british red cross abingdon newapproachcomprehensive report … · 2019. 4. 9. · •...

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, other information know to CQC and information given to us from patients, the public andother organisations.

Ratings

Overall rating for thisambulance locationEmergency and urgent care services

British Red Cross Society

BritishBritish RReded CrCrossoss AbingAbingdondonQuality Report

Red Cross HouseColdwell DriveAbingdonOX14 1AUTel: 01235 552662Website: www.redcross.org.uk

Date of inspection visit: 04 - 04 November 2015Date of publication: 13/04/2016

1 British Red Cross Abingdon Quality Report 13/04/2016

Letter from the Chief Inspector of Hospitals

The British Red Cross is part of the International Red Cross and Red Crescent Movement, the world’s largestindependent humanitarian organisation. Within the UK, the Red Cross is split into three regions, within which are anumber of areas. The British Red Cross Abingdon is part of the Thames Valley area.

The British Red Cross Abingdon provides an ambulance service in Oxfordshire and Berkshire through a contract with thelocal ambulance trust. There is also an events service that provides first aid support, at public events. The British RedCross Abingdon has contracts with a number of organisations, which hold events in the local area. The Red Crossoperates ambulances as a means by which the organisation can provide humanitarian support and assistance to thosewho need it in a crisis.

We inspected British Red Cross Abingdon on 4-5 November 2015. This was a pilot comprehensive inspection to test ournew methodology for inspecting independent ambulance services. Therefore, we did not rate this service.

Our key findings were as follows:

Is the service safe?

• Staff did not always make sure they stored patient records securely after they completed them.• Staff raised concerns around the lack of radios on vehicles. Staff relied on mobile phones to raise concerns and seek

additional support.• Staff knew how to report a safeguarding concern and completed safeguarding adults and children at risk training.

However, staff were not always confident about what would be considered a safeguarding concern.• Cupboards on some ambulances were not labelled which made it difficult to locate items in an emergency. There

was no standard equipment list on the ambulance so staff could check all items were available. However, allambulances were well stocked.

• Staff reported incidents and senior staff investigated these. The sharing of learning and action points took placelocally and nationally.

• Staff completed their statutory and mandatory training.• Staff followed infection prevention and control procedures. Vehicles in general were clean and tidy, with regular deep

cleans taking place to reduce the risk of infection.• The environment and equipment at the three locations visited and on the ambulances was well maintained. Vehicles

had a current MOT, insurance and regular servicing took place.• A new medicines management system was in the process of being introduced which would improve stock control,

traceability and storage of medicines.• There were effective systems to manage staffing requirements for contract and event first aid work, to ensure the

appropriate number of skilled staff were on duty.• Staff participated with other services in response training for major incidents.

Is the service effective?

• Staff provided care to patients in line with national guidance. Staff were able to seek additional clinical advice, ifneeded, whilst caring for patients.

• Staff completed relevant training for their role, and the majority of staff (85%) had received an appraisal in the lastyear.

• Ambulance staff raised concerns that the restrictions of the contract limited their scope of practice and did not utiliseall their clinical skills. Staff assessed and provided pain relief for patients as needed.

• We saw good multidisciplinary team working between ambulance crews and other emergency teams.• We saw patient consent was obtained before undertaking treatment or observations.

Summary of findings


• Staff did not demonstrate a clear understanding of the codes of practice for the Mental Capacity Act (2005) or MentalHealth Act (1983).

Is the service caring?

• Staff provided compassionate care to patients and their families and maintained patients’ privacy and dignity at alltimes.

• Nationally feedback from the Friends and Family Test was positive, with most patients extremely likely or likely torecommend the service.

• Staff explained the care and treatment they needed to provide in a way their patients could understand.• Patients were encouraged to be partners in their care and involved in decisions about their care and treatment.

Is the service responsive?

• The service worked effectively with the contract ambulance trust and commissioners for event first aid work, toensure they planned services to meet the needs of local people.

• Managers investigated complaints and provided a written response to the complainant. Managers consideredlearning from complaints, but it was not evident that this learning was shared with all staff, to improve services.

• Services were accessible to all and staff had training to support patients in vulnerable circumstances. However,language and communications guides, which were on the equipment lists , were not found on all vehicles, to supportpatients who had additional communication needs.

Is the service well-led?

• There was a local vision for the service, which reflected the national values of the organisation.• Governance arrangements were being developed nationally and locally, with greater attention given to monitoring

and reviewing the quality of the service, against a number of key outcomes. The contract provider monitoredresponse times for ambulance crews and discussed performance at monthly meetings with the service.

• Staff told us leaders were competent, approachable and visible. Staff felt well supported by their immediatemanager.

• Staff told us British Red Cross Abingdon was a friendly and caring place to work. However, staff raised concernsaround their personal safety and welfare, due to there being no panic alarm on ambulances.

• The service encouraged feedback from patients and staff through the use of surveys.• The service had identified ways to develop and sustain its services.

However, there were also areas of poor practice where the location needs to make improvements.

The location should:

• Ensure all patient records are stored securely at all times.• All staff should receive training on duty of candour in order to understand the principles of this and their role.• Review the effectiveness of the safeguarding adults and children at risk training so that staff are clear about what

constitutes abuse and when to report a concern.• Review the current communication channels and process for requesting support in an emergency, for example if the

staff are attacked.• Provide all staff with training on the mental capacity act and mental health act and ensure staff understand how to

use the codes of practice appropriately when caring for patients.• Ensure all vehicles contain the language and communication guides, to support patients with language difficulties

and ensure safe care and treatment.• Consider providing complaints information on all vehicles.• Review the provision of equipment for the safe transportation of children.

Summary of findings


Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Emergencyand urgentcare services

This was a pilot inspection to test our new methodologyfor the inspection of independent ambulance services;therefore, no ratings were applied.

Two information governance breaches around safestorage of patient records were identified during theinspection. Completed patient records were found in afirst aid bag, which was ready for use, and onunsupervised open ambulances potentially puttingpatient confidentiality at risk.

Staff had completed safeguarding training, but lackedconfidence to identify potential safeguarding concerns.Staff raised concerns around being unable to escalateconcerns promptly about deteriorating patients. Staffhad to rely on the use of mobile phones to seek help, asthere was no radio on the ambulance. There weresufficient numbers of suitably trained staff. Stafffollowed relevant procedures for reporting incidents andinfection prevention and control.

The environment and equipment were well maintained.Vehicles were well stocked. The provider had started tointroduce a new system for medicines management, toimprove the stock control, storage and traceability ofmedicines.

Staff followed relevant national guidance to provideeffective care for patients. Staff worked effectively withall healthcare professionals, involved in a patient’s care,to ensure care was planned and co-ordinated to meetthe patients’ needs. Staff did not feel confident in theuse of the codes of practice for the Mental Capacity Act(2005) and Mental Health Act (1983), when caring forpatients and in relation to consent for treatment.

Patients received compassionate care that respectedtheir privacy and dignity. Patients were involved indecisions about their care. Staff were caring,understanding and supported patients emotionally.Staff provided care which was person centred.

The needs of local people were considered whenplanning and monitoring services. Staff delivered care,which considered all the needs of the patient, not just

Summaryoffindings

Summary of findings


their medical needs. However, language andcommunication guides were not available on allvehicles. Complaints were investigated and respondedto, but learning was not widely shared with frontlinestaff.

The service had a local vision, which focused on theorganisation strapline ‘Refusing to ignore people incrisis’. There were governance arrangements in place tomonitor quality and risk, but improvements wereneeded to ensure action plans and risks were reviewed.The service was active in seeking feedback frompatients, volunteers and staff. Senior staff identifiedways to ensure sustainability and development of theservice. Staff spoke of a positive caring culture, withgood leadership. Staff did however raise concernsaround their personal safety, due to there being nopanic alarm on ambulances.

Summaryoffindings

Summary of findings


BritishBritish RReded CrCrossoss AbingAbingdondonDetailed findings

Services we looked atEmergency and urgent care


Contents

PageDetailed findings from this inspectionBackground to British Red Cross Abingdon 8

Our inspection team 8

How we carried out this inspection 9

Facts and data about British Red Cross Abingdon 9

Findings by main service 11

Background to British Red Cross Abingdon

The British Red Cross is part of the International RedCross and Red Crescent Movement, the world’s largestindependent humanitarian organisation. Within the UK,the Red Cross is split into three regions and each regionhas a number of areas. The British Red Cross Abingdon ispart of the Thames Valley area.

