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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 known to CQC and information given to us from patients, the public andother organisations.

UK Event Medical Services Limited

UKUK EventEvent MedicMedicalal SerServicvicesesLimitLimiteded SheffieldSheffieldQuality Report

Unit 22, 10 Jessell StreetSheffieldS9 3HYTel: 0114 244 9417Website: NA

Date of inspection visit: 16 May 2018Date of publication: 23/07/2018

1 UK Event Medical Services Limited Sheffield Quality Report 23/07/2018

Letter from the Chief Inspector of Hospitals

UK Event Medical Services Limited Sheffield is operated by UK Event Medical Services Limited. The company providesemergency and urgent care and a patient transport service. They also provide medical cover at public and privateevents. We did not inspect this part of the service as it is not currently a regulated activity.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of theinspection on 16 May 2018.

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 main service provided was patient transport services. Emergency and urgent services were a small proportion ofactivity; therefore we have reported our findings in relation to the urgent and emergency services in the patienttransport services section.

Services we do not rate

We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight goodpractice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• Staff were committed to providing the best quality care to patients. Staff displayed a caring and compassionateattitude and took pride in the service they were providing.

• Staff checked patients’ requirements prior to transporting them to ensure they were able to meet their needs.

• Staff followed evidence-based care and treatment and nationally recognised best practice guidance.

• The management team had taken action to improve governance and risk management systems within the past sixmonths.

• There were effective policies and procedures for safeguarding issues to be identified and referred for investigationby relevant, external organisations.

• There were effective systems for reporting and investigating incidents; the provider learnt from incidentinvestigations, for example, by making changes to equipment or care protocols.

• Vehicles and stations were visibly clean and tidy, with evidence of regular deep cleaning of vehicles.

• Relevant background checks had been carried out during recruitment processes. This included, for example, a fullDisclosure and Barring Service and a driving licence check.

• We observed good multidisciplinary working between crews and other NHS staff when moving patients.

• The management team worked with local NHS providers to supply services which met the needs of local people.

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

• Our review of patient record forms on GP urgent care journeys found that the records were not always complete;the records did not always indicate what actions staff had taken to mitigate identified risks.

Summary of findings


• Some systems for identifiying and disposing of out-of-date stock and sharps waste, had not been fullyimplemented.

• Some staff were not able to recall the information provided to them as part of a training programme. For example,not all staff could recall having had training in the Duty of candour.

• The systems for storing medicines needed to be reviewed to confirm that medicines were kept safely at all times.

• The provider did not currently check that all relevant staff had been immunised with selected vaccines, such asHepatitis B, which may be appropriate for their role.

Following this inspection, we told the provider that it should make improvements, even though a regulation had notbeen breached, to help the service improve.

Ellen Armistead

Deputy Chief Inspector of Hospitals, on behalf of the Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Patienttransportservices(PTS)

We have not rated this service because we do notcurrently have a legal duty to rate this type of service orthe regulated activities which it provides.

The main service was patient transport. Urgent andemergency services were a small proportion of activity.Where arrangements were the same, we have reportedfindings in the patient transport services section.

Summaryoffindings

Summary of findings


UKUK EventEvent MedicMedicalal SerServicvicesesLimitLimiteded SheffieldSheffield

Detailed findings

Services we looked atPatient transport services (PTS)


Contents

PageDetailed findings from this inspectionBackground to UK Event Medical Services Limited Sheffield 6

Our inspection team 6

Facts and data about UK Event Medical Services Limited Sheffield 6

Background to UK Event Medical Services Limited Sheffield

UK Event Medical Services Limited Sheffield is operatedby UK Event Medical Services Limited. The serviceopened in 2002. It is an independent ambulance servicein Sheffield in South Yorkshire. The service primarilyserves the communities of the Sheffield, Rotherham,Barnsley, Doncaster and Hull, but does operatethroughout the UK.

At the time of the inspection, UK Event Medical ServicesLimited Sheffield had a new team of directors who hadbeen in post since September 2017. The service held acontract with an NHS provider for non-urgent transfers of

patients from hospitals, home and care facilities. Theyalso held a contract to move patients in urgent need ofcare, for example, from their home to a hospital, on thebasis of GP referrals. They were in the process ofestablishing new contracts for patient transport servicesfor other local NHS providers.

The service has had a registered manager in post since2011. At the time of the inspection, the provider was inthe process of registering a new manager who hadrecently been appointed to the board of directors.

Our inspection team

The team that inspected the service comprised a CQClead inspector,one other CQC inspector, and a specialistadvisor with expertise in emergency and urgent care andpatient transport.

Facts and data about UK Event Medical Services Limited Sheffield

UK Event Medical Services Limited Sheffield has anambulance base in Sheffield, with administrative officesat a second location in Sheffield. There are 16 vehiclesavailable for patient transport at the base.

The service employs 45 people in managerial,administrative and clinical roles. The employed staff arecomprised of: five board-level directors, four office-based,administrative staff, two ambulance team leaders, onetraining manager, two ambulance lead drivers, one

ambulance controller, five technicians and one traineetechnician, three blue-light drivers and 21 ambulancecare assistants. There are also three paramedics workingon an casual, or non-contract, basis.

The service is registered to provide transport services,triage and medical advice provided remotely, andtreatment of disease, disorder or injury.

The service’s track record on safety for the current year,from September 2017 to May 2018 showed:

• No never events

Detailed findings


• 27 incidents

• No complaints

Since September 2017, an average of 860 patient journeyshad been undertaken each month under a contract toprovide non-urgent patient transport from hospitals,homes and care facilities; an average of 197 journeys hadbeen completed each month under a contract to provideurgent patient transport based on a GP referral.

During the inspection on 16 May 2018, we visited theambulance base and administrative offices. We spokewith ten staff including frontline ambulance crews andmembers of the management team. We spoke with two

patients about the care they had received. We also spokewith one member of staff who worked at a local hospitaland was involved in handing over care of patients fromthe hospital to the provider. During our inspection, wereviewed a sample of patient records. We checked two ofthe vehicles at the ambulance base.

