medical response services newapproachcomprehensive report … · 2019. 4. 9. · safe effective...

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.

Mr Warren Bolton

MedicMedicalal RResponseesponse SerServicvicesesQuality Report

Unit 1Cricket Street Business ParkWiganLancashireWN6 7TPTel:01942 217395Website:[email protected]

Date of inspection visit: 14 November 2017Date of publication: 04/05/2018

1 Medical Response Services Quality Report 04/05/2018

Letter from the Chief Inspector of Hospitals

This report describes our judgement of the quality of care at this location. We based it on a combination of what wefound when we inspected and from all information available to us, including information given to us from people whouse the service, the public and other organisations.

Medical Response Services is an independent ambulance service provider based in Wigan, Lancashire. MedicalResponse Services is registered to provide patient transport services. Medical Response Services offers ambulancetransport on an ‘as required’ basis and provides pre-planned transport. The service provides services on request fromlocal NHS ambulance trust and Clinical Commissioning Groups.

The patient transfers included patients detained under sections of the Mental Health Act 1983 going to or from mentalhealth units.

We inspected this service using our comprehensive inspection methodology. We carried out a scheduledcomprehensive inspection on 14 November 2017. The service had one base which we inspected.

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 by this service was patient transport.

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 issues that the service provider need to improve:

• Although there were processes in place for reporting incidents, staff did not receive feedback and shared learning toprevent them from occurring again and to ensure the safety of people using the service.

• Staff did not receive the appropriate training, to enable them to carry out the duties they were employed to perform.• The provider did not have robust safeguarding procedures and processes that made sure patients were protected.

Staff did not receive safeguarding training that was relevant and at a suitable level for their role. We found noevidence that it was updated at appropriate intervals and enabled them to recognise different types of abuse and theways they could report concerns.

• The provider did not ensure that staff had completed pre-employment checks completed prior to undertakingemployment including fit and proper persons assessments for directors.

• Although, the provider had a duty of candour policy in place and were open and transparent, staff did not receivetraining in the duty of candour.

• We did not find robust systems to assess monitor and improve the quality and safety of the services provided.• We found concerns regarding the governance and strategic risk management processes of the service. There were no

effective governance arrangements in place to evaluate the quality of the service or to improve delivery.

• There was no formal risk register in place at the time of the inspection and therefore we had no assurance that riskswere being tracked, managed or mitigated.

• A vision and strategy for the service had not been developed.

However, we found the following areas of good practice:

Summary of findings


• Staff were knowledgeable about how to report an incident and had access to incident reporting forms includingwhilst on ambulances. We saw evidence and examples of incident reporting.

• The service ensured a minimum of two staff were allocated to each patient transfer depending on risk and need. Thestaffing levels and skill mix of the staff met the patients’ needs.

• All vehicles and the ambulance station were visibly clean and systems were in place to ensure vehicles were wellmaintained.

• All equipment necessary to meet the various needs of patients was available.• Services were planned and delivered in a way that met the needs of the local population. The service took into

account the needs of different people, such as bariatric patients or people whose first language was not English, andjourneys were planned based upon their requirements.

• We observed good hand hygiene, and infection control processes.• The service had a system for handling, managing and monitoring complaints and concerns.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North), 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 found the following issues that the service providerneed to improve:

• Although there were processes in place forreporting incidents, staff did not receive feedbackand shared learning to prevent them from occurringagain and to ensure the safety of people using theservice.

• Staff did not receive the appropriate training, toenable them to carry out the duties they wereemployed to perform.

• The provider did not have robust safeguardingprocedures and processes that made sure patientswere protected. Staff did not receive safeguardingtraining that was relevant and at a suitable level fortheir role. We found no evidence that it wasupdated at appropriate intervals and enabled themto recognise different types of abuse and the waysthey could report concerns.

• The provider did not ensure that staff hadpre-employment checks prior to undertakingemployment including fit and proper personsassessments for directors.

• Although, the provider had a duty of candour policyin place and were open and transparent, staff didnot receive training in the duty of candour.

• We did not find robust systems to assess monitorand improve the quality and safety of the servicesprovided.

• We found concerns regarding the governance andstrategic risk management processes of the service.There were no effective governance arrangementsin place to evaluate the quality of the service or toimprove delivery.

• There was no formal risk register in place at thetime of the inspection and therefore we had noassurance that risks were being tracked, managedor mitigated.