The British Red Cross Abingdon provides an ambulanceservice in Oxfordshire and Berkshire through a contractwith the local ambulance trust. Through this contract,British Red Cross Abingdon is involved with theemergency transfer of patients to the accident andemergency department or the appropriate hospitaldepartment or ward. In addition, the service transferspatients between hospitals, if the patient needs to beadmitted to a different ward for continuing care. There isalso an events service, which provides first aid support, atpublic events. The British Red Cross Abingdon hascontracts with a number of organisations, which hold

events in the local area. The Red Cross operatesambulances as a means by which the organisation canprovide humanitarian support and assistance to thosewho need it in a crisis.

The service provides cover seven days a week, for itscontract work. There are five eight-hour shifts eachweekday, which cover the period 8.30am until 11pm. Twoshifts each from Reading and Slough, with one shift fromAbingdon. At the weekend, there is one shift fromAbingdon and one from Reading. Cover for event work ispredominantly at weekends. The British Red CrossAbingdon has a mix of employed staff and volunteers.

We visited three locations Abingdon, Reading and Sloughand accompanied staff on ambulances to observe caregiven to patients.

We inspected British Red Cross Abingdon on 4-5November 2015. This was a pilot comprehensiveinspection to test our new methodology for inspectingindependent ambulance services. Therefore, we did notrate this service.

Our inspection team

Our inspection team was led by:

Inspection Manager: Lisa Cook, Care QualityCommission

The team of four included an inspection manager, aninspector and two specialists, an ambulance technicianand an advanced paramedic.

Detailed findings


How we carried out this inspection

To get to the heart of people who use services’ experienceof care, we always ask the following five questions ofevery service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Before visiting British Red Cross Abingdon, we reviewed arange of information we held about the location andasked other organisations to share what they knew. Wecarried out an announced visit on 4 and 5 November2015.

During the inspection, we observed how people werebeing cared for and reviewed patient records of peoplewho use services. We spoke with 14 staff including

emergency care assistants, a team leader and servicemanagers, including the senior service manager. We alsospoke with the leads for safeguarding, complaints, qualityand fleet management. We observed four interactions ofcare, by accompanying staff on an ambulance, when theyresponded to a call. This included the interactionsbetween the ambulance crew and hospital staff or otheremergency crews. We reviewed four patient records. Wealso looked at local and national policies which staffworked to and checked servicing records for a sample ofambulance vehicles and equipment on these vehicles.Random spot checks were carried out on six vehicles andat the three bases Reading, Abingdon and Slough to lookat cleanliness, infection control practices and stock levelsfor equipment and supplies.

We would like to thank all staff and patients for sharingtheir views and experiences of the quality of care andtreatment provided by British Red Cross Abingdon.

Facts and data about British Red Cross Abingdon

British Red Cross Abingdon key facts and figures

Safe

• 84 incidents (January 2015 to August 2015). Fiveaccidents, 10 near misses and 67 other incidents.

• Currently 99.71% of our volunteers and staff haveSafeguarding training. Up to 1st October 2015Safeguarding was delivered as a two-part package, part1 on Children & part 2 on Adults.

Effective

• The percentage of total staff receiving an appraisal

Ambulance Crew - Staff 76.9%

Ambulance Technician 50.0%

Ambulance Team leader 100.0%

Service Manager 100.0%

Senior Service Manager 100.0%

Caring

• Nationally, the majority of ‘Friends and Family’ testrespondents would be ‘extremely likely’ or likely torecommend the British Red Cross event first aid andambulance services (September 2015).

Responsive

• The provider works with a local ambulance trust totransport patients into hospital when requested by theirGP or another clinician.

• In their event work they have grown the trainingframework to include technicians, along with furthertraining & development of our staff and volunteers todeliver high quality care that avoids the need forhospital admission where clinically appropriate.

Well-led

• During 2016 the key priorities for Ambulance Operationswithin the Thames Valley are:

• To increase the cost recovery to 97% and achieve breakeven.

Detailed findings


• To maintain the current level of provision to the localambulance trust.

• To achieve a 95% conversion of Emergency DrivingInstitute drivers to D2 or its equivalent.

• To enhance the commercial relationship with the localambulance trust to enable long term planning for 2017.

• During 2016 the key priorities for Event First AidAmbulance Operations within the Thames Valley are:

• Increase the number of qualified volunteer ambulancecrew.

• Streamline the fleet of vehicles to ensure they are usedto their best effect.

• Further enhance the offered continuation training toambulance crews and prospective ambulance crews toprovide development and growth within theirvolunteering roles.

• Encourage volunteers to attend events both locally andfurther afield where their skills can be utilised andexpanded.

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the serviceBritish Red Cross Abingdon provides an emergency andurgent care service to patients across the Thames Valleyarea. This is through a contract with the local ambulancetrust and by the provision of event first aid, for local andnational events in the area.

Emergency and urgent care services were operated fromthree locations, Abingdon, Reading and Slough. The mainoffice is at Abingdon, with a further office at Reading. Theoffices were used for all aspects of British Red Cross work,not just emergency and urgent care services. Vehicles usedfor contract work were kept at Abingdon or Reading. Twovehicles were kept at Slough for event first aid work, with asmall rest room for crews to use, if they were in the area.The service had a mix of employed staff, for contract workand volunteers for event first aid.

During the inspection, we visited all three locations. Wespoke with 14 staff including emergency care assistants, ateam leader and service managers, including the seniorservice manager. We also spoke with the leads forsafeguarding, complaints, quality and fleet management.We observed four interactions of care, by accompanyingambulance crews, when they responded to a call andreviewed four patient records. We also analysed dataprovided by the service both before and after theinspection.

Summary of findingsThis was a pilot inspection to test our new methodologyfor the inspection of independent ambulance services;therefore, no ratings were applied.

Two information governance breaches around safestorage of patient records were identified during theinspection. Completed patient records were found in afirst aid bag, which was ready for use, and onunsupervised open ambulances potentially puttingpatient confidentiality at risk.

Staff had completed safeguarding training, but lackedconfidence to identify potential safeguarding concerns.Staff raised concerns around being unable to obtainsupport in a timely way when a patient’s conditiondeteriorated. Staff had to rely on the use of mobilephones to seek help, as there was no radio on theambulance. There were sufficient numbers of suitablytrained staff. Staff followed relevant procedures for thereporting incidents and infection prevention andcontrol.

The environment and equipment were well maintained.Vehicles were well stocked. Following audits completedin April 2015 the provider had started to introduce a newsystem for medicines management, to improve thestock control, storage and traceability of medicines.

Staff followed relevant national guidance to provideeffective care for patients. Staff worked effectively withall health care professionals, involved in a patient’s care,to ensure care was planned and co-ordinated to meet

Emergencyandurgentcare

Emergency and urgent care services


the patients’ needs. Staff did not feel confident in theuse of the codes of practice for the Mental Capacity Act(2005) and Mental Health Act (1983), when caring forpatients and in relation to consent for treatment.

Patients received compassionate care that respectedtheir privacy and dignity. Patients were involved indecisions about their care. Staff were caring,understanding and supported patients emotionally.Staff provided care, which was person centred.

The needs of local people were considered whenplanning and monitoring services. Staff delivered care,which considered all the needs of the patient, not justtheir medical needs. However, language andcommunication guides were not available on allvehicles. Complaints were investigated and respondedto, but learning was not widely shared with frontlinestaff.

The service had a local vision, which focused on theorganisation strapline ‘Refusing to ignore people incrisis’. There were governance arrangements in place tomonitor quality and risk, but improvements wereneeded to ensure action plans and risks were reviewed.The service was active in seeking feedback frompatients, volunteers and staff. Senior staff identifiedways to ensure sustainability and development of theservice. Staff spoke of a positive caring culture, withgood leadership. Staff did however raise concernsaround their personal safety, due to there being nopanic alarm on ambulances.