The service was inspected for the first time in January2013. It was subsequently inspected a further two timesto check that specific standards had been met. The lastinspection had been carried out in February 2014; theservice was meeting all of the required standards ofquality and safety it was inspected against at that time.

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the serviceThe main service was patient transport. Urgent andemergency services were a small proportion of activity.Where arrangements were the same, we have reportedfindings in the patient transport services section.

Summary of findingsWe found the following areas of good practice:

• Staff were committed to providing the best qualitycare to patients. Staff displayed a caring andcompassionate attitude and took pride in the servicethey were providing.

• Staff checked patients’ requirements prior totransporting them to ensure they were able to meettheir needs.

• Staff followed evidence-based care and treatmentand nationally recognised best practice guidance.

• The management team had taken action to improvegovernance and risk management systems within thepast six months.

• There were effective policies and procedures forsafeguarding issues to be identified and referred forinvestigation by relevant, external organisations.

• There were effective systems for reporting andinvestigating incidents; the provider learnt fromincident investigations, for example, by makingchanges to equipment or care protocols.

• Vehicles and stations were visibly clean and tidy, withevidence of regular deep cleaning of vehicles.

• Relevant background checks had been carried outduring recruitment processes. This included, forexample, a full Disclosure and Barring Service and adriving licence check.

• We observed good multidisciplinary workingbetween crews and other NHS staff when movingpatients.

Patienttransportservices

Patient transport services (PTS)


• The management team worked with local NHSproviders to supply services which met the needs oflocal people.

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

• Our review of patient record forms on GP urgent carejourneys found that the records were not alwayscomplete; the records did not always indicate whatactions staff had taken to mitigate identified risks.

• Some systems for identifiying and disposing ofout-of-date stock and sharps waste, had not beenfully implemented.

• Some staff were not able to recall the informationprovided to them as part of a training programme.For example, not all staff could recall having hadtraining in the Duty of candour.

• The systems for storing medicines needed to bereviewed to confirm that medicines were kept safelyat all times.

• The provider did not currently check that all relevantstaff had been immunised with selected vaccines,such as Hepatitis B, which may be appropriate fortheir role.

Are patient transport services safe?

Incidents

• The service had an incident reporting policy that wasavailable to all staff. Staff we spoke with were able togive examples of what constituted an incident and wereaware of the incident reporting process. They were ableto locate incident report forms and knew how to submitthese. The service was also trialling an electronicrecording system for reporting incidents at the time ofthe inspection.

• We reviewed incident reports that had been completedbetween September 2017 and May 2018. Twenty sevenincidents had been recorded which covered a range ofissues including equipment faults, patient complaints,and patient or staff injuries.

• We reviewed two incident reporting forms in moredetail. We saw evidence that the incidents had beenproperly investigated and the learning shared with staff.We discussed examples of actions taken in relation to aspecific incident with the director of care and quality.They showed us an example of a ‘near miss’ incidentwhich had been investigated. Following the incident,staff who were directly involved were retrained inmoving and handling protocols; lessons learned werealso shared with all staff through a weekly newsletter.

• The director of care and quality showed us that theywere also keeping a separate incidents register inrelation to a specific contract for moving patients inresponse to an urgent GP referral. This had been inresponse to identifying a systematic problem in thebooking process which had led to a number ofoccasions when the wrong type of crew had beenrequested. For example, an ambulance crew had beenrequested with only care assistants, but it wassubsequently found that the patient required ahigher-level of care and in fact needed to be moved withthe help of a trained technician. Staff had beeninstructed not to move patients in these cases andreport their concerns to the senior management team.

• The director noted that they had provided theirambulance staff with additional written guidance aboutwhat was within, or without their scope of practice, with




a view to minimising risks and maintaining safe levels ofcare. They were also working with the contractor toresolve and prevent the concerns identified with thebooking process.

• The service had reported no never events or seriousincidents in the past year. Never events are seriousincidents that are entirely preventable as guidance, orsafety recommendations providing strong systemicprotective barriers, are available at a national level, andshould have been implemented by all healthcareproviders.

• Incidents were monitored by the director of care andquality, who demonstrated that each incident was riskassessed and prioritised for investigation. There was abi-weekly directors’ meeting where higher-risk incidentswere reviewed to identify what further actions wereneeded.

• The management team told us that in the event of ajoint investigation with a contracting service theyprovided information and received feedback, asrequired.The director of care and quality showed us howthey communicated with the NHS provider that theyheld a contract with to ensure a flow of informationacross services.

• The service had a Duty of candour policy which hadbeen reviewed and implemented in February 2018. Thedirector of care and quality was responsible for ensuringcompliance with the Duty of candour. The Duty ofcandour is a regulatory duty that relates to opennessand transparency and requires providers of health andsocial care services to notify patients (or other relevantpersons) of certain ‘notifiable safety incidents’ andprovide reasonable support to that person.

• Some, but not all, of the ambulance crew that we spokewith were aware of the duty of candour. Staff wereintroduced to the company’s Duty of candour policyduring their staff induction process. However, two of thestaff that we spoke with could not recall having hadtraining in the Duty of candour.

• The managers told us that there had been no incidentsbetween September 2017 and May 2018 that hadresulted in moderate, or above, patient harm that wouldtrigger the Duty of candour process.

Mandatory training

• Mandatory training for all staff comprised: clinical scopeof practice, incident reporting, whistleblowing, healthand safety, fire safety, moving and handling, basic lifesupport, infection prevention and control, safeguarding,dementia care, capacity and consent, end-of-life careand do not attempt cardiopulmonary resuscitationorders.

• The clinical director confirmed that the mandatorytraining was renewed on an annual basis.

• Intermediate care technicians completed annual clinicalrefresher training courses (First Response EmergencyCare) to maintain their clinical skills and knowledge.

• We saw records of completed driver assessments, aspart of a staff induction course, which was used toassess if staff were safe to drive the ambulances. Thesenior management team confirmed that it wasexpected that all staff would complete a further driverassessment on an annual basis to ensure that staffremained competent in their role.