• A vision and strategy for the service had not beendeveloped.


Summaryoffindings

Summary of findings


• Staff were knowledgeable about how to report anincident and had access to incident reporting formsincluding whilst on ambulances. We saw evidenceand examples of incident reporting.

• The service ensured a minimum of two staff wereallocated to each patient transfer depending on riskand need. The staffing levels and skill mix of thestaff met the patients’ needs.

• All vehicles and the ambulance station were visiblyclean and systems were in place to ensure vehicleswere well maintained.

• All equipment necessary to meet the various needsof patients was available.

• Services were planned and delivered in a way thatmet the needs of the local population. The servicetook into account the needs of different people,such as bariatric patients or people whose firstlanguage was not English, and journeys wereplanned based upon their requirements.

• We observed good hand hygiene, and infectioncontrol processes.

• The service had a system for handling, managingand monitoring complaints and concerns.

Summaryoffindings

Summary of findings


MedicMedicalal RResponseesponse SerServicvicesesDetailed findings

Services we looked atPatient transport services (PTS)


Contents

PageDetailed findings from this inspectionBackground to Medical Response Services 7

Our inspection team 7

Facts and data about Medical Response Services 7

Action we have told the provider to take 21

Background to Medical Response Services

Medical Response Services is operated by MedicalResponse Services. The service opened in 2011. It is anindependent ambulance service in Wigan, Lancashire.The service primarily serves the communities ofLancashire. However, patients are transported across theUK as required. The service predominantly providespatient transport services to adults only and transport forpatients detained under the Mental Health Act (1983). Theservice also provides bariatric transport with all vehiclesequipped with bariatric equipment.

The service provides medical patient transport services toNHS trusts and clinical commissioning groups. Theservice provided ambulance provision for event work;however this was a small portion of the work carried out.

The service is registered to provide the followingregulated activities:

Diagnostic and screening services

Transport services, triage and medical advice providedremotely

Treating of disease, disorder or injury

We last inspected Medical Response Service in March2014. Suitable arrangements were in place to ensurepeople using the service were provided with effective,safe and appropriate personalised care.

The service has had the same registered manager in postsince 2011. This person is also the managing director.

Our inspection team

The team that inspected the service comprised a CQClead inspector and one other CQC inspector. Theinspection team was overseen by Nicholas Smith, Head ofHospital Inspection (North West).

Facts and data about Medical Response Services

During the inspection, we visited the registered locationambulance station in Wigan. The service was managedfrom this location. Ambulances and other vehicles weresecurely garaged at this location.

We spoke with four staff members of the managementteam. We conducted random spot checks on threevehicles and inspected cleanliness, infection controlpractices and stock levels for equipment and supplies.

During our inspection we looked at 10 patient records.We looked at three of the patient transport ambulanceswhich were also used to transport patients with mentalillnesses. We reviewed other documentation includingpolicies, staff records, training records and call log sheets.

The CQC has not completed any special reviews orinvestigations of this service. The service has been

Detailed findings


inspected once, and the most recent inspection tookplace in March 2014, which found that the service wasmeeting all the standards of quality and safety it wasinspected against.

Activity (September 2016 to September 2017)

We requested information in relation to the number ofpatient transport journeys undertaken from the period ofSeptember 2016 to September 2017. However, thisinformation was not kept by the provider.

Track record on safety

• There had been no never events reported by theorganisation.

• There were no serious clinical incidents or seriousinjuries reported by the service.

• There were no complaints.

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the serviceMedical Response Services was initially established in 2011by the current managing director. . The company providespatient transport to meet the needs of NHS Hospital trusts.The company employs twenty patient transport servicesstaff, and an additional five office and management staff,operating a fleet of 15 vehicles.

Summary of findingsWe found the following issues that the service providerneed to improve:

• Although there were processes in place for reportingincidents, staff did not receive feedback and sharedlearning.

• Appropriate recruitment checks were not completedfor employees prior to commencing employment.

• Records confirmed staff were not up to date withmandatory training.

• Reliable safeguarding systems were not in place, toprotect adults, children and young people fromavoidable harm.

• Staff were not aware of the requirement to notify theCQC when there was an allegation of abuseconcerning a person using the service.


• Staff were knowledgeable about reporting incidentsand had access to incident reporting forms whilst onambulances.

