hospital car services newapproachcomprehensive report ... ·...

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.

Streamline (Kent) Limited

HospitHospitalal CarCar SerServicvicesesQuality Report

Unit 8 Headcorn Business ParkBarradale FarmMaidstone RoadHeadcornAshfordKentTN27 9PJTel: 01622 750000Website:

Date of inspection visit: 6 December 2017Date of publication: 20/03/2018

1 Hospital Car Services Quality Report 20/03/2018

Letter from the Chief Inspector of Hospitals

Hospital Car Services is operated by Streamline (Kent) Limited. It provides a patient transport service.

The service uses wheelchair-adapted vehicles and saloon cars purchased and used solely for the purposes of providingpatient transport services. All vehicles have livery branding. The service carries out pre-planned, non-urgent patienttransport journeys only, such as transport to outpatient appointments. Non-clinical patient transport drivers withrelevant training and competencies to carry out patient transport undertake all journeys. An NHS ambulance servicecommissions all the provider’s patient transport journeys.

We inspected this service using our comprehensive inspection methodology. We carried out this announced inspectionon 6 December 2017.

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.

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 prided themselves on giving compassionate care to patients. Patient feedback we reviewed demonstrated ahigh level of patient satisfaction.

• The culture encouraged learning from incidents and complaints to drive continuous improvements. We sawexamples of learning the service shared with staff, such as following incidents of inappropriate parking. Staff feltwell supported by the management team and felt confident to raise concerns.

• The management team demonstrated an understanding of risks related to the service. Managers held and keptrecords of monthly governance meetings. This demonstrated ongoing oversight of quality and governance issuessuch as policies, risk management and human resources.

• All staff had undertaken mandatory training in key areas to provide them with the knowledge and skills theyneeded to do their jobs safely.

• We saw evidence the service had appropriate processes to keep vehicles roadworthy and meet legal requirementsrelating to vehicles. This included evidence of road tax, motor insurance and regular servicing and maintenance.

• The service had appropriate processes to ensure business continuity in a variety of business continuity incidents,such as loss of power or vehicle incidents.

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

• At the time of our visit, the provider transported small numbers of children under the age of 18. At this time, staffhad completed level one safeguarding children training. This was not in line with the national intercollegiateguidance, which recommends all staff that have contact with children as part of their role undergo level two

Summary of findings


training. We raised this issue with the provider, who took action to arrange level two safeguarding children trainingfor all drivers. The provider subsequently sent evidence they had booked face-to-face safeguarding children leveltwo training sessions on 20 and 21 January 2018 for all drivers to ensure they met the national intercollegiateguidance.

• The service checked the presence of fire extinguishers on all vehicles daily and as part of their six-weekly “qualityand compliance spot checks”. Although the fire extinguisher on the vehicle we inspected was in date, the providerdid not have a system to obtain ongoing assurances all fire extinguishers were in date. Following our feedback, theprovider planned to introduce this to their “quality and compliance spot check” audit tool.

• Although staff received an induction and drivers and managers were able to describe the process, there were nowritten induction records.This meant the provider might not have had assurances new staff received a consistentinduction in all relevant areas.

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

Amanda Stanford

Deputy Chief Inspector of Hospitals (South), 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)


• The provider had appropriate systems for infectionprevention and control (IPC). The provider hadrecently introduced audit tools to provide ongoingassurances around cleanliness and drivercompliance with IPC policies.

• Staff prided themselves on giving compassionatecare to patients. Patient feedback we revieweddemonstrated a high level of patient satisfaction.

• The culture encouraged learning from incidents andcomplaints to drive continuous improvements. Stafffelt well-supported by the management team andfelt confident to raise concerns.

• The management team demonstrated anunderstanding of risks related to the service.Managers held and kept records of monthlygovernance meetings. This demonstrated ongoingoversight of quality and governance issues such aspolicies, risk management and human resources.

• All staff had undertaken mandatory training in keyareas to provide them with the knowledge and skillsthey needed to do their jobs safely.

• We saw evidence the service had appropriateprocesses to keep vehicles roadworthy and meetlegal requirements relating to vehicles. Thisincluded evidence of road tax, motor insurance andregular servicing and maintenance.

• The service had appropriate processes to ensurebusiness continuity in a variety of businesscontinuity incidents.

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

• At the time of our visit, the provider transportedsmall numbers of children under the age of 18. Atthis time, staff had completed level onesafeguarding children training. This was not in linewith national intercollegiate guidance, whichrecommends all staff that have contact with

Summaryoffindings

Summary of findings


children as part of their role undergo level twotraining. We raised this issue with the provider, whosubsequently took action to arrange level twosafeguarding children training for all drivers. Theprovider subsequently sent evidence they hadbooked face-to-face safeguarding children level twotraining sessions for all drivers on 20 and 21January 2018 to ensure they met the nationalintercollegiate guidance.

• The provider checked the presence of fireextinguishers on all vehicles as part of their “qualityand compliance spot checks”. Although the fireextinguisher we checked was in date, the providerdid not have a system to obtain ongoing assurancesall fire extinguishers were in date. Following ourfeedback, the provider planned to introduce this totheir “quality and compliance spot check” audittool.

• Although staff received an induction and driversand managers were able to describe the process,there were no written induction records. This meantthe provider might not have had assurances newstaff received a consistent induction in all relevantareas.

Summaryoffindings

Summary of findings


HospitHospitalal CarCar SerServicvicesesDetailed findings

Services we looked atPatient transport services (PTS)


Contents

PageDetailed findings from this inspectionBackground to Hospital Car Services 7

Our inspection team 7

How we carried out this inspection 7

Our ratings for this service 8

Background to Hospital Car Services

Hospital Car Services is operated by Streamline (Kent)Limited. The service first registered with the Care QualityCommission in January 2017. It is an independentambulance service in Headcorn, near Ashford, Kent. Theservice primarily serves the communities of Sussex andprovides non-urgent patient transport services only, suchas transport to outpatient appointments.