Are emergency and urgent care servicessafe?

SummaryBy safe, we mean people are protected from abuseand avoidable harm.

Staff did not always make sure they stored records securelyafter they completed them. During the inspection we foundsix patient records in an event first aid kit bag, with the bagplaced in the clean store, indicating it was ready for use. Wealso saw patient records on two ambulances, which wereunlocked, with no staff on the vehicle. The provider hadalready started to address performance issues with relationto the records in the kit bag.

Staff knew how to report safeguarding concerns andcompleted safeguarding adults and children training.However, they did not always understand what wouldconstitute a concern.

Staff raised concerns around the lack of radios on vehicles.They had to rely on mobile phones to raise concerns andseek additional support.

Staff felt confident when reporting incidents, which seniorstaff investigated. Learning and action points were sharedlocally and nationally. Staff did not receive feedback if theyreported an incident to the contract provider. The servicehad plans to introduce a new process to improve this.Senior staff received training on Duty of Candour.

Staff completed their statutory and mandatory training.Driver training for emergency situations was beingupdated, to meet the new standard set by the ambulancecontract provider.

Staff followed infection prevention and control procedures.Vehicles in general were clean and tidy, with regular deepcleans taking place to maintain hygiene standards. Staffhad access to spare uniform and personal protectiveequipment, to reduce the risk of the spread of infection.

The environment and equipment at the three locations andon the ambulances was well maintained. Ambulances werewell stocked, but cupboards on two vehicles were notlabelled, which made it difficult to locate items in an




emergency. Ambulances did not carry a standardequipment list meaning staff could not check they had allthe items. Most ambulances did not have specificequipment for transporting children.

The provider was introducing a new system for medicinesmanagement to ensure improvements in stock control,traceability and storage of medicines. There were nocontrolled drugs stored at the locations.

There were effective systems to manage staff levels/numbers needed for contract and event first aid work.

Staff took part in joint response training for majorincidents, with other services. Business continuity planswere in place, in the event of an emergency, but were out ofdate.

Incidents

• The service had a paper-based system in place for staffto report accidents, incidents and near misses (referredto as incidents for this report). All staff we spoke withwere aware of their responsibility to report incidentsand knew how to do this. Staff told us in general theyreceived feedback when they reported an incident.

• There was a concern amongst staff that the contractprovider did not provide feedback on incidents reporteddirectly to them. In response to these concerns, theprovider was introducing new paperwork for thereporting of incidents. There would be a formalreporting mechanism, which would include feedback.

• Incident data was collated locally. At a local level, thehealth and safety team was responsible for monitoringthis information. The quality and outcome team wasresponsible for the reporting at a national level.

• The local incident spreadsheet did not indicate whetheran incident resulted in low, moderate or severe harm.This meant it was not possible to see at a glance thelevel of impact of the incident on patients or staff.

• Senior staff and team leaders understood theirresponsibility to investigate incidents; they had receivedadditional training to support them in this role. Theincident spreadsheet, showed who had investigated theincident, action taken to prevent recurrence, any furtherinvestigations that took place and whether a riskassessment was reviewed or completed as a result ofthe incident.

• For November 2014 to July 2015 a total of 82 incidentswere reported. There were five accidents 10 near misses

and 67 other incidents, 38 of which were clinicalincidents. The majority of these clinical incidents werestaff being unable to drive under emergency conditions(‘blue lights’), due to the restrictions in place under thecontract. Senior staff were working with the provider toresolve this issue and all eligible staff were to completeadditional driver training to enable them to drive underemergency conditions.

• Learning from incidents was shared with staff throughemail updates, bulletins on the intranet, face to facetraining and by a newsletter for volunteers.

• We saw that safety alerts were emailed to team leadsfrom the contract provider, these were then shared withstaff. Ambulance staff were required to sign to say theyhad read any safety alerts, to show they were aware ofchanges they needed to make to their practice.

• Senior staff gave an example of national learningbecause of a local incident, following the failure of asuction machine. This had resulted in a national reviewwithin the organisation, of the piece of equipment and achange in the testing procedure for the equipment.

• The Duty of Candour legislation requires healthcareproviders to disclose safety incidents that result inmoderate or severe harm, or death. Any reportable orsuspected patient safety incident falling within thesecategories must be investigated and reported to thepatient, and any other ‘relevant person’, within 10 days.Organisations have a duty to provide patients and theirfamilies with information and support when areportable incident has, or may have occurred.

• Nationally the British Red Cross were in the process ofapplying the principles of Duty of Candour across allservices. A new guidance document had been approvedby the board and was to be introduced. Senior staff hadrelieved training of staff, as managers would haveaccountability to make an apology on behalf of theorganisation. The serious incident procedure includedthe requirements of the duty of candour legislation.

Mandatory training

• Mandatory training for staff took place via face-to-facetraining, such as for basic life support and manualhandling, which were updated annually. Some trainingwas delivered via e-learning modules. Data showed 99%of staff had completed their manual handling training,




at the time of the inspection. The service did not providespecific information on which modules were consideredpart of staff mandatory training or the target compliancerate for mandatory training.

• Team leaders were able to review records to see thetraining staff had completed and training, which wasdue for renewal.

• The service had undertaken a recent review of the levelof driver training needed by staff to enable them to driveunder blue lights. This was in response to concernsraised by the ambulance provider whom the contractwas held with, as their staff were required to have adifferent level of training. A rolling programme had beenintroduced for staff to complete the Institute of HealthCare Development emergency driving training (D2). Atthe time of the inspection, 45% of ambulance staff hadcompleted this training, with a target of 95% completionduring 2016. Some staff needed to gain additionaldriving experience before it was appropriate for them toundertake the D2 course, due to the requirements thathad to be met to start the course.

Safeguarding

• Safeguarding adults and children at risk training wasone of the mandatory training subjects for staff. Staff wespoke with confirmed they had completed this training.As of September 2015, 99.7% of staff (Volunteers andemployed) had completed safeguarding training.

• Staff we spoke with were aware of their responsibility toraise a safeguarding concern and knew how to do this.However, staff could not confidently describe thedifferent types of abuse. A safeguarding concern aroseduring an observation of care. Staff did not initially raisethis as a concern. This was discussed with the teamleader and a referral made the next day. Ambulancecrews were clear on the different process to follow, ifthey needed to raise a concern whilst undertakingcontract work with the ambulance provider. Staff knewwhere to access the current policies and procedures, forsafeguarding adults and children at risk, both forin-house and contract work.

• Staff of all grades told us they did not regularly receivefeedback from the contract provider or the localauthority about safeguarding concerns they had raised,to enable learning. The lead for safeguarding told us thisinformation was provided if they contacted the service.The national safeguarding lead followed- up cases ofsignificant concern.

• Senior staff had additional training to support them intheir role as safeguarding officers and leads. There wasan escalation process in place in the event of a staffmember raising a serious concern, this included out ofhours support, both locally and nationally. Changes toprocedures were shared to frontline staff, through thelocal officers. We were told additional safeguardingtraining had been provided for staff in response to anincreasing number of referrals around self-neglect.

• There were robust systems in place for safe storage anddisposal of safeguarding records held locally, whichfollowed national policy.

Cleanliness, infection control and hygiene

• A national infection control policy was in use, supportedby a procedure for staff to follow, including informationon hand hygiene.

• We visited three premises belonging to the service; allclinical areas at these locations were visibly clean andtidy. We also checked six ambulances, all were clean oninitial observation, however on two ambulances, areasnot obvious to the patient, such as around the suctionmachine, the machine for measuring oxygen levels andbehind the seats were noted to be dirty and dusty. Oneambulance was untidy, as it had not been cleaned atthe end of the shift, as expected. This was not in linewith the procedure on prevention and control ofinfection.

• All vehicles we checked had a record of the last deepclean, which was in date. A deep clean involved steamcleaning a vehicle to reduce the presence of certainbacteria. An external company completed this on a sixweekly basis for vehicles used under contract and 12weekly of those used for events. Set locations on thevehicle, were swabbed pre and post each deep clean, toconfirm the clean had been effective and the resultsreported to the service. In the event of a significantcontamination, the company provided a deep clean atshort notice. Staff told us they responded promptly.