• Ambulances and the station were visibly clean andstaff followed infection control procedures. Staffused hand gel in clinical areas to maintain goodhand hygiene and used personal protectiveequipment.

• Systems were in place to ensure vehicles were wellmaintained with equipment to meet the needs ofpatients.

• Systems were in place to identify, assess and managepatients whose condition deteriorated.

Patienttransportservices

Patient transport services (PTS)


• Staff carried or had access to a pocket guide withclinical information which was developed from thelatest guidance.

• The service had systems and processes to monitorhow the service was performing.

• Systems were in place for the planning of patientjourneys and the care patients required.

• The service took account of the particular needs ofpatients and ensured flexibility, choice andcontinuity of care.

• The service had a system for handling, managing andmonitoring complaints and concerns.

• Staff knew how to advise a patient if they wished tomake a complaint.

Are patient transport services safe?

Incidents

• The service had an accident and incident reportingpolicy, which was updated in April 2017. Themanagement team had introduced a new system forreporting and recording incidents. The policy describedhow accidents and incidents should be reported. Itmade reference to a company incident reporting formand that all incidents were to be reported within 24hours.

• Staff were required to report and record incidents via apaper record and also called the office to log theincident. Each vehicle had a folder containing accidentand incident reporting forms. Prior to the new systembeing introduced, staff recorded incidents asstatements. The registered manager informed they hadno recorded incidents. However, upon checking staffstatements we identified three incidents which hadtaken place between October 2016 to March 2017 whichconcerned the safety of patients. No near misses wererecorded.

• In the three serious incidents that we reviewed we didnot see evidence how the service had investigated orreviewed them to prevent recurrence of a similarincident. There was no evidence of sharing of anylessons learnt following these incidents with the widerstaff team.

• Staff we spoke with were able to describe the newprocedures for reporting incidents. They stated theywere confident to report any accidents, incidents ornear misses.

• Staff who worked remotely could speak with the dutyperson at the control room and the services on-callmanager.

• The service reported that there were no never events inthe last 12 months. A never event is a serious, whollypreventable patient safety incident that has thepotential to cause serious patient harm or death, hasoccurred in the past and is easily recognisable andclearly defined.




• Vehicle accidents and equipment defects were recordedon a separate defect report. From January to March2017, 58 defects had been recorded. We saw examplesof minor accidents, which managers had discussed withstaff.

• The service had a Duty of candour policy (2016), whichdescribed their responsibilities under the Duty ofcandour legislation. Duty of candour is a requirementunder The Health and Social Care Act 2008 (RegulatedActivities) Regulations 2014 for a registered person toensure staff act in an open and transparent way withrelevant persons in relation to care and treatmentprovided to service users in carrying on a regulatedactivity. Staff did not receive training in duty of candourand not all staff were familiar with the term. Despitetheir lack of training, the registered manager told usthey would be open and honest with people if thingswent wrong and would immediately seek support if apatient experienced avoidable harm.

Cleanliness, infection control and hygiene

• All the vehicles we looked at were uncluttered andvisibly clean. The ambulance station was tidy and wellorganised. The floors were swept clean in theambulance parking area and there was no excessequipment so the areas were not cluttered, makingthem easy to clean.

• Crews were required to ensure their vehicle was fit forpurpose, before, during and after they had transported apatient. Decontamination cleaning wipes were availableon all vehicles and we were informed that staff cleanedsurfaces, seats and equipment after each patient.

• The crew assigned to the vehicle each day completedthe day to day cleaning of vehicles. We found the dailycleaning sheet record on all vehicles had beencompleted consistently but vehicle cleaning standardshad not been audited.

• Cleaning materials and chemicals were available forstaff use. Different coloured mops and buckets wereavailable for different areas; advice as to which mopshould be used in which area was prominentlydisplayed to prevent cross infection. The station roomwas divided into clean and dirty areas by signage.

• Staff followed infection control procedures, includingwashing their hands and using hand gel after patientcontact.

• Hand washing facilities were available at the ambulancestation.

• We saw no evidence of infection, prevention and controlaudits or hand hygiene audits within the service. Thismeant the service could not be assured staff werecompliant.

• There were arrangements with the local hospitals fordisposing of used linen and restocking with clean.

• The service followed operational procedures in relationto infection control. Staff told us that if a patient wasknown to be carrying an infection, they were nottransported with another patient. The vehicle would becleaned afterwards in accordance with infection controlpolicy and procedures.