We inspected Hospital Car Services on 6 December 2017.This was the service’s first inspection since registrationwith CQC.

The service has had a registered manager in post sinceJanuary 2017. The registered manager had changed sincethe service first registered, and a new manager registeredwith the CQC in May 2017.

Thirty-eight patient transport drivers worked at theservice, which also had a bank of four additional staff thatit could use. The drivers were non-clinical staff that allhad training to provide patient transport services. Thisincluded relevant mandatory training in areas includingsafeguarding, infection prevention and control, and basiclife support.

The provider had a fleet of 38 vehicles that it used to carryout the regulated activity. This consisted of 20wheelchair-adapted vehicles and 18 saloon carspurchased and used solely for the purposes of providingpatient transport services. All vehicles had livery brandingwith the Hospital Car Services logo. An NHS ambulanceservice commissioned all the provider’s patient transportjourneys.

Our inspection team

The team that inspected the service comprised a CQClead inspector, two CQC inspectors, and a specialistadvisor with expertise in ambulance services. Theinspection team was overseen by Catherine Campbell,Head of Hospitals Inspection.

How we carried out this inspection

During the inspection, we visited the registered location.We spoke with six members of staff, including patienttransport drivers and the management team. During ourinspection, we reviewed 21 completed patientsatisfaction questionnaires.

Detailed findings


Our ratings for this service

Our ratings for this service are:

Safe Effective Caring Responsive Well-led Overall

Patient transportservices N/A N/A N/A N/A N/A N/A

Overall N/A N/A N/A N/A N/A N/A

Notes

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the serviceThe service is registered to provide the following regulatedactivity:

• Transport services, triage and medical advice providedremotely

During the inspection, we visited the registered location.We spoke with six members of staff, including patienttransport drivers and the management team. During ourinspection, we reviewed 21 completed patient satisfactionquestionnaires.

There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection. This was the service’s firstinspection since registration with CQC, which found thatthe service was meeting all standards of quality and safetyit was inspected against.

Activity (January to November 2017)

• There were approximately 60,000 patient transportjourneys undertaken. Almost all journeys involved thetransport of adult patients aged 18 and over. The NHSambulance trust that subcontracted work to theprovider held all patient data. Therefore, we wereunable to obtain the exact numbers of children andyoung people the service had transported. However, alldrivers we spoke with told us they had transported onlyone or two children or young people under the age of 18during the past year. These were all older children andyoung people aged 16 and 17.

Track record on safety (January to November 2017)

• The service reported no never events during the reportingperiod.

• The service reported five clinical incidents.

• The service reported no serious injuries.

• The service reported four formal complaints.

An NHS ambulance trust based in another regionsubcontracted work to Hospital Car Services. All patienttransport work the service carried out came from thesubcontracting NHS ambulance trust. However, there wasno formal long-term contract for this arrangement.

Patienttransportservices

Patient transport services (PTS)


Summary of findingsThe only core service provided was patient transportservices. The service carried out approximately 228patient journeys each day, five and a half days a week.In the eleven-month reporting period, January toNovember 2017, the service carried out approximately60,000 patient journeys.


• The provider had appropriate systems for infectionprevention and control (IPC). The provider hadrecently introduced audit tools to provide ongoingassurances around cleanliness and drivercompliance with IPC policies.

• Staff prided themselves on giving compassionatecare to patients. Patient feedback we revieweddemonstrated a high level of patient satisfaction.

• The culture encouraged learning from incidents andcomplaints to drive continuous improvements. Stafffelt well-supported by the management team andfelt confident to raise concerns.

• The management team demonstrated anunderstanding of risks related to the service.Managers held and kept records of monthlygovernance meetings. This demonstrated ongoingoversight of quality and governance issues such aspolicies, risk management and human resources.

• All staff had undertaken mandatory training in keyareas to provide them with the knowledge and skillsthey needed to do their jobs safely.

• We saw evidence the service had appropriateprocesses to keep vehicles roadworthy and meetlegal requirements relating to vehicles. This includedevidence of road tax, motor insurance and regularservicing and maintenance.

• The service had appropriate processes to ensurebusiness continuity in a variety of business continuityincidents.

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

• At the time of our visit, the provider transportedsmall numbers of children under the age of 18. At thistime, staff had completed level one safeguardingchildren training. This was not in line with nationalintercollegiate guidance, which recommends all staffthat have contact with children as part of their roleundergo level two training. We raised this issue withthe provider, who subsequently took action toarrange level two safeguarding children training forall drivers. The provider subsequently sent evidencethey had booked face-to-face safeguarding childrenlevel two training sessions for all drivers on 20 and 21January 2018 to ensure they met the nationalintercollegiate guidance.

• The provider checked the presence of fireextinguishers on all vehicles as part of their “qualityand compliance spot checks”. Although the fireextinguisher we checked was in date, the providerdid not have a system to obtain ongoing assurancesall fire extinguishers were in date. Following ourfeedback, the provider planned to introduce this totheir “quality and compliance spot check” audit tool.

• Although staff received an induction and drivers andmanagers were able to describe the process, therewere no written induction records. This meant theprovider might not have had assurances new staffreceived a consistent induction in all relevant areas.




Are patient transport services safe?

Incidents

• The service reported no never events in the 12 monthperiod before our inspection. 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 healthcareservices. Each never event type has the potential tocause serious patient harm or death. However, seriousharm or death is not required to have happened as aresult of a specific incident occurrence for that incidentto be categorised as a never event.