• Ambulance crews completed and signed daily vehiclecheck sheets to confirm the vehicle was clean at the endof the shift. Staff told us that each event first aid vehiclehad a cleaning logbook kept in the vehicle. We checkedtwo event first aid vehicles. One vehicle did not have alogbook, another had three books, and these had notbeen filled in by date order. There was no log kept onthe vehicle to show when it was last used tocross-reference this with the cleaning record.




• Staff completed infection control training as part of theirinitial training. We observed one member of staff notcleaning their hands prior to putting on gloves. This didnot follow the process stated in the procedure. For allother observations of care, staff followed best practice,to minimise the risk of the spread of infection betweenstaff and patients.

• On all vehicles we checked, the hand sanitiser gel wasavailable, but on some vehicles, it was not immediatelyvisible, to encourage staff to maintain good handhygiene practices.

• Personal protective equipment, such as gloves andaprons were provided for staff, both on vehicles and atpremises, to protect staff from contact with infectiousmaterials.

• We saw staff cleaning relevant areas and pieces ofequipment on vehicles between patient contact. Sparelinen was provided on vehicles and a system was inplace at all hospitals for dirty linen to be exchanged forclean. For event first aid work, disposable linen was inuse. Spills kits were provided on all vehicles, to minimisethe hygiene risk until the vehicle could be cleaned.Disposable mop heads were used to clean vehicles atthe end of a shift, to reduce the spread of infection.

• Containers for the disposal of clinical waste and shapeswere in place on each vehicle. There were suitablefacilities at all premises for the disposal of clinical waste,at the end of a shift.

• Staff were provided with sufficient uniform, whichensured they could change during a shift if necessary.Staff were responsible for cleaning their own uniform,unless it had been heavily contaminated, when it wasdisposed of as clinical waste.

Environment and equipment

• We checked six ambulances all were well stocked withsingle use items. We checked approximately thirty itemsand all were all within their expiry date and safe to use.The location of equipment and consumable items incupboards was not the same on each vehicle, includingvehicles of the same model. Also, on two vehicles thecupboards were not labelled. This meant that if a crewused a different vehicle there may be delays inaccessing equipment and consumables in anemergency situation.

• There was no standard equipment list on each vehicle,therefore, it was not possible for staff to check andidentify missing items. There was a potential for patient

safety to be put at risk. The daily vehicle check requiredstaff to check essential items the defibrillator, hand heldand power suction machines, but no other items. Wereviewed an audit, completed in September 2015 forone vehicle, this identified items that were out of dateand needed replacing or where stocks were low. Therewas no minimum frequency for repeating this audit.

• We were told that the service had recently introducedvehicle champions, to encourage a high standard ofquality to be maintained on vehicles, such as stocking ofequipment and monitoring of cleanliness. All staff wereresponsible for maintaining stock on vehicles, byrestocking when back at base, or during a shift ifneeded. Stock was clearly arranged at each location,with expiry dates visible were applicable. We were toldthat a stock check was completed every three monthsfor items in the make ready cupboards, however, thiswas not written down to enable more detailed analysisof items used, for audit purposes.

• The organisation was introducing standardised kit bags,such as for burns and resuscitation, across all vehicles,which meant staff could access all the items theyneeded for an incident quickly. Within these bags wasan expected kit list and a diagram on the layout ofequipment within the bag. Team leaders and vehicleschampions were responsible for maintaining thesebags. A tagging system was used to indicate a bag wasready for use. We checked four bags, and found theywere stocked correctly.

• An asset register for medical equipment wasmaintained. This included the item number, next servicedate and the frequency of service. We checked twoitems and the servicing information matched the stickeron the piece of equipment. The logistics of arrangingservicing of both equipment and vehicles and ensuringenough vehicles for a safe service, were well managed.We were told external companies worked flexibly withthe service to meet their need and where possibleservicing was grouped to limit the time the vehicle wasnot in use.

• All vehicles had an up-to-date MOT, service and wereinsured. Keys were stored securely with only relevantstaff having access but staff did not have to sign whenthey took or returned vehicle keys, to identify who hadthe keys in an emergency.




• We saw a vehicle log used in the crew room at Reading,to enable staff to see at a glance any major issues withvehicles and the action taken. One vehicle we checkedhad a ‘not in service’ sign in the front window, as thebattery was flat and awaiting replacement.

• The service did not transport bariatric patients. We weretold an appropriately equipped vehicle, from anotherservice, would be requested if a bariatric patient wasseen at an event and needed transport to hospital.

• There was limited provision on vehicles for thetransportation of children. Only one vehicle we checkedhad a seat with an adjustable child restraint. Staff toldus they would sit the child on the parent’s lap or getthem to lie with the child on the stretcher, if they had totransport a child. On one vehicle, we did not find a babypulse oximeter or a paediatric blood cuff, to ensureappropriate observations could be carried out.

• Staff had training on the safe use of equipment andmanual handling as part of their induction. Updateswere provided by the service as needed. We saw stafffollowing safe manual handling procedures whenmoving patients.

• One vehicle, which was new, did not have a mobiledisplay terminal (MDT), but was in use. Staff had to relyon information about the patient and the location of theincident being called through to them on a mobilephone. The MDT was also used to programme thesatellite navigation system, to enable the crew torespond quicker to the call. This piece of equipment wasin place on the other ambulances.

• The service had completed a premises audit for Readingand Abingdon. An action plan had been produced and anumber of actions completed with changes made toimprove staff and visitor safety. For example, ensuringareas were clear from clutter, waste, completion, anddisplay of Control of Substances Hazardous to Health(COSHH) assessments for the cleaning products used.However, some actions logged in March 2105 remainedoutstanding.

Medicines

• There was a clear system for the order receipt and safestorage of medicines. The keys to storage areas werestored securely. We checked the order, receipt and stocklevel for one medicine at Abingdon, which was correct.

• Medicines management audits had been completed forReading and Abingdon, in March and April 2015respectively, for both event first aid and contract work.

Managers had addressed key actions, includingproviding new key cupboards to restrict, which staff had,access to the central medicines store and ambulanceoperations medicines.

• We checked seven items in the central store at Reading,these were all in date and stock levels matched thoseon the stock control sheet, providing assurance thatmedicines were being safely managed and distributed.However, there was no system in place at any locationto record stock levels for items placed in the make readycupboards, which all staff could access, or in kit bags onvehicles. It was not possible to trace where medicineshad been issued to (vehicle or kit bag) and by whom.There were plans to introduce a new medication usagechart. We checked a sample of items across sixambulances, all were in date other than on two vehiclesout of date glucose tablets were found. Medical gascylinders were also checked and were in date andcylinders at least half-full. Staff checked levels at thestart and end of the shift and restocked as needed.There was no system in place for recoding the exchangeof gas cylinders. This was to be introduced and we sawthe new procedure and transfer record sheet. AtReading, the stock levels in the central gas store had notbeen checked for a week, to ensure a sufficient supply.Medical gases were stored securely and safely at alllocations.

• A coloured tagging system was used to show if amedicines bag was fully stocked and items in date. Ifstaff used an item, but sufficient stock and itemsremained in date a different coloured tag was applied.There was no log sheet in the medicines bag to ensuretraceability of medicines issued to patients. Three out ofsix bags we checked did not have a tag on them.

• Staff could administer different medications dependingon their role. Staff were clear which medications theycould issue. All vehicles contained the full range ofmedicines, in case a vehicle was used for event first aidwork, rather than contract work. There was the potentialfor staff to be in a compromising situation, as they hadtraining and access to additional medicines, but couldnot use them due to the restrictions of the contract.

• Medicines administered to patients were recorded onthe patient report forms (PRF’s). As part of the medicinesaudit a sample of PRF’s were audited, to ensure correctdocumentation. Areas of concern were discussed withthe staff member concerned or a general reminder sentto all staff by email.




• A log was kept of medicines that were disposed of, toensure traceability and safe disposal.

Records

• Secure records storage was available at each office orstation for staff to leave records on completion of theirshift. The team leader was responsible for collecting andreviewing the records on the subsequent day. There wasa secure storeroom for the archiving of records.