• The provider also had three members of staff who hadundergone additional response (blue light) training incase this was needed for their work.

• We spoke with the clinical director, who was in charge oftraining. They showed us how they kept oversight ofstaff training compliance. There was a trainingstandards spreadsheet with records of compliance foreach member of staff. The spreadsheet specified timeframes for renewing different types of training.

• At the time of the inspection, all staff were either up todate with their training or were booked on to a relevanttraining course.

• The staff we spoke with told us that they had all beenasked to complete new training at the start of theiremployment with the provider, regardless of priorexperience.

Safeguarding

• The provider had an up-to-date safeguarding policyavailable to staff. The policy had been implemented inDecember 2017 following a reorganisation of themanagement structures.




• The policy included information for staff about how toreport concerns within the organisation, as well as flowcharts for how to escalate concerns to externalorganisations including social services and the police.

• The staff we spoke with gave us examples of whatconstituted a safeguarding concern and were able todescribe the process for reporting these.

• We observed that there were safeguarding informationbooklets on the vehicles to support staff understandingof what constituted a safeguarding incident and how toescalate any concerns for investigation.

• We reviewed one incident record that had caused theambulance crew to report their concerns within theorganisation. Our discussions about this case with thesenior management team confirmed that the issue hadbeen reported appropriately to the relevant NHSprovider’s safeguarding referral process, for whom thepatient transport work had been carried out under acontract. This showed that the safeguarding policy wasin use and had been followed.

• Staff were aware of guidance related to specificsafeguarding issues and there were policy documentsthat supported staff to follow identification andreporting protocols. For example, information had beenprovided to staff about the legal requirement forreporting incidents of female genital mutilation andstaff had been made aware of the PREVENT strategy foridentify and preventing radicalisation.However, wefound that some of the staff that we spoke with wereunaware of the PREVENT strategies.

• Frontline ambulance staff had all completedsafeguarding training to level two. Training was renewedevery year; all staff were up to date with their training atthe time of the inspection. The training incorporatedissues related to protecting both children andvulnerable adults.

• The director of care and quality and the clinical directorhad completed level four safeguarding training andwere acting as the safeguarding leads within theorganisation.

Cleanliness, infection control and hygiene

• The service had an infection, prevention and controlpolicy that was available to all staff. The staff we spokewith were aware of their responsibilities related toinfection, prevention and control.

• Infection, prevention and control training was deliveredto all staff as part of their induction training andmandatory training updates.

• Personal protective equipment was available on allambulances. This included, for example, disposableclinical gloves and aprons. Staff were aware of whenthese should be used and we observed that they wereappropriately used.

• The ambulance base that we visited had store roomsand shelves for the use of the transport services. Thesewere well organised, with all equipment and stockstored off the floor.

• Cleaning equipment was available at the ambulancebase. A coding system was used which separatedequipment that was to be used in different areas. Forexample, in ambulances and in non-clinical areas. Therewere also separate mops labelled for use in eachvehicle. There were posters located next to all cleaningequipment to support staff in identifying the correctequipment to use.

• There was information available to determine whichcleaning agents needed to be used, as required bystandards for control of substances hazardous to health.

• We reviewed daily cleaning records for the station andvehicles. There was a schedule with a checklist for eachof the vehicles, demonstrating that the correct tasks hadbeen carried out.

• All vehicles had decontamination wipes which werewithin the manufacturer’s expiry date. We observedambulance staff cleaning down the equipment after thetransfer of a patient to ensure that the vehicle was cleanfor the next patient. We observed that staff regularlyused hand gel between patient contact as part of aroutine of maintaining good hand hygiene.

• We spoke with both of the ambulance team leaders.They explained that there was a “deep clean” processfor internal parts of the vehicles that was carried out byan external contractor. The urgent care vehicles weredeep cleaned every 45 days and the lower risk patient




transport vehicles were deep cleaned every 90 days.Wewere shown documents with details of the date that thiscleaning occurred; this included details regarding theextent of the “deep clean”.

• The ambulance crew that we spoke with noted that theychecked at handover points if patients had infectionsthat would preclude them from either travelling withother patients on the vehicle or would require thatambulance needed to be deep cleaned after use.

• At the end of each shift, ambulance crews took clinicalwaste bags off the vehicles and these were placed inclearly identifiable, locked bins at the depot. These wereemptied by a private contractor.

• There were sharps bins available and in use. On the dayof the inspection we noted that there seven sharps binsawaiting collection from the private contractor and oneof these was not correctly sealed. We asked the seniormanagement team why these had not been collected ina more timely manner. They noted that they had beenmaking changes as regards to the contract for themanagement of the clinical waste by an externalcontractor, but would now act promptly to ensuretimely removal of sharps waste.

Environment and equipment

• The ambulance team leaders confirmed that there were16 ambulances in use at the base. The ambulancescould be fitted for a range of functions includingbariatric ambulances, stretcher ambulances andmulti-seat ambulances and wheelchair-carryingambulances.

• We found the ambulance stations, including the garagesand equipment storage areas, were clean and well laidout.

• Hazardous substances were stored in a locked room, ora locked cupboard. There were appropriate control ofsubstances hazardous to health assessments in place.

• We observed that staff were responsible for completinga daily vehicle check before every shift. The daily vehiclechecks were recorded on a form.This included checkingif the vehicle was in a good state of repair and had thecorrect equipment available.

• There was one vehicle off the road on the day of theinspection; a vehicle check had identified a fault on the

day prior to the inspection. The provider had an externalcontractor who maintained the vehicles. The fault wasfixed and the vehicle returned in working order on theday of the inspection.

• During our inspection we found that the equipment wasin good working order. This included, for example, carrychairs, wheelchairs, strapping and valve masks. Therewas also relevant equipment for paediatric and bariatrictransfers. Any items that needed to be replacedperiodically were labelled with a date. Relevantequipment had been serviced in line with themanufacturer’s guidance.