• The service reported five incidents since it registeredwith CQC in January 2017. Drivers reported incidents tothe general manager by providing a written account ofthe incident through email. The general manager thenforwarded the driver’s account of the incident to theNHS ambulance service that subcontracted work toHospital Car Services (HCS). The NHS ambulance serviceinvestigated the incident and informed the generalmanager of the outcome of the investigation. Thegeneral manager shared feedback from the incidentwith staff.

• The service managed incidents well. Drivers told us theyalways received feedback on incidents from the generalmanager, for example, following a vehicle accident.Drivers said the general manager shared feedback withall drivers through email if there were relevant learningpoints for all staff. We saw evidence of learning theservice shared with drivers through email following anincident involving potentially unsafe parking practicesat a hospital. This allowed the service to learn fromincidents and improve safety.

• The duty of candour, Regulation 20 of the Health andSocial Care Act 2008, relates to openness andtransparency. This duty requires services of health andsocial care services to notify patients (or other relevantperson) of ‘certain notifiable safety incidents’ andprovide reasonable support to that person. While therewere no incidents during the reporting period thattriggered duty of candour, the registered manager andgeneral manager both demonstrated awareness andunderstanding of their regulatory duty of candour.

Mandatory training

• The service provided mandatory training in key skills toall staff and made sure everyone completed it. All staffattended mandatory training provided by an externaltrainer. Provider data demonstrated 100% of staff hadcompleted mandatory training in the following areaswithin the last 12 months: Passenger safety; basic lifesupport; first aid; basic health and safety and riskassessments; infection control; deprivation of libertysafeguards; and safeguarding. The provider confirmedin writing that the basic life support training includedpaediatric, as well as adult, basic life support. We alsosaw copies of certificates providing evidence staff hadcompleted their mandatory training.

Safeguarding

• The service reported four safeguarding concernsbetween January and November 2017. Staff reportedsafeguarding concerns by providing an email account ofthe concern to the general manager. Staff could alsotelephone the contact centre at the NHS ambulancetrust that subcontracted work to HCS to reportconcerns. Staff at the contact centre subsequentlycompleted the NHS ambulance trust’s internalsafeguarding report form following information directlyfrom the driver or from HCS’s general manager. Thesafeguarding lead at the NHS ambulance trustsubsequently investigated the concerns and alerted thelocal safeguarding authority where applicable.

• Staff understood how to protect patients from abuseand the service worked well with the commissioningNHS ambulance trust to do so. All staff we spoke withknew how to report safeguarding concerns. We revieweda safeguarding concern raised by a driver shortly beforeour inspection. We saw that the driver had identifiedand raised concerns about an adult at risk, and thegeneral manager had reported the concern to the NHSambulance trust for investigation. The general manageralso described another example where a driver hadappropriately identified and reported safeguardingconcerns about an adult at risk. This demonstrated staffwere able to identify and report any safeguardingconcerns involving adults at risk.

• Provider data and staff training certificatesdemonstrated that all staff had completed safeguarding




adults at risk and safeguarding children level onetraining. There is no national guidance stipulating thelevel of safeguarding adults at risk training required fordifferent staff groups.

• However, the intercollegiate guidance document“Safeguarding Children and Young People: roles andcompetences for health care staff” (2014) states, “Allnon-clinical and clinical staff who have any contact withchildren, young people and/or parents/carers” requiresafeguarding children level two training. As the serviceoccasionally transported children and young peopleunder the age of 18, this meant drivers might not havehad a sufficient level of training to allow them torecognise child safeguarding concerns at the time of ourvisit.

• We raised this issue with the provider, who subsequentlytook action to arrange level two safeguarding childrentraining for all drivers. The provider sent evidencedemonstrating they had booked face-to-facesafeguarding children level two training sessions for alldrivers on 20 and 21 January 2018 to ensure they metthe national intercollegiate guidance.

Cleanliness, infection control and hygiene

• The service required drivers to carry out daily andweekly vehicle cleaning tasks to maintain vehiclecleanliness. We saw the provider’s “Infection preventionand control (IPC) policy”, which was within its reviewdate and provided comprehensive guidance to staff onvehicle cleanliness, personal-protective equipment(PPE) and infection prevention and control. The service’s“quality governance, patient safety and risk committee”meeting minutes (dated 23 October 2017) demonstratedthat the service had agreed to give staff an extrahalf-hours’ pay to cover time spent cleaning theirvehicle following a shift.

• Staff we spoke with were able to describe their daily andweekly cleaning responsibilities relating to vehicles andequipment in line with the IPC policy. Provider datashowed 100% of staff completed IPC training as part oftheir mandatory training. Staff had recently completed“infection control audit questionnaires”. We reviewedcompleted questionnaires, and saw staff answers

demonstrated knowledge of, and compliance with, theprovider’s IPC policy, national guidance and bestpractice. This meant the provider had assurancesaround staff knowledge of IPC.

• Vehicles also had a deep clean every three monthsthrough an external cleaning company, or sooner in theevent of any significant contamination with blood orbodily fluids in line with the provider’s IPC policy. Wesaw evidence of deep cleaning within the last threemonths for all vehicles, which provided assurancesaround vehicle cleanliness.

• We inspected one vehicle that staff had cleaned ready totransport patients. We saw all areas of the vehicle werevisibly clean and tidy. We saw decontamination wipesavailable for staff to clean the vehicle. We also sawaprons and gloves available for staff, as well as alcoholhand sanitiser to allow staff to clean their hands. Driversdid not have a uniform, although the service requiredstaff to wear clean, presentable and non-brandedclothing for each shift. As we were unable to observeany patient journeys, we were unable to observe staffclean their hands or use personal protective equipment(PPE).