• There was a national policy on records management,which covered creation, storage, security anddestruction of records.

• During the inspection, we found six completed patientreport forms (PRF’s) dated 18 September 2015, in anevent first aid kit bag. These had not been removed atthe end of the event, to ensure safe storage and accessto records, as per the records management policy. Inaddition, the bag was in the clean store, identifying ithad been checked by an event first aid coordinator andwas ready for use. This checking process had not foundthe PRF’s. The team leader took immediate action andmade senior staff aware of this incident. Issues relatingto staff compliance with this process were beingaddressed by the service.

• There was a risk of unauthorised access to confidentialinformation as completed PRF’s were left on unlockedand unattended ambulances, which was not in keepingwith the records management policy. This stated thatrecords were not to be left unattended in vehicles. Whilethere was a level of accepted risk, to help manage therisk, staff moved records to a secure location at the basewhen they visited during their shift.

• All patient records were completed on carbonatedforms. The original form was passed to staff at thereceiving hospital, to ensure all staff delivering care forthe patient could access the information. The secondcopy was kept by the organisation to ensure they had arecord of care and were also used for auditing thestandard of record keeping

• The service audited PRF’s every three months. FourPRF’s were reviewed for each crew. Feedback was givento staff on both the content of the PRF and the care theyprovided to patients. Some, but not all staff told us theyhad received feedback, to enable learning andimprovement.

• The ambulance contract provider undertook a monthlyexternal review of record quality for patients seen by theservice. This information was shared with senior staff,

who discussed any concerns with the member of staffconcerned. Senior staff told us that the provider hadasked for this process to be completed internally goingforward and the findings shared at the monthlymeeting.

Assessing and responding to patient risk

• Staff completed clinical observations on patients, aspart of their care and treatment, to assess for early signsof deterioration.

• Ambulance crews worked as dual emergency careassistant (ECA) crews for the ambulance contractprovider. This restricted the type of calls they were sentto. However, staff told us they were sometimes asked toattend as an initial response to a higher risk patient,with back up then provided. Staff told us they riskassessed, through discussion as a crew and with theteam leader, before accepting the call.

• All the ambulance crews raised concerns around thelack of radios in vehicles. They told us this made itdifficult to escalate concerns about deterioratingpatients, seek support or raise concerns about their ownsafety. Staff used mobile phones, but reported theyoften could not get through in a timely manner to therelevant department. For example, a crew requestedback up for a patient whose condition was deterioratinghowever, by the time they had received a call back, thecrew had arrived at the hospital.

• Senior staff told us a national solution was beingconsidered for the lack of radios, however, we were notgiven a timeframe for this. There was no assurance thatthe risk to patient and staff safety was being addressedpromptly.

• Staff completed training as part of their induction toenable them to provide emotional support to patientswith challenging behaviour and those experiencing amental health crisis. A police officer accompanied anypatients detained under the Mental Health Act (1983), aspart of the agreement with the contract provider.

Staffing

• Team leaders and senior staff, regularly reviewedstaffing levels and appropriate skill mix of staff to covershifts through the contract with the local ambulancetrust and event work.

• For event work, a workforce plan was devised based onthe workload from the previous year and any commentsfrom debrief sessions after events, about whether the




level of staffing was appropriate to meet the needs ofthe patients seen. Volunteers were asked which eventsthey could commit to. Shortfalls were managed byasking volunteers to work additional sessions or seekingsupport from neighbouring British Red Cross teams. Theservice would sub-contract the work to another service,should they not be able to resource an event sufficiently.

• For work supporting the local ambulance service, anagreed number of ambulances were provided on eachday of the week. An electronic rostering system wasused to plan shifts. Shortfalls in cover were shown onthis system and staff could request to work additionalshifts. Shifts that were short staffed, were sometimescovered with paid staff from a neighbouring service orby casual workers, employed by British Red Cross. Noagency staff were used.

• We were told that some shifts had to be cancelled ifcover could not be found. Earlier this year this had beenone to two shifts per month, but had recently increasedto three to four a month. It was harder to find staff tocover shifts due to some vacancies remaining unfilledfor a number of months. There were 2.5 whole timeequivalent ambulance crew vacancies as of September2015. There was an ongoing active recruitmentcampaign. Lack of available staff, identified as a risk inSeptember, was on the local risk register. The contractdid not stipulate a set number of sessions per monthover a given time period, which made it difficult forsenior staff to fully anticipate staffing requirements.

• We reviewed the rotas for the two days during ourinspection. Actual staffing levels were as planned. Wealso saw that staff sickness had been recorded on therota for a session in October and cover provided byanother member of staff.

• Staff did not raise any concerns about access to time forrest and meal breaks. We saw crews taking their breaks.

Anticipated resource and capacity risks

• The service worked with the ambulance contractprovider to ensure planned changes to staffing, affectingthe number of vehicles that the service could operate,were communicated to them in good time. The servicehad reduced the number of vehicles from five to fourduring December, due to staff completing vehicletraining. It was not possible with the current number ofstaff for the training to be completed and all shiftscovered.

• Business continuity plans were in place for event firstaid and contract work, to enable the service to plan for,manage and operate in the event of significantdisruption to services. The current plans were out ofdate. However, senior staff told us they had beeninvolved in updating the current versions, and the newversions were in a draft format.

Response to major incidents

• A member of staff told us and we saw on the rota, thatstaff had completed recent road traffic collision trainingwith the fire service as part of the major incident trainingfor staff.

• Ambulance crews were not routinely sent to majorincidents as this was outside their scope of practice.However, there were occasions when crews would bedispatched to ensure enough resources were availablefor patients or they were the closest initial ambulance tothe location of the incident.

• We were told that vehicles did not contain a triage pack,for the assessment and labelling of patients accordingto need, in the event of a major incident, due to theinfrequency that they attended these events.

• Through the work with the local ambulance trust, theservice was part of the local resilience forum, whichprovided a co-ordinated response in an emergency. Amember of staff told us how the service had beeninvolved in transporting patients during flooding inOxford.

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

Summary

By effective, we mean that people’s care, treatmentand support achieves good outcomes, promotes agood quality of life and is based on the best availableevidence.

Staff provided care to patients in line with nationalguidance. The service had procedures for staff to getadditional clinical advice, if needed.




Staff completed relevant training for their role, however,staff did not demonstrate a clear understanding of theMental Capacity Act (2005) or Mental Health Act (1983). Staffknew the limitations of their knowledge and asked othersfor advice if needed.

The majority of staff had an appraisal in the last year.Ambulance staff raised concerns that the restrictions of thecontract, limited their scope of practice and did not use alltheir clinical skills. Staff worried they could loose theseskills. Time was allocated for staff training.

Staff assessed and provided pain relief for patients asneeded. The contract restricted which pain relievingmedications they could give to patients. Staff did not feelthey could always manage patients’ pain effectively due tothese restrictions.

We saw good multidisciplinary team working betweenambulance crews and other emergency teams. Informationshared during patient handover was relevant and enabledcontinuing care of the patient.

Staff asked patients for consent before starting treatmentor observations.

Evidence-based care and treatment

• Staff based care and treatment on national guidancefrom the British Red Cross. This guidance was includedas part of the training programme for all staff, both paidand volunteer. A pocket reference guide was availablefor staff to use to ensure they provided patients with themost appropriate care. The national guidance wasbased on guidelines from the Joint Royal CollegesAmbulance Liaison Committee (JRCALC).

• The national clinical advisory group undertook reviewsof current clinical guidance, including from JRCALC, toensure staff provided evidence-based care that wascurrent.

• Staff followed guidance and protocols of the ambulanceprovider, if patients were detained by the police undersection 136 of the Mental Health Act and they needed totransport the patient to hospital.

Assessment and planning of care

• Staff adhered to relevant national and local guidance fortheir role, when assessing and planning care forpatients.

• If staff needed clinical advice, they contacted the clinicalsupport desk, based in the emergency operations centrefor the ambulance provider. Staff told us the adviceprovided enabled them to support the patient further.

• Ambulance crews took patients to the nearestappropriate hospital for their treatment, as advised bythe health care professional who had requested thehospital admission or transfer. For event first aid, thepatient was taken to the nearest accident andemergency department, the agreement includedconveying a patient, should it not be possible to care forthem at the event.