• Consumable stock was stored on a number of shelves instore rooms or at the entrance to the vehicle garage. Thelevel of stock was managed by the team leaders. Thestaff we spoke with told us there was never any problemreplacing used consumables.

• However, in one of the ambulances that we checked wefound some out-of-date stock in a paramedic bag. Forexample, there was an out-of-date drawing up needleand suction catheter. These items were disposed of onthe day of the inspection. We discussed this with thesenior management team; they noted that theparamedic bags were not currently in use due to thenature of the current contracts that they held. However,they would be instigating an audit of the bags to identifyany other stock in need of replacement. The director ofcare and quality also showed us that there was a newonline calendar system to prompt different members ofthe team to carry out audits.

• The Ministry of Transport test due dates, servicingschedules and insurance certificates were beingmonitored by the ambulance team leaders. Theyshowed us that they had a noticeboard which displayedthe different due dates for each vehicle. We checked thevehicle history for two of the ambulances. Thisconfirmed that they had a current test certificate andthe servicing was up to date.

• The vehicles used an radio handset and a satellitenavigation system in the vehicle.All essential equipmentin all the vehicles had been checked and safety tested.

Medicines

• The service had a medicines management policy.Thiswas available to all staff.




• Medicine packs were stored in a stock room in anumerical-coded, locked cupboard.

• There was also a colour-coded tag system to indicatewhen a pack had been openedand requiredreplenishing. Packs which needed renewing had a redtag; unopened packs had a green tag.However, thesetags were not always properly secured to the packs andwere instead next to the packs.

• There was a weekly medicines check to monitor stocklevels, replenish packs and re-order supplies. The checkincluded a drug count to check for any discrepanciesbetween what had been ordered, what had beenadministered, and what was found to be held in stock.

• The provider also kept supplies of medical gases,including oxygen and nitrous oxide. Oxygen and nitrousoxide were stored in a separate, lockable facility, withcylinders stored off the ground. All of the cylinders wechecked were in date.

• The clinical director showed us that they were in theprocess of training all staff in administering oxygen.More highly-skilled staff, such as technicians andparamedics, had already completed this training.

• Staff that had already been trained could administeroxygen based on a prescription recorded during thebooking process for the patient journey. They could alsoadminister oxygen that had not been prescribed, asnecessary, based on their own assessment of clinicalneed.

• Staff we spoke with knew about their responsibilitieswhen administering oxygen. The amount of oxygen thatpatients required was requested as part of the bookingprocedure and the relevant information was availableon a hand held computer device for staff to review.Staffcommented that, if they became aware that patientsrequired oxygen, but this had not been shown on thehand held device, then they would contact the controlroom for the NHS provider for an accurate prescriptionand ask that it be recorded onto the hand held device.

Records

• Patient records were routinely kept for patients movedas part of a GP urgent request.

• The provider did not keep their own patient records forthe patient discharge transfers, for example, when

patients were moved from a hospital discharge loungeto their own home. However, the staff working on thisservice were required to use the NHS provider’s ownsystem for recording information about the patient’sjourney. For example, staff recorded, on handhelddevices, the time the job was accepted, the time thatthey arrived and met the patient, the time that they setoff on the journey and when they arrived at theirdestination.

• We asked the senior management team what staff onthe patient discharge service would do if they needed toprovide an unexpected level of care or treatment, forexample, when oxygen was given outside of what wasspecified as part of the booking process. There were noarrangements in place for keeping patient records onthese occasions. The staff that we spoke with confirmedthat they could not record additional notes or text ontotheir hand held devices, but that they would contact thecontrol room for additional advice and ask them toupdate the hand held devices.

• Information about special notes including do notattempt cardio pulmonary resuscitation orders,dementia or mental health diagnoses, andrequirements related to end-of-life care, were includedas part of the booking process. Staff understood theneed to review all of the booking notes and to check forthe presence of do not resuscitate orders. We observedstaff carrying out relevant checks of information andpatient notes prior to transporting patients.

• We reviewed a sample of five patient records kept forthe GP urgent request contract. We found that there waslimited evidence of staff acting in response to riskinformation recorded on the forms. For example, staffwere not consistently recording actions taken in regardsto high pain scores, or high early warning scores.

• The clinical director had audited the patient recordforms within the past six months, in line with a requestfrom the NHS provider with whom they held a contract.However, the audit requested had not included a reviewof these items.

• We discussed our findings with the senior managementteam; they confirmed that they would now be reviewing




their systems for recording patient information. Thiswould include retraining staff in how to record actionstaken and the appropriate response to different levels ofearly warning signs.

Assessing and responding to patient risk

• Risk information about patients was collected throughthe booking system of the NHS provider who the serviceheld a contract with. This information was shared withthe provider’s staff when they were scheduled for a job.

• There had been a range of incidents in the past sixmonths when the company had received inadequatebooking information from the NHS provider. This hadled to, for example, a crew being dispatched without therequired levels of skill or training. This had specificallybeen in relation to the GP requests for urgent transfers.

• In these cases, the provider had acted in line with thecontractor’s request for their own staff to visit thepatient and then request additional support at thescene. They confirmed that they did not move patientswithout having the correct level of staffing. For thiscontract, all staff completed a patient record for everyindividual that was being transferred; this included anassessment of risks.

• The director of care and quality had held a number ofmeetings with the NHS provider with a view to resolvingthe booking concerns.Some actions were now in placeto improve the service and information exchange. Forexample, the provider’s crews were now calling ahead toeach patient they were transferring as part of the GPurgent request service. This allowed the patient to planfor their move, and also for crews to pick up anyadditional information directly before they arrived.

• The ambulance crews we spoke with had a clearunderstanding about what to do if a patientdeteriorated during a journey. They told us they wouldcall the NHS provider’s control room to notify them ofthe change in the patient’s condition; they would thenproceed to either the nearest accident and emergencydepartment or the ward from which the patient wasdischarged. Staff discussed a recent example where theyhad instigated this protocol.