• The service had recently introduced a new “quality andcompliance spot check” audit tool. We also saw copiesof completed audits with a similar tool, which theprovider previously used to gain assurances in this area.We saw the new audit tool, which included assessmentsof IPC compliance, for example, hand sanitiser, PPE,vehicle cleanliness and driver appearance. We saw acopy of a completed audit for one vehicle carried out bya senior driver in November 2017. The service wasauditing all vehicles within December 2017, and a seniordriver we spoke with confirmed they had carried someof the audits out. Going forward, the service planned toaudit every vehicle on a six-weekly basis to obtainongoing assurances of cleanliness and IPC compliance.

Environment and equipment

• We reviewed documents relating to six of the provider’s38 vehicles. We saw evidence of servicing within the lastsix months for all six vehicles, as well as evidence ofregular maintenance when required. This providedassurances the service maintained its vehicles to keepthem roadworthy.




• We saw evidence of motor insurance and road tax for allvehicles. This demonstrated the provider was meetingtheir legal requirements in this area.

• Most of the service’s vehicles were less than three yearsold and therefore did not require an MOT. One ofdocuments we reviewed was for a wheelchair bus,which was older than three years. For this vehicle, wesaw evidence of an up-to-date MOT in line with legalrequirements.

• Staff kept vehicles at their home addresses overnight.This was to allow staff to go straight out to their first jobfrom home after first checking their vehicle eachmorning. Staff took responsibility for holding vehiclekeys securely at all times a vehicle was in their charge.The provider held spare sets of vehicle keys in a secureplace at the registered location.

• Staff recorded vehicle checks of oil, water, lights andtyres on their weekly timesheets. We reviewedcompleted timesheets, which provided assurances staffwere carrying out these checks. However, staff did notalways record the dates of checks they performedduring the course of each week. This meant the providercould not have had assurances staff carried out therequired checks every time they started a shift.

• Following our feedback at the end of the inspection, theservice re-designed the staff timesheets and shared acopy with us. We saw that the new version had spaces torecord oil, water, lights and tyre checks next to each dayof the week. This would allow the provider to gainassurances staff performed all vehicle critical checks atthe start of each shift.

• Drivers carried basic equipment on board all vehicles.This included a basic first aid kit, PPE, cleaningequipment and bottled water. We saw an equipmentchecklist prompting staff to check the following items atthe start of each shift: Fire extinguisher, first aid kit,non-latex gloves, antiseptic hand gel, antibacterialwipes, sick bags, paper towels, bottled water and anumbrella. The checklist also reminded staff to checktheir personal digital assistant (PDA) used to accesspatients records and charge lead, and their fuel card.

• Although the equipment checklist prompted staff tocheck equipment at the start of each shift, there was norequirement for staff to sign and date each daily check.The service audited all items on the equipment

checklist as part of the six-weekly quality andcompliance spot checks. However, the lack ofdocumentation of daily checks meant the provider didnot have daily assurances all staff completed everycheck before all shifts.

• We checked the first aid kit on the vehicle we inspectedand saw that all single-use items were sealed (whereappropriate) and within their use-by dates. Checks ofsingle-use equipment as part of the quality andcompliance spot checks helped the provider obtainassurances single-use items were safe and fit forpurpose.

• Drivers carried a wheelchair on their vehicle. Staff toldus they rarely needed to use the wheelchairs, as mostpatients that needed a wheelchair used their own. Thewheelchairs had not yet been serviced, as they were lessthan one year old. However, the provider gave us anexample of a wheelchair that had been replaced due toa fault. Following our feedback, the provider planned tointroduce annual servicing of all wheelchairs by anengineer. This would give the provider ongoingassurances all wheelchairs were safe and fit for purpose.

• Drivers carried a fire extinguisher on board all vehicles.We saw that the “quality and compliance spot check”included confirmation of the presence of a fireextinguisher on the vehicle. Drivers were also requiredto check a fire extinguisher was on board at the start ofevery shift. However, the spot checks did not include acheck of the expiry dates or the pressure gauges on fireextinguishers. This meant the service might not havehad assurances all fire extinguishers were within theiruse-by dates. Following our feedback at the end of theinspection, the provider told us they planned to addchecks of fire extinguisher use-by dates and pressuregauges to their compliance and quality spot-checks.

• We saw clinical waste bags available on the vehicle weinspected for staff to dispose of any contaminatedwaste, for example, following the cleaning of any spiltbodily fluids. Staff disposed of any clinical waste bagson arrival at hospital after transporting the patient,where hospital staff sent them for incineration.

Medicines

• As the service did not have any registered clinical staff,drivers did not carry or administer any medicines. TheNHS trust that subcontracted work to HCS advised




patients in advance that they would be responsible forhandling their own medicines during transport. Thisincluded patients with small portable oxygen cylinders,who were required to ensure in advance that they hadsufficient oxygen for the duration of their journey.

Records

• Drivers used personal digital assistants (PDAs) tocomplete electronic records of patient journeys. ThePDA was a small, hand-held computer that allowed thetransfer of information between drivers and the NHSambulance trust that subcontracted work to HCS.Electronic records went from the PDA inside the vehicleto the NHS ambulance trust, and HCS did not retain anypatient records. Therefore, we were unable to reviewany patient records during our inspection.

Assessing and responding to patient risk

• The provider told us staff would stop the vehicle and call999 for an emergency ambulance should a patientbecome seriously unwell during a journey. There was nowritten policy detailing this practice, however thegeneral manager explained that this information wasgiven to staff as part of their induction process. All staffwe spoke with all told us they would call 999 for anemergency ambulance if a patient deteriorated during ajourney. This demonstrated drivers knew how torespond in an emergency in line with the informationgiven in their induction. However, the lack of writteninduction records meant the provider may not have hadassurances this was always covered as part of everyinduction.