• For event first aid crews there was no guidance orprotocol to follow to identify which patients must beadvised to attend hospital and those who did not needto attend, for example, after a patient had sustained aminor head injury. Patients were potentially at risk dueto lack of a standardised operating procedure for staff tofollow.

• All ambulance crews we spoke with had a limitedunderstanding of the Mental Health Act and theassociated code of practice. We were not assured thatpatient with a mental health problem would beidentified correctly and supported appropriately.

Response times and patient outcomes

• The ambulance provider monitored response times forwork undertaken as part of the contract and reportedthese to the service at monthly meetings.

• Data was recorded and compared to the provider forinitial response time, on scene time and turnaroundtime once at the hospital. The provider acknowledgeddifferences in the calls attended by the service, affectedsome of these results. In addition, turnaround timescould not always be captured as patients were taken todepartments, which did not have a handover screen.This meant the arrival time at the hospital could not berecorded.

• Ambulance crews again raised concerns around thescope of practice they worked to and the impact of thison response times and possible patient outcome. Staffgave an example where they had responded to a cardiacarrest patient under normal road speed. Staff had notbeen able to respond or convey patients under bluelights, due to the provider requesting a specific level of




driver training. Staff logged as an incident all calls theyresponded to where they unable to drive underemergency conditions due to the restrictions of thecontract.

• The service had worked with the provider to addressthis and 45% of staff had now received the requireddriver training. Further training sessions were to beoffered later this year. The system used by the providerenabled them to see which drivers had the relevantdriving standard and allocate suitable calls to crews.

• The service did not routinely collect or monitorinformation on patient outcomes, such as the numberof patients seen by the event first aid team, who weretreated at the scene versus admitted to hospital.

• Patients seen as part of the contracted service weregenerally planned admissions to hospital, the collectionof outcome data was therefore limited. There were alsodifficulties around access to data as the contractprovider held this.

• Data was collected on the incidence of cardiac arrest aspart of the audit requirements of the Sudden death andcardiac arrest in event first aid policy. The data for 2014identified that for nine out of 26 patients, who suffered acardiac arrest, there was a return to spontaneouscirculation (patient had a pulse) before the patient leftthe care of the service.

• Staff did not raise any concerns about the relationshipbetween the service and the different departments theytook patients to.

Pain relief

• Staff were observed asking patient’s about their level ofpain. This was scored and recorded on the patientreport form. Emergency care assistants (ECA’s) managedthe patient’s pain within their scope of practice, definedby the framework in which they worked. . Staff told usthey found this situation frustrating, as they could notfully manage the patient’s needs.

Training with the British Red Cross covered a wider range ofmedicines, to give a greater range to help control pain.When undertaking emergency work staff requested backup from other emergency staff who could issue moreeffective pain relief or supported the patient the best theycould, until they got the patient to hospital. This situationdid not affect event first aid staff, who could work to theirfull scope of practice.

Competent staff

• There was a comprehensive induction process in placefor all staff, employed and volunteers. This includedmodules on first aid and providing an emergencyresponse to patients. A matrix system indicated whichmodules staff needed to complete depending on theirrole. Training programmes developed nationally weredelivered locally for both staff and volunteers.

• New ambulance crew staff undertook a four-weekinduction programme. There was a competence basedwritten and practical assessment. During this time, theyworked with an experienced crewmember. Staff wereissued with a preceptorship log, which had to becompleted and signed by an experienced colleague, todemonstrate competencies such as infection controlpractices and clinical skills. We saw the completedpreceptorship log for one member of staff.

• All staff were required to update some modules on anannual basis, such as basic life support, to demonstratethey were still competent to safely care and treatpatients. Ambulance crew volunteers, were required toattend a minimum of 20 hours continuation trainingeach year, this was included in their job description.Some elements had been to be renewed on a threeyearly rolling basis.

• Discussions were taking place with an external trainingprovider to offer a new nationally recognised techniciantraining course. It was hoped this programme would berecognised by the local ambulance trust and enablestaff to care and treat more complex patients.

• Staff had an annual appraisal. As of September 2015,three staff groups had achieved 100% completion. Forambulance crew staff 77% had received an appraisaland for ambulance technicians 50% had completed anappraisal.

• A team leader told us that it was difficult to complete sixmonth reviews or hold regular three monthly reviewswith staff because of the current staffing pressures.However, if there were areas of poor performance, thesewould be addressed through this process and a writtenlog kept, we saw an example supporting this. Standardsof driving were also monitored. This data was capturedthrough the vehicle tracking system and could beaccessed by senior staff. Staff were offered additionaltraining were necessary. Team leaders and the servicemanager undertook clinical shifts, which enabledroutine supervision of staff to take place.




• Ambulance staff told us that they completed somecontinuing professional development in their own time,due to current staffing pressures. However, the servicedid provider quarterly update training days, which wesaw allocated to staff on the rota.

• There were no staff trained to paramedics levelemployed at this location, however event staffvolunteers may be paramedics. These volunteers had tohave been qualified for a year and hold a currentregistration with no restriction. They had to be insuredand registered with British Red Cross to work with theevents team. There was a yearly due diligence processto ensure they maintained their registration.

Coordination with other providers

• Ambulance staff worked to agreed care pathways underthe agreement with the local ambulance trust, to ensurestandardisation of care for patients across both services.

• Patients were taken to the most appropriate hospitaldepartment for continuation of their care. This had beendetermined by the health care professional requestingthe ambulance. We observed that patients were notalways taken to A&E, if another department was moresuitable, such as the children’s’ ward.

• The service had agreed processes in place for workingwith the police. This included the transportation of adeceased patient and patients detained under themental health act.

• Through the work with the contract provider the servicewas part of the local resilience forum, which provided aco-ordinated response in an emergency.

Multidisciplinary working

• We observed good multi-disciplinary team workingbetween ambulance crews and other emergency staffwhen responding jointly to a call. The teams workedwell together to coordinate the care for the patient andagree onward transfer arrangements to hospital.

• We also observed three handovers between ambulancecrew and hospital staff, for patients who weretransferred to another hospital for continuing care.Appropriate information was shared to ensure safe careof the patient during the journey. Staff once at thereceiving hospital gave handover information clearlyand brought any urgent concerns to the attention ofstaff, such as a patient needing a meal, due to a delay intheir transfer.

Access to information

• Staff told us and we observed that if multiple serviceswere involved in the care of a patient, one set ofpaperwork was completed and this stayed with thepatient, to ensure safe care and treatment at all stagesof their care. Forms were carbonated so individualservices could keep a copy for their own records andaudit purposes.

• Staff did not have access to ‘special notes’ about apatient such as pre-existing conditions, safety risks oradvanced care decisions, unless the patient told themor the information was provided by the emergencyoperations centre who dispatched the crew to the call.Staff told us they would check for a care plan in apatients’ home or if they collected a patient from anursing home. For inter-hospital transfers thisinformation was provided by staff during the handover.

• Staff did not raise any concerns around access toinformation on patient location and the reason for thecalls they responded to

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• We observed staff, in non-emergency situations,explaining procedures, giving patients opportunities toask questions, and seeking consent from patients beforeproviding care or treatment. Verbal consent totreatment was recorded in the patients’ records. Forchildren, consent was sought from the parent orguardian.

• Staff we spoke with had a limited understanding of theMental Capacity Act (MCA) (2005) particularly around theassessment of capacity and completing a best interestassessment. There was a Service users’ informedconsent to support, care and treatment procedure(2015) available for all staff via the intranet.

• Staff told us they had received little training on the MCAor the Mental Health Act (MHA) Code of Practice (1983).This was covered as part of the initial basic training andat continuing professional development sessions. Nofigures were available on the completion of this training.Staff told us that they did not use the learning from thetraining they had received that often, to feel confidentwith supporting these groups of patients.

• Ambulance staff did not currently restrain patients aspart of their legal powers under the MCA or MHA. No




training had been provided on restraint, although thiswas under review, with a view to a change of policy onrestraint. Police support was requested when a patientneeded to be restrained.