• The ambulances used for patient transport serviceswere equipped with automatic external defibrillators

and oxygen that could be used in the event of anemergency. This equipment was checked daily by staffand we observed that they were in good working orderon the day of the inspection.

• All staff received first aid training as part of theirinduction. This included providing cardiopulmonaryresuscitation and the use of oxygen in an emergencysituation.

Staffing

• On the day of the inspection 15 vehicles were in use. 13vehicles were covering patient transport services fromhospital discharge lounges in the local area and GPurgent care requests. The ambulance team leaders toldus that they also typically scheduled two moreambulance crews who could be requested to work byother providers on an ad hoc basis. These crews were inuse on the day of the inspection.

• We reviewed the staffing arrangements with the humanresources administrator. They confirmed that there wereboth substantive and casual workers available to fill theshifts.

• The team leaders were in charge of organising the staffrota; they confirmed they had adequate numbers ofstaff to meet the current demand.

• We discussed staffing levels with the ambulance crews.They confirmed there had been sufficient staff to covershifts but that this had sometimes been by relying onstaff to provide flexibility and over time; they were awareof the need for additional staff recruitment to guaranteeadequate cover.

• The senior leadership team had reviewed staffing levelsas part of their performance monitoring. This hadrecently led to the additional recruitment of four moreambulance care assistants to ensure that they met thecurrent demand for their service. These new membersof staff were due to start within the next month.

• Staff worked on a 20-week rota. Full time staff werescheduled to work between 37.5 and 42 hours per week.The shifts were eight to eleven hours long. Breaks werehalf an hour and the frequency depended on the lengthof the shift.

• A new online, computer application had been launchedin the company within the past three months to aid




scheduling shifts and booking staff holidays. At the timeof the inspection, casual shifts were advertised on theapplication, but regular shifts were not yet scheduled onthe system.

Anticipated resource and capacity risks

• The provider anticipated resource and capacity risksthrough the maintenance of a local risk register.

• The director of care and quality showed us that the riskregister covered a range of items including financialrisks to the business, for example, through loss ofcontracts as well as safety items, such as levels ofstaffing or outcomes of audits. We found that there werecoherent action plans in place to mitigate potentialrisks.

• The risk register was reviewed at the bi-weekly seniormanagement team meeting.

Response to major incidents

• A business continuity plan was in the process ofdevelopment at the time of the inspection; the directorof care and quality showed us how they were adding keyelements to support the written policy, for example,with details of local suppliers, so that they could beoperated in the event of an unexpected disruption tothe service, including loss of premises, for example dueto fire or flooding.

• The director of care and quality told us they had helddiscussions with their local NHS providers regardingsupporting and assisting other services in the event of amajor incident, but they had not been requested todevelop a formal plan to aid in the response.

Are patient transport services effective?

Evidence-based care and treatment

• Staff followed national guidelines, which included theJoint Royal Colleges Ambulances Liaison committeeguidelines.

• We saw evidence that the provider’s internal protocolshad been updated against recently published advice.

• The provider developed a range of policies andprotocols to support patient-centred and safe care. This

included for example a ‘care to care’ policy forsupporting patients in a caring and empathetic mannerand scope of practice documents to ensure staff wereworking within their level of skill and competence.

• The ambulance crew that we spoke with were aware ofrelevant protocols and guidance; they were working toimplement the processes accurately. They were awareof which policies and protocols had recently beenupdated and cited examples.

Assessment and planning of care

• The patient transport service provided non-emergencytransport for patients who required transferringbetween hospitals, transfers home or to another placeof care. There was also a contract to provide urgent caretransfers upon request from a GP. Staff had priorinformation about the patients they would be requestedto transfer through a booking process.

• Key information about the patient was supplied duringthe booking process. Staff reviewed this information toensure a safe transfer. For example do not attemptcardio pulmonary resuscitation orders were noted, aswell as other special notes, such as the requirement foroxygen therapy.

• There had been some concerns about the quality ofbooking information received by ambulance crew priorto transporting urgent care patients on GP referrals. Themanagement team were working with the NHS providerwith whom they held a contract to provide this type oftransport to resolve these concerns. Staff were alsocarrying out their own assessment of care and recordingthis on a patient record form for every patient beingtransferred as an ‘urgent’ case.

• We observed that staff held discussions with NHS staffat the discharging service, the patient or their relativesto help plan each journey and complete the transfersafely and with minimum discomfort to the patient.

• The ambulance crew were sensitive to patients’ needs.For example, if a longer-distance journey wasscheduled, the trip would be planned with stops to usethe toilet and for refreshments. All of the ambulancesheld bottled water to give to patients, as required,during a journey.

Response times and patient outcomes




• The provider did not monitor response times for theirservice. The senior management team noted that theNHS provider with whom they held a contract totransport patients did monitor response times throughthe use of handheld device logging system.

• Data on response times was reviewed at monthlycontract meetings. We saw that action logs were kept asa result of these meetings including whether the actionwas still required or had been closed or completed.

• An audit of patient care records had been carried out inline with the NHS provider’s request under the contract.However, this had not systematically reviewed clinicaloutcomes for patients. Our review of the completion ofpatient record forms highlighted some areas forimprovement, for example, around recording responsesto risk and pain scores.

• The senior management team were responsive to ourfeedback in this area and confirmed that they would bereviewing their auditing systems to monitor patientoutcomes more closely.

Competent staff

• There was a two-day induction training programme forall new staff. This consisted of both face to face andonline training packages. Mandatory training wascovered in the induction as well as moving and handlingtraining, information governance, data protection, useof equipment, completion of patient records and theinternal ‘care to care’ protocol.

• There was a driving competency assessment which wascarried out as part of the staff induction.

• Staff started work upon completion of the induction andmandatory training courses. Staff we spoke with hadcompleted the induction process in line with the policy.

• The clinical director told us that staff would be requiredto refresh their mandatory training on an annual basis.

• The human resources administrator completed drivinglicence checks when staff started working for thecompany. They reviewed these annually and weretracking the outcome as part of a new, human resourcesaudit. The director of care and quality told us that staffwith over six points on their licence were not allowed todrive the ambulances.