• All staff had basic life support training for adults andchildren as part of their mandatory training programmeand could provide basic life support while waiting for anambulance to arrive should the need arise.

• A driver also told us about an incident where a patientfelt unwell on the journey home from an outpatientappointment. The driver subsequently liaised with thepatient’s treatment centre and took the patient to anearby emergency department for assessment andtreatment with verbal consent from the patient. Thisdemonstrated drivers took action to help patientsaccess further care and treatment if they needed it.

• Staff told us they had not experienced any physicallyviolent patients. We saw examples of two occasions

when staff had raised concerns regarding patients’attitudes. In one case, a patient was rude and verballyaggressive with staff. We saw that the NHS ambulancetrust that subcontracted work to HCS investigated anddealt with the concerns. This demonstrated staff feltconfident to escalate inappropriate behaviour, and thatany concerns raised were addressed.

Staffing

• We saw the service’s staff rota, with staff allocated tospecific shift patterns to meet the needs of patients. Theservice employed 38 permanent drivers. There was abank of four additional drivers to provide holiday andsickness cover. The bank drivers had the same trainingand competencies to carry out the role as thepermanent drivers. Rotas demonstrated a sufficientnumber of drivers to provide a safe service.

• Following feedback from staff, the service hadreorganised shift patterns to allow patients attendingregular appointments to have the same driver wherepossible. This allowed continuity of care.

Anticipated resource and capacity risks

• The service’s bank of four additional drivers meant thatthere were additional staff available to work, forexample in the event of staff sickness.

• In the event of a vehicle being off the road following anaccident, the service would allocate one of its othervehicles to the relevant driver. A vehicle sustained somedamage the day before our visit. Staff informed us thatthe service allocated another vehicle to the driver whilethe damaged vehicle underwent repair. This allowedservices to continue as normal.

• The service required staff to risk assess situations suchas adverse weather. If staff felt the weather conditionswere too unsafe to transport a patient, they wouldreport to the general manager. The general managerwould subsequently liaise with the NHS ambulancetrust that subcontracted work to HCS to find anothermeans of transporting the patient, such as by NHSambulance. At the time of our visit, there was no writtenpolicy for staff around adverse weather; however, thegeneral manager told us staff received this informationverbally during their induction.

• The service was in the process of drafting a winterresilience plan at the time of our visit. Following




feedback from the NHS ambulance service thatsubcontracted work to HCS, the general manager wasadding further detail to the plan. Once complete, theservice planned to share the winter resilience plan withall staff to provide them with written guidance.

Response to major incidents

• We reviewed the provider’s business continuity policy(BCP). The BCP set out staff roles in the event ofbusiness continuity incidents, and details for keycontacts such as power suppliers and insurers. We sawmitigation against risks, such as managers being able toaccess the service’s systems and telephone lines fromhome in the event of a premises incident at theregistered location.

• The registered location had a back-up generator toprovide ongoing power in the event of power failure.During our inspection, we observed a power cut in theoffices and saw that the generator resumed powerwithin seconds.

Are patient transport services effective?

Evidence-based care and treatment

• The service had recently introduced a new “quality andcompliance spot check” audit tool. Audits allowed theprovider to assess staff compliance with policies. Wealso saw copies of audits with a similar tool the providerpreviously used to gain assurances around quality andcompliance.

• The new tool assessed compliance with the provider’sIPC policy, equipment checks, and security checks suchas checking staff wore their identification badges. Wesaw one completed audit using the new quality andcompliance spot check tool, which the provider hadstarted to use to assess all vehicles on a six-weeklybasis. This showed a high standard of compliance in allareas. We saw the auditor had also identified areas forimprovement and fed these back to the driver forcorrection. This demonstrated the service used theaudit to gain assurances around staff compliance withpolicies and to drive improvement.

• The NHS ambulance trust that subcontracted work toHCS assessed patient needs and booked transportaccordingly. Drivers subsequently received booking

information direct from the NHS ambulance trustthrough their personal digital assistant (PDA). Driversreported the NHS ambulance trust made appropriatebookings, for example, by ensuring all patients livingwith dementia had an escort in line with their policy.Drivers could telephone the bookings office at the NHSambulance trust if they had any concerns about thesuitability of the arranged transport to meet thepatient’s needs.

Assessment and planning of care

• Staff told us the PDA contained all relevant patientinformation they needed. The PDA included specialnotes, which flagged any individual needs such asdementia. The PDA also contained other keyinformation, such as patients with a preference forsitting in the front or back of a vehicle. This alloweddrivers to plan and prepare accordingly.

• Drivers carried bottled water and cups for patients on allvehicles. This allowed patients to stay hydrated, forexample, during hot weather.

Response times and patient outcomes

• An application on drivers’ PDAs allowed the monitoringof pick-up, drop-off and journey times. The NHSambulance trust that subcontracted work to HCSrecorded and monitored this information. The NHSambulance trust also monitored performance againstkey performance indicators (KPIs), such as journey timesfor renal patients. As the NHS ambulance trust collectedand reported this data, and not Hospital Car Services,we were unable to include it in this report.

• The general manager and registered manager told usthey received regular feedback from the NHSambulance trust regarding performance against KPIs.The general manager described how the NHSambulance trust had fed back when the service had notmet a KPI. The general manager spoke with drivers andinvestigated. They found that a lack of mobile signal inthe underground car park at a particular hospitaldelayed drivers reporting that they had completed ajourney through their PDA until they had exited the carpark and found a safe place to stop. Feedback from theNHS ambulance trust helped the service to make anychanges to ensure they met the KPIs.