Are emergency and urgent care servicescaring?

Summary

By caring, we mean that staff involve and treatpatients with compassion, kindness, dignity andrespect.

We observed staff providing compassionate care topatients and their families. Staff anticipated and respondedto patients’ needs. Staff maintained patients’ privacy anddignity at all times. Staff were kind and showed empathy topatients’ they were caring for, particularly when upset or inpain

Nationally feedback from the Friends and Family test waspositive, with most patients extremely likely or likely torecommend the service.

Staff explained the care and treatment they needed toprovide appropriately for each patient so they understood.They encouraged patients to be partners in their care andalways asked for consent before they gave care.

Staff completed training on supporting patients who weredistressed, anxious or who had mental health condition,but they did not often care for these groups of patients, solacked confidence.

Compassionate care

• Staff were respectful, friendly, kind and compassionatewhen providing treatment or care to patients. Theyspoke with patients in a gentle manner and offeredreassurance, particularly if the patient was distressed orin pain.

• Staff were professional in their approach and spokepolitely to patients and carers travelling with thepatient. They were responsive to patients’ needs, suchas opening the window on the ambulance , to help keepa patient cool.

• Staff maintained patients’ privacy and dignity. Anemergency care assistant offered support to a nursingcolleague, when a patient needed support to getchanged and the other member of nursing staff was ofthe opposite gender.

• Emergency care assistants raised concerns aroundmaintaining patients’ privacy and dignity whentransferring a patient from a wheelchair to a stretcher.The layout and space within the ambulances meant thissometimes had to be performed outside, in the hospitalor care home. Staff did ensure that the patient wascovered by use of a blanket or sheet.

• Friends and Family test data for event first aid andambulance services was reported at national level.Response rates were acknowledged as being low, with atarget response rate of 10% for each month. Date forSeptember 2015 showed, that for both services, themajority of patients were either extremely likely or likelyto recommend the service they were treated by. Theresponse rate for event first aid was 6% and ambulanceservices 1%.

Understanding and involvement of patients and thoseclose to them

• Staff gave clear explanations to patients about the careand treatment they could provide. Most patientstransported by the ambulance service had been referredto hospital by another health care professional. Thereason to admit to hospital had already been discussedwith the patient or carer.

• All information provided to patients was verbal. Therewas no written information to support discussions,which had taken place. An emergency care assistant(ECA), was observed talking to a child. The ECA ensuredthey were at the child’s level when talking to them, sothe child felt involved and not intimidated. Theyexplained things in a way that the child understood.

• Another patient was encouraged to walk to theambulance. This was their preferred choice and it wassafe for them to walk. Using a wheelchair, could havedrawn attention to the patient and possibly increasedthe patient’s anxiety.

• Crews asked permission to enter the patients’ home,when they collected a patient from their home to takethem to hospital.

Emotional support




• We observed staff showing empathy to patients and totheir carers. Discussions took place in a timely mannerand at an appropriate stage during the journey tohospital.

• All staff were required to complete the British Red Crosspsychosocial training programme, as part of theirinduction training, which enabled them to offeremotional support to grieving families or patients whowere distressed anxious or confused.

• Staff were aware of the need to support patientsexperiencing a mental health crisis, but did not haveregular experience of supporting this group of patients.

• The service did not normally transport deceasedpatients. Staff received training on looking after thedeceased with care and dignity should they transport adeceased patient. Staff we spoke with were aware of thelimitations of their experience and knew how to seekadvice and support.

• Staff who encountered difficult or upsetting situations atwork could speak confidentially with a member of stafffrom the psychosocial team.

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

Summary

By responsive, we mean that services are organised sothat they meet people’s needs.

The service worked effectively with the contract ambulanceprovider and commissioners for event first aid work toensure they planned services to meet the needs of localpeople. The contract provider monitored response timesfor ambulance crews and discussed performance atmonthly meetings with the service.

The location of the Reading office, on a busy road,sometimes made it difficult for ambulances to exit safelyfrom the site and provide a prompt response in anemergency.

Services were accessible to all and staff had training tosupport patients in vulnerable circumstances. However,language and communications guides were not found onall vehicles, to support patients who had additionalcommunication needs.

Managers investigated complaints and provided a writtenresponse to the complainant. Learning from complaintswas considered by managers, but it was not evident thatthis learning was shared with all staff, to improve services.

Service planning and delivery to meet the needs oflocal people

• The service worked with the local ambulance trust, aspart of the contract, to support them to meet patientdemand for their service across the area they covered.British Red Cross Abingdon provided five ambulancesacross three different areas, from their bases inAbingdon and Reading. Some of these shifts were inareas were the contract provider found it difficult torecruit staff to, due to the high cost of living.

• There was fluctuation in demand from the provider,which made service planning difficult. This instabilitywas identified as a risk on the local risk register, withmonthly meetings taking place with the provider toestablish current demand. Staff did not know whatcover they would be expected to provide after the endof the year, which was causing concern and anxiety.

• The service had a number of contracts to provide eventfirst aid, for local and national events within the area.Senior staff told us a post event briefing was held withthe organisers to review the service provision at theseevents. This included whether people’s needs were metand areas for improvement at future events, such as thenumber of staff needed to ensure a safe service.

• The Reading office was located on a residential street.There was no ambulance station, ambulances wereparked in the car park, limiting parking space, andcreating a possible security risk as the vehicles could beseen from the main road. To mitigate the risk, at night,the gates to the car park were closed, once the lastvehicle had returned. All outside storage areas werelocked to prevent unauthorised access to equipmentand medical gases.

• The location also made exiting the car park difficult inan emergency. Cars were parked close to the entranceand on both sides of the road. Staff told us and we sawon the incident log, that parked cars had been damageddue to these difficulties. In addition, exit could bedelayed due to having to wait for cars to pass, due totraffic going in one direction only due to the parked cars.

• We were told that the local council were consideringhow the situation could be improved, includingmarkings on the road to limit car parking by the exit.




Staff told us that due to the instability of the work fromthe ambulance provider it was not considered viable atpresent to provide a more suitable building and locationfor the ambulances.

Meeting people’s individual needs

• A phrase book of common questions and answers in anumber of alternative languages had been developed,to aid communication with non-English speakingpatients. A communications book was also in use. Thiscontained pictures for common words and medicalproblems, such as level of pain, high temperature andpart of the body affected, to support patients withlanguage difficulties, complex needs, or those unable tocommunicate due to their medical condition.

• The service told us that these books should be on allvehicles. None of the three vehicles we checked had thelanguage guide and only one had the communicationsbook. A pile of the books was seen in the crew room atReading.

• Complaints/comment cards could be provided in 11different languages and large print, to ensure viewscould be captured from all service users.

• Contract work undertaken for the ambulance providerlimited the range of calls that crews responded to andtheir involvement with people in vulnerablecircumstances. All staff received training on supportingpeople experiencing a mental health crisis orresponding to challenging situations. Where patientswere detained by the police under section 136 of theMental Health Act, staff would follow the guidance andprocedures of the ambulance contract provider.

Access and flow

• Ambulance crews had travelling time built into theirshift, if they were due to start their shift some distancefrom their base location. This ensured an efficientresponse could be provided to patients, when a call wasreceived from the emergency operations centre.

• Response, on scene and turnaround times were allmonitored by the contract provider. These figures werereported on at the monthly meeting between theservice and the provider. Comparison was made to thecontract ambulance provider response times andtargets. However, direct comparison was difficult due to

the difference in the number of calls responded to andthe type of calls which the service were sent to by theprovider. There was no assurance that similar data wasbeing compared for both services.

Learning from complaints and concerns

• Patients, carers and members of the public couldprovide feedback via the British Red Cross website, byemail, letter or telephone. The website providedinformation on the complaints process and theexpected response times to acknowledge a complaintand provide a written response. These timeframesmatched with information contained within the service’sComplaints, compliments and comments policy andprocedure, both of which were in date.

• A complaints/ comments card had been introduced andwas to be available on all ambulances. We did not seethese cards on the five ambulances we checked.

• Staff knew were to access the complaint policies andprocedures on the intranet site. The information wasalso provided as ‘quick guides’ so less senior staff couldaccess the part which was relevant to their role.