• A record was also kept in relation to staff members’professional registration with appropriate organisations.For example, paramedics’ registration with the Healthand Care Professions Council was checked andrecorded.

• Formal staff appraisals were in the process of beingcompleted at the time of the inspection. This was thefirst time that appraisals had taken place since thechange in staffing and contracts in September 2017.Thirteen appraisals had been completed. We reviewedone of the completed appraisals and saw that theysupported staff to identify career goals and furtherlearning needs. One of the ambulance crew staff that wespoke with confirmed that they had had a recentappraisal and that it had been useful to identify howthey could progress within the company. The operationsdirector told us that they would be reviewing the staffappraisals to identify any company-wide concerns ortraining targets.

Coordination with other providers

• The provider had good working relationships with theNHS providers they worked with.

• We discussed the service provided with staff working inan NHS hospital discharge lounge where the ambulancestaff collected patients. They told us they were satisfiedwith arrangements and that the provider worked hard tomeet their needs.

• The director of care quality told us they held regularmeetings with the NHS provider that they held contractswith to monitor the provision of care. The NHS staff wespoke with confirmed that they had held a recentmeeting to review the quality of care provided; theycommented that they had a positive workingrelationship with the provider and that they wereproactive in resolving any concerns or issues as theyarose.

• The ambulance crews that we spoke with commentedthat they found they had a good working relationshipwith NHS ambulance control room staff whoco-ordinated the patient booking process.

Multidisciplinary working




• We observed good multidisciplinary team workingbetween crews and other NHS staff when caring forpatients. We saw co-ordinated care and transferarrangements when crews were handing the care overto NHS staff.

• We observed that ambulance crews asked hospital staffappropriate questions to make sure that theyunderstood the patients’ needs prior to each transport.

• Staff checked that they had received the correctdocumentation and information on the handhelddevices at handover points; they raised issues about thecompleteness of information, if necessary.

Access to information

• Staff had access to policies and standard operatingprocedures at the ambulance station. At the time of theinspection, the service was also in the process ofimplementing an online system which staff would beable to use to access relevant information about theirworking protocols and procedures.

• The ambulances were equipped with a satellitenavigation system and an electronic tracker (globalpositioning system) to enable communication andmonitoring of the vehicle whereabouts.

• Ambulance crews were provided with key informationand special notes regarding care plans though thebooking process. The booking information wastransferred directly to their hand held devices. We alsoobserved that relevant information about each patientwas available on whiteboards in the hospital dischargeservice to support staff to understand each patient’stransport needs.

• Staff were aware of the importance of do not attemptcardiopulmonary resuscitation orders, for example, inpatients being transferred as part of an end-of-life carepathway. We observed instances where the crewchecked this information was available and completedcorrectly prior to transporting patients.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• The service provided staff training on consentprocesses, as well as protocols for following the terms ofthe Mental Capacity Act (2005), through the inductiontraining and annual mandatory training up dates.

• Staff we spoke with had good knowledge about theimportance of understanding patients’ mental capacity,how they could act in line with ‘best interest’ decisions,and the importance of involving patients in decisionsabout their own care, wherever possible.

• Staff also understood the requirements of Gillickcompetence. Gillick is a term used to describe if a childunder 16 years of age is able to consent to their ownmedical treatment without the need for parentalpermission or knowledge.

Are patient transport services caring?

Compassionate care

• All of the staff that we spoke with during the inspectionshowed a commitment to providing the best possiblecare.

• We observed care being provided on patient journeys byone ambulance crew. Staff were respectful, kind andconsiderate towards the patient in their care. The crewintroduced themselves and explained to the patientwhat was happening.

• Staff showed an awareness of the importance ofmaintaining patients’ privacy and dignity, for example,by providing additional blankets or checking thatpatients were comfortable with what they were wearing.

• Staff were also careful about continuity of care afterpatients’ transfers were completed. For example, theychecked with patients and relatives about theavailability of ongoing care and support after thetransfer had been made from hospital to home. In oneexample, we observed staff transferring a patient intotheir own home with considerable care to minimise anydistress; the patient was successfully transferred in areclining chair in their home.

• We spoke with patients and relatives who had beentransported by the ambulance crews. They noted thatthe staff had been caring, careful and helpful.

Understanding and involvement of patients and thoseclose to them

• Staff demonstrated an awareness of involving patients,and their relatives or carers, in any decisions that weremade about their care.




• The ambulance crew we observed were supportive ofpatients and remained committed to involving them intheir care at all times. For example, we noted theyexplained what was happening as they were beingmoved and checked that patients were comfortablewith what was happening. In one example, the crewoffered a patient an option to sit up which was declinedby the patient; the crew carried out the transport in linewith the patient’s request.

• The provider had a written ‘care to care’ protocol forstaff to follow when providing care to patients. Thisincluded directions on providing adequateintroductions, staff identification and information with aview to ensuring that patients understood what washappening at each stage of their journey. We observedstaff providing information in line with the provider’spolicy.

• One of the patients we spoke with commented that theambulance crew had been very good, explaining wherethey were going and what to expect.

Emotional support

• Staff understood the impact they could have onpatients’ wellbeing and acted to emotionally supporttheir patients and relatives during transfers.

• We observed instances where the ambulance crewoffered verbal reassurance during patient transfers. Forexample, in one episode in a discharge lounge where apatient was initially reluctant to leave the hospital. Thecrew patiently provided reassurance about the transferprocess and were careful not to move the patient untilverbal consent was obtained and the patient was readyto move.

• Staff consistently engaged patients with steady and lightconversation as a way of helping patients through thetransport experience.

Are patient transport services responsiveto people’s needs?

Service planning and delivery to meet the needs oflocal people

• At the time of inspection the service held contracts withone NHS provider. This was to transport patients

between hospital sites, homes and care facilities. Therewas also a contract to provide urgent transfer of patientsfrom their homes to another provider under a GPreferral. The contracts allowed for some bariatric patientsupport and paediatric transfers.