Competent staff




• We saw the provider’s yearly appraisal form for drivers.This was comprehensive, and included clear criteria forassessment by driver and appraiser, as well as a reviewof training undertaken in the last year.

• At the time of our visit, the provider was beginning tocarry out appraisals, with a target to ensure 100% ofstaff received an appraisal by mid-January 2018. Thiswould ensure that all staff received an appraisal withinone year of the service registering with CQC. We sawevidence that showed six drivers had received an annualappraisal within the reporting period. The registeredmanager and general manager explained they hadplanned appraisals for the remaining staff in earlyJanuary 2018. This was because the service wasgenerally quieter after Christmas and New Year. Thiswould ensure the service met their target of 100% ofdrivers receiving an appraisal within one year.

• We reviewed four staff folders and saw that the serviceperformed enhanced Disclosure and Barring Service(DBS) and reference checks before employing staff. Wesaw that the service checked and obtained copies ofstaff driving licences. We also saw that the service askedall new staff to complete an occupational healthself-assessment questionnaire. These checks providedassurances all drivers had appropriate driving skills,character and health to transport patients safely.

• All new staff underwent mandatory training provided byan external trainer before starting work, as well asreceiving an induction. The general manager told us theinduction included a verbal briefing by their linemanager, as well as shadowing an experienced driverbefore transporting patients alone. However, there wasno induction checklist to provide a record of each staffmember’s induction or competencies. This meant theprovider might not have had assurances new staffreceived a consistent induction in all relevant areas.

Coordination with other providers

• The service coordinated with the NHS ambulance trustthat subcontracted work to HCS. They also coordinatedwith acute hospitals, dialysis services and residentialcare homes that they transported patients to and from.

• Staff told us examples of times when they hadcoordinated with other services to ensure patientsreceived the care they needed. One such example waswhen a driver transported a patient to the nearest

emergency department after they felt unwell on ajourney home following outpatient treatment. Thedriver contacted the treatment unit on the patient’sbehalf, who advised them to transport the patient to thenearest emergency department for assessment.

Multi-disciplinary working

• Staff we spoke with described good workingrelationships with staff at hospitals and other servicesthey coordinated with.

Access to information

• The PDA alerted drivers of special notes such as thepresence of a do not attempt cardiopulmonaryresuscitation (DNACPR) order. This then prompteddrivers to check patients had a copy of the DNACPRorder. Patients were required to bring a copy of theirDNACPR order with them on all journeys in line with theNHS ambulance trust’s policy.

• PDAs had a satellite navigation function, which wasregularly updated. The PDA also had a telephonefunction. This allowed drivers to call the NHSambulance trust contact centre to obtain any additionalpatient information they needed.

• The cleric application on the PDAallowed drivers toaccess policies and procedures. This meant driverscould access policies and standard operatingprocedures any time they needed to while on shift.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• All staff received training in the Deprivation of LibertySafeguards (DoLS). Provider data showed 100% of staffcompleted DoLS training within the past year. We sawthe provider’s “Mental Capacity Act and Deprivation ofLiberty Safeguards (DoLS)” policy, which providedguidance to staff on the Mental Capacity Act (2005). Wesaw that this contained appropriate guidance on bestinterest decisions and the least restrictive principle.

• The provider told us they had never transported apatient with a DoLS order in place. However, the servicetransported small numbers of patients living withdementia, and the training and guidance staff receivedmeant the provider had assurances staff had awareness




around patients that may lack capacity. All drivers wespoke with told us patients living with dementiatravelled with a carer who was familiar to the patientand could support them during transport.

• The service had never transported any patients detailedunder Section 136 of the Mental Health Act 1983 or usedrestraint.

• Staff we spoke with said they obtained verbal consentbefore transporting patients or helping them onto or offa vehicle.

Are patient transport services caring?

Compassionate care

• Staff cared for patients with compassion. Feedback frompatients confirmed that staff treated them well and withkindness. We reviewed 21 completed patient experiencequestionnaires completed in January 2017. We foundthat 95.2% of the 21 patients said they felt drivers did“extremely well” at treating them with dignity andrespect. The remaining 4.8% of these patients feltdrivers did “well” at treating them with dignity andrespect. This meant that all patients whosequestionnaire responses we reviewed felt staff treatedthem with dignity and respect.

• We obtained many examples of compassionate carethrough our interviews with staff and from reviewingpatient feedback. For example, the general managerdescribed an occasion where a driver put their ownmoney on a patient’s gas meter to ensure the patientwould stay warm after the patient did not have any cashavailable for this. Drivers spoke of the pride they took intheir work in ensuring patients were comfortable. Onepatient said of their driver, “[He] always goes out of hisway to ensure everything is okay. I feel safe in theknowledge he is picking me up and very comfortable inhis presence”.

• Patient questionnaires we reviewed showed 90.5% ofpatients were extremely likely to recommend the serviceto friends and family. The remaining 9.5% of patientssaid they were likely to recommend the service. Thismeant 100% of patients whose feedback we reviewedwould recommend the service to friends and family.

Understanding and involvement of patients and thoseclose to them

• The service tried to arrange staff shift patterns so thatregular patients, such as renal patients travelling severaltimes a week, had the same driver where possible. Thisallowed continuity of care for patients. One patient’srelative commented, “My husband is very vulnerable. Ithas been lovely to have the same driver, who is caringand friendly”.

• Vulnerable patients such as those living with dementiaroutinely travelled with a carer. This allowed someonefamiliar to support them on all journeys.

