestemergency department. Staff told us, if possible, theywould call ahead or contact 999 for urgent assistance.

The service had defibrillators on patient transport vehicles,but they did not contain all the patients monitoringequipment they had on urgent and emergency vehicles.

The rest of assessing and responding to patient risk acrossthe service was the same for both the emergency andurgent care service and the patient transport service. Theevidence detailed in the emergency and urgent care servicesection of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Staffing

The service staffed patient transport journeysappropriately.

Staff were allocated to regular patient transport shifts theservice did for an NHS trust. The service would also staffany ad hoc private patient journeys if they were booked.

The registered manger and staff told us that if a bookingwas for a long-distance journey three crew would beallocated. This meant one to drive, one to remain with thepatient and one to sleep. Or if the patient was self-caring,they would provide a two person crew.

The rest of staffing across the service was the same for boththe emergency and urgent care service and the patienttransport service. The evidence detailed in the emergencyand urgent care service section of this report is alsorelevant to the patient transport service and therefore hasbeen used to rate the service.

Records



Good –––


Staff kept detailed records of patients’ care andtreatment during patient transports.

Bookings were received electronically or over the phone.On this inspection there was an electronic booking systemand electronic patient transport forms.

We reviewed the booking system and were told that thestaff member taking the booking was responsible forcompleting the form. Information required included thepatient details, the collection address, destination andreason for journey. We were told that on booking staffwould request clinical details, diagnosis, infections ormental health needs, the presence of a do not attemptcardio-pulmonary resuscitation order (DNACPR) and anyescorts to accompany the patient.

The rest of the management of records the service was thesame for both the emergency and urgent care service andthe patient transport service. The evidence detailed in theemergency and urgent care service section of this report isalso relevant to the patient transport service and thereforehas been used to rate the service.

Medicines

The service stored patients own medicationappropriately.

The service did not store drugs on patient transportvehicles. Patients own medication was kept with theirbelongings. Medicines to be taken home from hospitalwere placed in the patients’ bags by staff at the hospital.

The rest of the management of medicines across theservice was the same for both the emergency and urgentcare service and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Incidents

The management of incidents across the service was thesame for both the emergency and urgent care service andthe patient transport service. The evidence detailed in theemergency and urgent care service section of this report isalso relevant to the patient transport service and thereforehas been used to rate the service.

This service did not have any incidents reaching thethreshold for duty of candour.

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

Good –––

We rated effective as good.

Evidence-based care and treatment

The management of evidence-based care and treatmentacross the service was the same for both the emergencyand urgent care service and the patient transport service.The evidence detailed in the emergency and urgent careservice section of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Response times

The service monitored arrival and departure times forjourneys. The service did not have waiting time targets inthe patient transport service, patients were assigned by thetrust for transfer when they were not able to do so.

Competent staff

The management of competent staff across the service wasthe same for both the emergency and urgent care serviceand the patient transport service. The evidence detailed inthe emergency and urgent care service section of thisreport is also relevant to the patient transport service andtherefore has been used to rate the service.

Multi-disciplinary working

The management of multi-disciplinary working across theservice was the same for both the emergency and urgentcare service and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

The management of consent, mental capacity act anddeprivation of liberty safeguards across the service was thesame for both the emergency and urgent care service and



Good –––


the patient transport service. The evidence detailed in theemergency and urgent care service section of this report isalso relevant to the patient transport service and thereforehas been used to rate the service.

Are patient transport services caring?

Not sufficient evidence to rate –––

During the inspection we did not observe any direct patientcare and were unable to talk to or contact patients, familiesor carers. Therefore, we were unable to rate caring.However, we read compliments received by the service thatshowed compassion and kindness shown by staff topatients, friends and staff from other organisations.

Compassionate care

The management of compassionate care across the servicewas the same for both the emergency and urgent careservice and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Emotional support

The management of emotional support across the servicewas the same for both the emergency and urgent careservice and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Understanding and involvement of patients and thoseclose to them

The management of understanding and involvement ofpatients and those close to them across the service was thesame for both the emergency and urgent care service andthe patient transport service. The evidence detailed in theemergency and urgent care service section of this report isalso relevant to the patient transport service and thereforehas been used to rate the service.

Are patient transport services responsiveto people’s needs?(for example, to feedback?)

Good –––

We rated responsive as good.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved.

The service held a regular patient transport service contractwith one NHS provider and would also provide patienttransport for this service on an ad hoc basis.

The service would also carry out some privately paidtransfers for patients. They also sometimes providedoccasional free transfers for a variety of patients dependenton individual circumstances.