• Staffing levels, shift patterns and availability of vehicleshad been planned in line with each contract’srequirements.

• The ambulance team leaders told us that they regularlyused between 13 and 15 vehicles each day to meet thedemands of the NHS contracts. They typically scheduledtwo additional crews and vehicles than were booked onany given day to allow for a flexible approach to meetingdemand. These additional crews could be requested asand when they were needed by NHS providers.

• The senior management team told us they held regularmeetings with representatives from the NHS Trusts thatthey worked with to check that they were meeting theirrequirements and to plan for any additional work.

Meeting people’s individual needs

• There were a range of measures to ensure staff couldmeet patient’s needs.

• Information that had been received as part of thebooking process was communicated to staff via theirportable electronic devices. Additional conversationswere held between staff from different services athandover points.

• A telephone interpreting service was available at alltimes and translation services could be arrangedpromptly for patients who did not speak English as afirst language. Staff knew how to arrange the service.

• Staff told us, and we observed that, patient’srequirements and preferences were discussed andpractical adjustments were made, to meet individualneeds prior to transporting patients. For example,longer journeys were planned with comfort breaks, bothseated and stretcher vehicles were available, and ‘samesex’ crew members could be provided, where required.

• Staff understood do not attempt cardio pulmonaryresuscitation orders and checked for the presence ofthese when working patients who were receivingend-of-life care.




• Staff were able to escalate concerns to the NHS or theprovider’s clinical director to access advice if a patient’shealth rapidly deteriorated during transfer so that anappropriate plan for management could be made.

• Staff had completed specific training in dementia careto support them to meet some patients’ needs.

• The ambulance crews that we spoke with alsoconfirmed that there were appropriate arrangements formoving patients with particular needs for example,bariatric patients or young children. This included theprovision of additional equipment.

Access and flow

• At the time of the inspection, the average deploymentper day was between 13 and 15 ambulances. Therewere a total of 16 ambulances available for use, thusensuring that there was adequate service cover in theevent of a vehicle breakdown. On the day of theinspection, there was one vehicle being repaired; thishad been repaired within a one day turnaround and wasback on the road at the end of the inspection day.

• Bookings were managed through an NHS provider’scentralised dispatch centre; there were two ambulanceteam leaders who supported their staff’s deploymentfrom the provider’s side.

• The centralised dispatch centre provided bookinginformation to an individual staff member’s electronicportable device so that they could review anyinformation. They logged an activity on the device toconfirm that the booking had been received andreviewed.

• We observed staff following these processes on the dayof the inspection.

• The NHS providers that the service worked withreviewed information about performance, for example,in relation to the number of patients transported eachday. They reviewed this with the service at contractreview meetings.

• We asked staff in the discharge lounge about the flow ofinformation between themselves, the centraliseddispatch centre, and the provider’s ambulance crews.They commented that the ambulance crews wereresponsive when they received the information.

Learning from complaints and concerns

• There was a formal complaints policy. Staff were awareof this policy and acted in line with it.

• We saw that the ambulance crew members carriedbusiness cards with them to give to patients so that theycould provide the service with feedback directly,including about how to complaint.

• The NHS provider commissioning the service forwardedinformation about any complaints they received inrelation to the service to the senior management team.If necessary, there was a process for joint investigationand learning across the different providers.

• The director of care and quality was responsible formonitoring and investigating any complaints. Theycollected evidence and statements from staff andcompiled an internal report

• Complaints were reviewed at the bi-weekly directors’meeting to monitor for any trends, or identify anyopportunities for shared learning across the business.

• There was an internal target for completing aninvestigation, and responding to any complainant in full,within 25 working days.

• The service had received two complaints in the pastyear through the NHS provider that they werecontracted to work with; we saw that these had beendealt with in line with the provider’s incident reportingand investigation policy as the responsibility forresponding directly to the complaint lay with the NHSprovider.

• We asked staff about how learning from complaints wasshared to prevent a recurrence of the concerns raised.They noted that they were kept up to date with theoutcome of any complaints, concerns or incidentsthrough the staff news bulletins.

• The director of care and quality also noted thatindividual members of staff who were the subject of anycomplaint would be spoken with directly about theiractions and either disciplined or offered retrainingaccordingly.

Are patient transport services well-led?

Leadership of service




• The senior management team consisted of onoperations director, a clinical director, a specialistservices director and the director of care and quality.

• The operations director, who had oversight of theoperational ambulance crews and vehicles, wassupported by team leaders, lead drivers and a controller.The clinical director, who had oversight of training, wasalso supported by a training manager.

• There had been a period of service transformationfollowing the changes to the ownership of the business.This had led to a complete re-structure of the seniormanagement team and the implementation of a rangeof new policies and protocols. There had also beenwide-ranging changes to the staffing of the ambulancecrews following changes to contracts awarded to theservice by an NHS provider.

• The staff we spoke with were largely positive about thechanges that had occurred since the change inownership and management structure. They told usthey were aware of the leadership team and their rolesand responsibilities. They noted that the localmanagement team were approachable and responsivewhen they had any concerns.

• There were appropriate staff reporting procedures toescalate concerns about co-workers and colleaguesthrough the operation of a whistleblowing policy.

Vision and strategy for this this core service

• We discussed the vision and strategy for this service withthe senior management team. They were committed todeveloping the business further and were in the processof establishing new contracts with other providers. Newvehicles had been ordered, and additional staff hadbeen recruited, to support a planned period ofmanaged growth.The operational staff that we spokewith were aware of the plans to grow the business.

• The management team stressed the importance ofcaring for patients and supporting their staff. In the pastsix months, patient-centred care had been highlightedto staff through the ‘care to care’ policy and workingprotocols. Staff had been supported to engage in newtraining, had been given the opportunity to providefeedback through a staff survey and were now beingengaged in a formal appraisal process.

Governance, risk management and qualitymeasurement (and service overall if this is the mainservice provided)

• There had been a period of service transformationfollowing the changes in ownership and managementstructures in September 2017.