• We reviewed a compliments letter from a patient. Thepatient said of their two drivers, “They are both verycaring and we have some interesting conversations,which makes the journey more enjoyable”.

• The NHS ambulance trust that subcontracted work toHCS took patient bookings and was responsible forcommunicating eligibility for transport to patients.

Emotional support

• All staff we spoke with demonstrated awareness of theemotional impact of treatment patients may beundergoing. One patient commented, “Driversunderstand this is a stressful time, and they treat us withsympathy and consideration”.

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

Service planning and delivery to meet the needs oflocal people

• The service carried out approximately 228 patientjourneys each day, or approximately 65, 200 journeysper year. All patient transport work was subcontractedfrom an NHS ambulance trust. Although the NHSambulance trust subcontracted patient transport workto HCS, this arrangement took place outside of a formalcontract. HCS was keen to secure a formal contract withthe NHS ambulance trust to provide job security for staffand to secure the ongoing sustainability of the service.

• The service had ongoing contact and meetings with thesubcontracting NHS ambulance trust and planned its




staff rotas to align with patient need. Thesubcontracting NHS ambulance trust was responsiblefor allocating journeys to specific drivers and vehicles.Managers at HCS reported that the subcontracting NHSambulance trust sometimes incorrectly estimatedexpected journey times. Managers felt that this wasbecause the NHS ambulance trust did not operate in thesame area and therefore its staff maybe did not fullyunderstand the geography and traffic conditions acrossthe patch. HCS had provided feedback on this issue tothe subcontracting NHS ambulance trust and they wereworking together to resolve it.

• The service provided patient transport in cars andwheelchair adapted vehicles only. For any patients thatrequired stretcher transfer, the subcontracting NHSambulance trust used other services that could providean ambulance.

• Drivers we spoke with told us they knew the locations ofpublic toilets across the patch they worked in. They saidthey stopped at these locations to allow patients to usethe toilet should the need arise during a journey.

• We saw that drivers carried an umbrella on vehicles tocover patients during transfer to or from vehicles in wetweather.

• All staff we spoke with expressed frustration around notreceiving details of their next days’ jobs until late thenight before. For example, some drivers started theirshift at 5.30am but did not receive details of theirpatients for the day until 11.30pm the night before. Thismeant they had no time to review their patient listbefore starting their shift and obtain any furtherinformation they might need from the contact centre,which did not open until 6.30am. Staff and managerstold us they had fed this information back to thesubcontracting NHS ambulance service, which had notmade any changes to practice as a result.

Meeting people’s individual needs

• The service occasionally transported patients living withdementia. Staff told us all patients living with dementiaroutinely travelled with a carer to support them.

• The service sometimes transported wheelchair users,and all staff received training in moving and handling aspart of their induction. One of the drivers we spoke withtold us they supported colleagues in this area as they

had extensive experience of wheelchair transport inprevious roles. From the patient questionnaires wereviewed, four out of six wheelchair users felt thatdrivers carried out wheelchair transfer “extremely well”.The remaining two wheelchair users were unsure as tohow wheelchair transfers should be carried out,therefore they were unable to rate the performance ofdrivers in this area. This demonstrated that mostwheelchair users that completed the questionnaire feltdrivers transferred them appropriately.

• Drivers carried a wheelchair on every vehicle. Staff toldus that although wheelchair users usually took theirown wheelchair, they occasionally used the companywheelchairs to help any patient who needed wheelchairassistance from their home to the vehicle, or from thevehicle into a hospital department.

• The service transported very few patients who did notspeak English. The NHS ambulance service thatsubcontracted work to HCS made transport bookingsand advised patients of the day and time of theirtransport. The NHS ambulance trust had access totranslation services available if necessary to support thebooking process. Drivers told us the few patients theytransported that spoke limited English spoke enough tounderstand and verbally consent to transport. All driversalso had access to an online multilingual translationservice if needed through their personal digitalassistants.

• The provider told us they had not transported anypatients with learning disabilities or other complexneeds.

Access and flow

• The subcontracting NHS ambulance trust managed allbookings and allocated resources for patient transport.

• Drivers’ personal data assistants (PDA) allowed thecollection of data to monitor pick-up and journey timesfor all journeys. This information securely flowed fromthe PDA directly to the subcontracting NHS ambulancetrust. The subcontracting NHS ambulance trust tookresponsibility for monitoring performance in this area.The general manager and registered manager told usthey received regular feedback about performancearound journey times from the subcontracting NHSambulance trust.




• Drivers told us they routinely called ahead to confirmpatients’ expected pick-up times. One patient whoprovided feedback commented, “The driver has beenexcellent- [they] ‘phone in advance if arriving earlier orlater than expected”.

• The service asked patients for feedback about staffpunctuality as part of patient experiencequestionnaires. We reviewed 21 questionnaires patientscompleted in the year before our visit. This showed57.1% of respondents felt drivers were “extremelypunctual”. The remaining 42.9% said drivers werepunctual. This meant all patients that responded to thequestionnaire felt that staff collected them on time.

Learning from complaints and concerns

• We reviewed copies of all patient complaints the servicehad received since it registered with CQC in January2017. The service had received four complaints in thereporting period January to November 2017.

• Patients sent any complaints about the service to theNHS ambulance trust that subcontracted work to HCS.We saw patient information leaflets giving details abouthow to give feedback or make a complaint on thevehicle we inspected. The NHS ambulance trustsubsequently investigated all complaints andresponded to complainants in line with their owncomplaints policy. As part of the complaintsinvestigation process, we saw that any HCS staffinvolved in a complaint provided a written account ofthe events.