• A manager was nominated to oversee the investigationof each complaint, with a formal written responseprovided to the complainant, identifying the outcomeand any actions taken.

• Senior staff told us that learning from complaints wasshared at both a local and national level. Staff we spokewith could not provide examples of learning, which hadtaken place as a result of a complaint.

• At a national level, as a result of feedback from patients,a review was to take place on the use of opaque glass inambulances. Patients found the restricted view difficultduring the journey to hospital. Alternative forms of glasswere to be considered, which still maintained privacyand dignity.

• During the last two years there had been 25 commentsreceived, across all services in the Thames Valley area.Fourteen were compliments, one comment and 10complaints.

• If a complaint was made to the ambulance provider,whom the contract was with, they would lead theinvestigation and reporting of the complaint.




Are emergency and urgent care serviceswell-led?

Summary

By well-led, we mean that the leadership,management and governance of the organisationassures the delivery of high- quality person-centredcare, supports learning and innovation and promotesan open and fair culture.

There was a local vision for the service, which reflected thenational values of the organisation. The service hadidentified ways to develop and sustain its services. Staffunderstood the key concerns for the service locally, but didnot know about the vision.

Governance arrangements were being developednationally and locally, with greater attention given tomonitoring and reviewing the quality of the service, againsta number of key outcomes.

Staff told us leaders were competent, approachable andvisible. Staff felt well supported by their immediatemanager. Staff told us British Red Cross Abingdon was afriendly and caring place to work.

The service encouraged feedback from patients throughsatisfaction surveys and from volunteers and staff, throughsurveys and debriefing sessions.

Staff raised concerns around their personal safety andwelfare, due to there being no panic alarm on ambulances.

Vision and strategy for this service

• The service had developed its vision and strategyaround the national strapline for the British Red Cross,‘Refusing to ignore people in crisis’ and identified howthe service could be developed in line with the keypoints from the corporate strategy. Key priorities hadbeen developed for both aspects of work, contract andevent first aid. These included focusing resources wherethey were needed the most and recruitment andretention of staff.

• Senior staff were keen to ensure they focused resourcestowards the most needy and ensure services were

developed with patients’ needs at the centre. Theyrealised the importance of recruiting and keeping theright staff, to enable them to develop their services anddeliver against the key priorities.

• Staff were aware of the key values for the organisation,but not the specific vision for this service. However, staffdid understand the instability of the work through thecontract with the local ambulance trust and the desireof the service to work with the provider to develop amore long-term plan.

Governance, risk management and qualitymeasurement

• The corporate strategy for the organisation hadidentified the need to improve how data was collectedand used, to monitor the quality of its services. At a locallevel, quality audits had been introduced across a rangeof areas, including premises, equipment and medicinesmanagement. Action plans were developed, howeverthese did not all contain completion dates or a reviewdate. There was no assurance that senior staff weremonitoring outstanding actions and escalating if notcompleted.

• There was no quality dashboard or scorecard, to provideeasy access to key performance information on quality,including feedback from patients, number of complaintsand incidents. It was not possible to see theperformance of the service on a monthly basis or overthe last year.

• There was no national audit schedule in place, althoughthis was to be discussed at the next national qualityworkshop. Local managers were encouraged to monitortheir service and complete audits, as they felt necessaryto ensure the monitoring of the quality of the service .

• All polices we reviewed were dated and had a reviewdate. However, some did not have a version number, toensure an audit trail was available for any updates andso staff could ensure they were looking at the mostup-to-date document and follow best practice.

• At a national level governance arrangements forproviding paramedics at event first aid work were beingdeveloped. This would enable expansion of this serviceat a local level, once the appropriate policies andprocedures were in place.




• There was a local risk register, with controls in place toreduce each risk. Service risks were monitored at bothregional and national level. The risk register includedconcerns raised by staff relating to the restrictionimposed on their role.

• Monthly meetings were held with the local ambulancetrust to discuss service performance and areas forimprovement as part of the contract.

• The duty folder for event first aid contained a number ofrisk assessments, these were out of date (November2014), but were still appropriate as a reference guide forstaff.

Leadership of service

• All staff spoke positively about the leadership of theservice. They told us that leaders, at all levels, werevisible and approachable. They felt leaders had theappropriate skills and knowledge for their role andmanaged their aspect of the service well.

• None of the staff we spoke with raised concerns aboutnot being able to access or speak with their immediateline manager. Staff felt confident to raise concerns to amore senior manager when appropriate.

• Senior managers had monthly area manager meetingsand a weekly teleconference, for support and sharing ofgood practice ideas.

• Team leaders and some senior managers, completedclinical shifts each month, to enable them to see andunderstand the challenges raised by staff.

• Leaders were aware of issues, which may affect thequality of the service and took appropriate steps toaddress these. For example, a team leader managed anumber of issues raised during the inspection,discussing these with the relevant member of staff orescalating when the concern was more serious.

Culture within the service

• Staff told us and we observed a positive culture withinthe service. Staff commented there was a familyatmosphere due to the small team size. Staff clearlycared for and supported each other.

• Staff told us and we saw there was good team workingbetween different departments and services, based atthe main offices in Reading and Abingdon.

• Team leaders and senior staff were competent tomanage staff performance. Action was taken if staff didnot perform or conduct themselves to the expectedstandard.

• All ambulance crews raised concerns about the lack ofradios on ambulances, which meant they could notquickly raise concerns about their personal safety andwelfare. They had to use their own phone or the one inthe vehicle.

• Senior staff told us they discussed with staff, werepossible, proposed changes to services. For the contractwork, this was not possible as discussions had to takeplace and be agreed with the provider first.

Public and staff engagement

• The service gathered the views and experiences ofpatients through the Friends and Family test, introducednationally in April. Response rates were very low locallyand nationally, around 2.5% of all patient contacts.Services were considering how to improve responserates. Patients could also provide feedback via thecompliments, comments and complaints process.

• Volunteer staff provided feedback via the regionalvolunteer council. Their work was acknowledgedthrough the annual area forum for volunteers, wherelocal awards were presented.

• Debriefs were held after events so volunteers couldprovide feedback and suggest changes for future events.Senior staff told us, online surveys were also being usedto capture feedback after events.

• Feedback was also gathered from commissioners ofevent services, through a feedback form, which was sentwith every invoice. These responses were collatednationally. No local feedback was available for us toreview.

• Volunteers and staff were invited to complete theannual ‘People survey’, which asked their views on anumber of key topics. We saw the 2013 survey results,but no action plan was provided so it was not possibleto see the changes the organisation had made, inresponse to the survey.

• A local staff survey, for employed ambulance staff,completed February 2015, asked for their views on fourareas, including support from their manager. Themajority of staff felt their manager was approachableand would act on concerns they raised, however, staffdid not agree that they were given feedback on theirperformance. This supported what staff verbally told us.

Innovation, improvement and sustainability

• The service had identified some areas for serviceimprovement and sustainability. These included




stopping a community transport service, as this wasoffered by other providers. The service felt its resourcescould be used to support patients in more immediateneed. There was a national review of the event first aidservice, to enable provision at a wider range of events,to increase income at both a national and local level.

• The work for the local ambulance trust remained afinancial risk for the service as work was only confirmeda few months in advance. Senior staff were in regularcontact with the provider to discuss this.




Areas for improvement

Action the hospital SHOULD take to improve

• Ensure all patient records are stored securely at alltimes.

• Taken steps to ensure that staff are aware of andcomplying with the duty of candour statutoryresponsibility.

• Review the effectiveness of the safeguarding adultsand children at risk training so that staff are clearabout what constitutes abuse and when to report aconcern.

• Review the current communication channels andprocess for requesting support in an emergency, forexample if staff are attacked.

• Provide all staff with training on the mental capacityact and mental health act and ensure staff understandhow to use the codes of these acts appropriately whencaring for patients.

• Ensure all vehicles contain the language andcommunication guides, to support patients withlanguage difficulties and ensure safe care andtreatment.

• Consider providing complaints information on allvehicles.

• Review the provision of equipment for the safetransportation of children.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


british red cross abingdon newapproachcomprehensive report … · 2019. 4. 9. · •...

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