• There was a governance framework in place withassociated staff policies and protocols. It was evidentthat a number of new policies and protocols hadrecently been implemented.

• The implementation had been supported by investmentin new computer software that was being trialled at thetime of the inspection, for example, to aid with rotas andstaff schedules as well as managing othergovernance-related processes such as incidentmanagement, complaints investigations and auditschedules.

• The governance frameworks and procedures were wellunderstood by staff. This ensured, for example, thetimely reporting and investigation of incidents andsafeguarding concerns.

• We looked at the risk registers for ambulanceoperations. A range of items were managed throughreviewing and updating the register. This includedfinancial risks to the business and safety concerns.

• The register was up to date and included actionsassigned to staff members to mitigate the riskshighlighted. Progress against the actions to mitigaterisks was recorded and up to date. The seniormanagement team met on a bi-weekly basis andregularly reviewed progress with the risk register.

• The service undertook some audits to identify areas forimprovement. These covered, for example, audits ofmedicines, patient report forms, and readiness ofambulances or vehicle defects.

• Audits were planned according to a schedule in anonline calendar. Staff were prompted to complete newaudits in a timely manner in response tocomputer-generated email reminders.

• The audits that we reviewed identified actions thatcould be taken to further improve the service. Actionsthat had subsequently been completed were noted.




• There was one example where we found that theauditing process had not effectively identified areas forconcern. This was in relation to the completion ofpatient record forms. The management team wereresponsive to our feedback and assured us that theywould review the audit questions and update them inlight of our feedback. .

• The service engaged in monthly meetings with the NHSprovider that it held contracts with to review theirperformance. They had also been inspected andaudited by the NHS provider in March 2018 to check thatthey were meeting the required standards under thecontract. Some actions had been identified at that time.We saw evidence that these actions had either beencompleted or were in progress at the time of theinspection.

• There was a recruitment policy for employing new staff.This included proof of identity, driving licence andenhanced disclosure and barring service checks.References and qualifications were also required. Wereviewed the recruitment records for five staff membersand found that relevant checks had been completed.

• Staff all completed a self-assessment in relation to theirphysical health. However, we found that the providerdid not currently check that staff who had direct patientcontact as part of their role had been immunised withselected vaccines, such as Hepatitis B, which may beappropriate for their role.

• We discussed this with the director of care and quality.They commented that they had recently reviewed thevaccines requirement for all staff and showed us adocument outlining which vaccines were required foreach role. They had identified that some vaccinationswere required for all operational staff, such as HepatitisB.However, they had not yet instigated a programme forassuring that all staff had been immunised; they wereexploring options for working with an occupationalhealth service to provide the required vaccinations.

Culture within the service

• There had been a period of organisational changestarting in 2017. The structure of the seniormanagement team had grown and there had been

wide-ranging staffing changes, in terms of theambulance crew staff, as a result in a change incontracts. The new management team had also rapidlyimplemented new policies and protocols.

• All of the staff we spoke with told us that the providerhad been good at keeping them informed and hadconsulted with them on the changes.They found themanagement team to be responsive to their ideas andconcerns.

• However, a staff survey in March 2018, which had beencompleted by 18 members of staff identified somedissatisfaction with the culture within the company. Forexample, some staff did not feel valued or felt therewere communication issues.

• We found that the management team had beenresponsive to this feedback. They had provided staffwith a full analysis of the survey and laid out writtenplans for improvement. This included actions topromote staff satisfaction, such as a pay review and staffrecognition programme, as well as improvement tocommunication methods through staff bulletins and theongoing implementation of online resources for staff.

Public and staff engagement (local and service level ifthis is the main core service)

• The senior management team showed us examples ofhow they had worked with other providers to makeimprovements to the service. For example, they hadworked to improve the GP urgent care service bydiscussing protocol changes with the NHS trust thatthey held a contract with. This had led to changes inpractice, for example, staff were now able to call aheaddirectly to patients to let them know when they wouldbe arriving. This helped patients to understand theprocess and to be ready when the crew did arrive.

• The provider had recently instigated staff meetings toimprove the flow of information between the seniormanagement team and operational staff.Thesemeetings were being held on a monthly basis. Wereviewed the meeting minutes from the previous threemonths. We found that the meetings coveredoperational concerns around rotas and overtime, plansfor business expansion as well as staff recognition, for




example through receipt of compliments and an‘employee of the month’ scheme. There was a weeklystaff bulletin which further supported efforts tocommunicate effectively with all staff.

• Staff told us that they enjoyed the staff meetings asthere was also an ‘informal’ element; the seniormanagement team took staff to a local restaurant andprovided dinner.

• The provider was in the process of implementing apatient feedback system through the provision ofstandardised forms on the ambulances. We reviewed aprototype form and saw that it covered areas of patientsatisfaction such as response times and caringattitudes.

• Ambulance crews were also carrying business cards togive to patients and inviting them to provide feedbackdirectly to the company.

Innovation, improvement and sustainability

• The service had introduced an ‘employee of the month’award based on feedback from internal and externalsources. The winner was announced at monthlyoperations meetings and recognised through the receiptof a shopping voucher.

• The provider was investing in new software to providestaff with immediate access to the most up to datepolicies and protocols. Longer term plans for the systemincluded using it for incident reporting with the aim ofensuring consistency of reporting and monitoring.




Areas for improvement

Action the hospital SHOULD take to improve

• The provider should further mitigate the risks to staffcarrying out care and treatment by ensuring staffwith direct patient contact had selectedimmunisations, such as Hepatitis B.

• The provider should check that staff understandrelevant information required for assessing andresponding to the risks to the health and safety ofservice users.

• The provider should review whether all staffunderstand their responsibilities under the Duty ofcandour regulation.

• The provider should review the implementation ofsystems for the safe management of clinical wasteand stock.

• The provider should put in place a system to keepmedicines safe at all times.

• The provider should improve their system formaintaining accurate patient records, includingactions taken to mitigate risks in relation to thehealth, safety and welfare of service users, inparticular for those where an unexpected level ofcare or treatment is required during a patientjourney.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


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