• The service treated concerns and complaints seriouslyand learned lessons from the results, which were sharedwith all staff. We saw that the NHS ambulance trustprovided feedback on the outcome of complaintinvestigations to the general manager at HCS. Thegeneral manager subsequently shared learning fromcomplaints with all drivers through email and could giverelevant examples of this, such as reminding drivers topark in appropriate places. We also saw complaintlearning shared with drivers such as reminding them toread the patient notes in advance to ensure theyremembered to accommodate specific patient requestssuch as sitting in a particular seat in the vehicle. Driverswe spoke with confirmed that the general manager

widely shared any learning from complaints with allstaff. Widely sharing learning in this way can helpservices improve and help avoid a recurrence of similarcomplaints.

Are patient transport services well-led?

Leadership of service

• Drivers reported to the general manager, whosubsequently reported to the registered manager. Alldrivers we spoke with told us they felt well supported bythe general manager and registered manager, whoformed the management team.

• As staff usually worked in a different county to theregistered location, they mostly communicated with themanagers by telephone or email. Drivers said they foundthe managers easily accessible by these routes.

Vision and strategy for this this core service

• The registered manager and general manager sharedtheir vision for the service with us. The immediatestrategy was to secure a formal long-term contract tocontinue providing patient transport services (PTS)across Sussex. At the time of our visit, there was nofixed-term contract in place, which meant the NHSambulance trust could choose to vary or stop the levelof work allocated to HCS at any time. Staff shared thevision for a formal contract to provide job security. Thelonger-term vision was to expand the service andprovide PTS in other areas.

• The service did not have a written set of values. Whenwe asked the management team what they thought theservice’s values were, they said, “patient care andsatisfaction”, “providing a good service” and “lookingafter patients”. All drivers we spoke with clearlydescribed how they worked to these values andprovided compassionate care. One driver said, “I feel Ican make a difference and improve people’s quality oflife”. Another said they were “dedicated” to serving theirpatients. Patient satisfaction results we reviewed alsodemonstrated staff applied these values to theirday-to-day work.

Governance, risk management and qualitymeasurement




• The provider had a “quality governance, patient safetyand risk committee”. The registered manager andgeneral manager sat on this committee, which metmonthly. We reviewed copies of meeting minutes for theperiod July to October 2017. The minutes demonstratedthe committee reviewed and quality and governanceitems such as policies, risk management and humanresources.

• We saw a copy of the service’s risk register. Thisdemonstrated regular review by the management team,with new risks being added on an ongoing basis andrisks being closed where appropriate. The highestscoring risk was the lack of a long-term contract with thesubcontracting NHS ambulance trust. Both the generalmanager and registered manager were able to describerisks to the service such as the lack of contract and thepotential impact of risks. They were able to describemitigation taken to reduce risks to the service, forexample, working to secure a formal contract. Thisdemonstrated the management team had appropriateawareness of risks to the service and took appropriateaction to mitigate known risks.

• The NHS ambulance trust that subcontracted work toHCS collected and maintained performance data. TheNHS ambulance trust gave regular feedback to HCS’smanagement team around performance against keyperformance indicators to help drive continuousimprovement.

Culture within the service

• All staff we spoke with spoke positively about theculture. Staff told us they enjoyed working for theservice and took pride in their work. All drivers said themanagers were approachable and listened to them. Thegeneral manager also said he felt supported by theregistered manager.

• All drivers we spoke with felt able to raise concerns, andsaid they had confidence in the management team toresolve any issues. Drivers reported good workingrelationships with colleagues and told us they wouldfeel confident to challenge any colleagues whosepractices were inconsistent with the standards the

service expected. Some drivers were able to giveexamples of times they had done this. Thisdemonstrated an open culture centred on providing ahigh level of service to patients.

• The general manager communicated any changes todrivers, such as learning from complaints, in writingthrough email. All drivers we spoke with told us theyreceived regular emails from the general managercommunicating any service updates.

• Although staff were positive about the local culturewithin HCS, some staff said that the lack of a long-termcontract with the subcontracting NHS ambulance trustcaused some uncertainties around job security. Thissometimes affected staff morale.

Public and staff engagement

• The service invited patients to complete satisfactionquestionnaires to give feedback about the care theyreceived. We reviewed completed patient satisfactionquestionnaires, which demonstrated a high level ofpatient satisfaction.

• The provider invited staff to complete an annual staffsurvey, and we saw the results for 2017. One areahighlighted for improvement was that staff said theywould like more face-to-face meetings. Some staff alsoreflected this in their discussions with us. However, atthe time of our inspection, the service had not yet takenaction to address this area for improvement.

Innovation, improvement and sustainability

• The management team described how they hadchanged staff rotas to allow regular patients that usedthe service several times a week to have the samedriver(s) where possible. Drivers felt this was a positiveimprovement to increase the continuity of care forpatients.

• The service was working to try to secure a formalcontract with the subcontracting NHS ambulance trust.The management team hoped this would secure theongoing sustainability of the service and provide greaterjob security to staff.




Areas for improvement

Action the hospital SHOULD take to improve

• The provider should consider revising theirequipment checklists for vehicles to allow them toobtain documented assurances staff check all itemsat the start of every shift.

• The provider should introduce a system to check theuse-by dates of fire extinguishers.

• The provider should introduce a system to providewritten assurances of each staff members’ induction.

• The provider should ensure they meet their target ofall staff having an annual appraisal.

• The provider should provide written guidance todrivers on what to do in an emergency involving adeteriorating patient.

• The provider should consider setting up additionalformal mechanisms of engaging with staff, such asstaff meetings or focus groups.

• The provider should ensure that any items ofreusable equipment such as wheelchairs receive anannual service before they reach the age of one year.

• The provider should consider sharing a written set ofvalues with all staff.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


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