The service provided free patient transfers for a localhospice. Staff had taken different patients to variousdestinations including football matches.

Meeting people’s individual needs

The service did not carry out transfers for patients fromsecure mental health facilities.

The management of meeting people’s individual needsacross the service was the same for both the emergencyand urgent care service and the patient transport service.The evidence detailed in the emergency and urgent careservice section of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Access and flow

People could access the service when they needed it,in line with national standards, and received the rightcare in a timely way.

Patients could access patient transport services throughthe regular or ad hoc contract with an NHS provider, thiswould be arranged by the hospital.

Private patient transport bookings were booked on the dayof travel or in advance. Staff assessed the resourcerequirements and capacity on an individual basis. The



Good –––


operations manager and registered manager wereresponsible for taking patient transport bookings. Theservice advertised a contact number for bookings whichwere linked to mobile phones if the office was unattended.

The service could collect patients who needed to berepatriated to other areas of the country. The registeredmanager told us that the service had collected one patientfrom Europe and returned them to the UK followingsurgery. The patient was clinically well and requiredtransport to return home.

Learning from complaints and concerns

The service had no complaints related to its patienttransport services.

The management of learning from complaints andconcerns across the service was the same for both theemergency and urgent care service and the patienttransport service. The evidence detailed in the emergencyand urgent care service section of this report is alsorelevant to the patient transport service and therefore hasbeen used to rate the service.

Are patient transport services well-led?

Good –––

We rated well-led as good.

Leadership of service

The management of leadership of the service across theservice was the same for both the emergency and urgentcare service and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Vision and strategy for this service

The management of vision and strategy for this serviceacross the service was the same for both the emergencyand urgent care service and the patient transport service.The evidence detailed in the emergency and urgent careservice section of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Culture within the service

The management of culture within the service across theservice was the same for both the emergency and urgentcare service and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Governance

The management of governance across the service was thesame for both the emergency and urgent care service andthe patient transport service. The evidence detailed in theemergency and urgent care service section of this report isalso relevant to the patient transport service and thereforehas been used to rate the service.

Management of risk, issues and performance

The management of risk, issues and performance acrossthe service was the same for both the emergency andurgent care service and the patient transport service. Theevidence detailed in the emergency and urgent care servicesection of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Information Management

The management of information management across theservice was the same for both the emergency and urgentcare service and the patient transport service. The evidencedetailed in the emergency and urgent care service sectionof this report is also relevant to the patient transportservice and therefore has been used to rate the service.

Public and staff engagement

The management of public and staff engagement acrossthe service was the same for both the emergency andurgent care service and the patient transport service. Theevidence detailed in the emergency and urgent care servicesection of this report is also relevant to the patienttransport service and therefore has been used to rate theservice.

Innovation, improvement and sustainability

The management of innovation, improvement andsustainability across the service was the same for both theemergency and urgent care service and the patient



Good –––


transport service. The evidence detailed in the emergencyand urgent care service section of this report is alsorelevant to the patient transport service and therefore hasbeen used to rate the service.



Good –––


Outstanding practice

The service provided free patient transfers for a localhospice and other patients who may needed them.

The service worked with events to try and research drugrelated illness. The service looked in drug amnesty binsand looked on internet forums to research the drugs thatwere commonly in circulation ad look at side effects inorder to help staff working at events as well as staff atfuture events.

The service worked with local schools in order to try andprevent injuries to children. The service sent a paramedicto a school following an incident when a child wasinjured during a fight. The paramedic explained theimpact that the injuries could have on the personinvolved in order to try and prevent this from happeningagain.

Areas for improvement

Action the provider MUST take to improve

• The service must ensure it complies fully with Duty ofCandour regulations following serious incidents. Thiswas a breach of regulation 20 – Duty of Candour.

Action the provider SHOULD take to improve

• The provider should ensure that staff completeinformation governance and prevent training.

• The provider should ensure that the safeguardingadults policy references modern slavery.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Transport services, triage and medical advice providedremotely

Treatment of disease, disorder or injury

Regulation 20 HSCA (RA) Regulations 2014 Duty of candour

The service did not fully comply with Duty of Candourlegislation

This was a breach of Regulation 20 (3) (4)

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Ambulance Station NewApproachComprehensive Report ......Nottingham Nottinghamshire NG15 8AA Tel:...

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Transcript of Ambulance Station NewApproachComprehensive Report ......Nottingham Nottinghamshire NG15 8AA Tel:...