• Staff had access to personal protective equipment suchas gloves and aprons to reduce the risk of the spread ofinfection between staff and patients. Crews carried aspills kit on their vehicles to manage any small spillagesand reduce the infection and hygiene risk to otherpatients.

• Staff did not routinely have to manage clinical waste.However, clinical waste bags were carried on eachambulance and full bags were disposed at the hospitalor at the ambulance station. The ambulance station hadfacilities for depositing and disposing of clinical wastethrough an external contractor.

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

• The ambulances we inspected were fully equipped, withdisposable single use equipment stored appropriatelyand in-date.

Environment and equipment

• The premises were clean and tidy with adequate spaceto safely store the vehicles. In addition the unit provideda suitable environment for taking bookings and therewas office space, facilities for staff, cleaning andseparate storage areas.




• The keys for the vehicles were stored securely. Therewas secure access to the station building and withinthat to the offices. Staff attended the office to collect thedesignated vehicle keys. All vehicles were locked whenunattended.

• Managers told us that all drivers had their driving licenceand eligibility to drive vehicles checked prior toemployment and on an ongoing basis by the Driver andVehicle Licensing Agency. We saw evidence of thesechecks.

• Medical Response Services had 15 ambulances for thetransport of patients. Systems were in place to ensurethat all vehicles were maintained, serviced, cleaned,insured and taxed appropriately.

• Vehicles were covered by a current Ministry of Transportsafety test certificates as required and a central log waskept at the station. Managers also ensured newerambulance vehicles were covered by a first Ministry ofTransport safety test certificates after 1 year as requiredin law. Records showed that drivers had the correctlicence category, Category B for the weight of thevehicles driven.

• Where vehicles were off road awaiting repair, this wasclearly displayed on the vehicle to prevent staff fromusing the vehicles. Vehicle defect report forms wereprovided on each vehicle, which included a descriptionof the fault or defect, action taken to resolve, and furtheraction required. Staff informed us they reported anydefects directly to managers; we saw when staff hadcompleted these.

• The records showed that vehicles had gone through aregular deep clean through a contract with an externalcompany every four weeks. This included all fixtures andfittings internally including seats, interior lighting, grabrails, flooring and foot wells.

• There was a system for reporting equipment defects andstaff had received appropriate training to useequipment safely. Some of the vehicles had an on-boardwheelchair available for patient use and this wassecured with fasteners. Equipment had been safetytested; stickers showed when the equipment was nextdue for testing and records were available to supporttheir suitability for use. The seatbelts and trolley strapswere in working order in the three vehicles we checked.

• We saw two items of consumables that were out of datein the stock room. For example, we saw a crepebandage which was dated June 2015.

• Ambulances were all equipped with tracking devicesand a mobile phone was provided in each vehicle wherestaff received messages from the control room dutymanager.

Medicines

• Emergency medicines were not carried on the patienttransport services ambulances and staff did notadminister medicines. Patients or their accompanyingcarers were responsible for their own medicinesadministration whilst in transit. Staff would ensuremedicines provided by the hospital for patients to takehome would be stored securely in a bag on theambulance.

• Oxygen cylinders were carried on vehicles. Anappropriate health care professional had to prescribethe oxygen so staff could administer it or the patient hadto have a home oxygen order form in place.

• Medical gases were managed properly. The service keptmedical gas cylinders in a locked cage in a locationoutside. Storage of medical gases was secure and therewere signs to alert staff and visitors to the flammablenature of the gases. Full and empty cylinders wereappropriately segregated.

• Oxygen cylinders were appropriately stored on theambulances. Oxygen stock was replaced frequently by amedical gas company.

Records

• Patient transpoert service drivers received work sheetsat the start of a shift, which were completed by the dutymanager in the control room and included the basicdetails of the journey to be completed. These includedcollection times and addresses. Patient specificinformation such as relevant medical conditions,mobility, and if an escort was travelling with the patient,patient’s health and circumstances were assessed bythe NHS Hospital trust and this information was given topatient transfer drivers during the handover process. Arecords management policy was not in place.

• The local NHS hospital trust provided ambulance crewswith patient details such as ‘do not attempt cardiopulmonary resuscitation information and any specialnotes or instructions, which stayed with the patient. Thisincluded their mental health needs and any potential




risks to staff. The booking process meant people’sindividual needs were identified and took into accountthe level of support required, the person’s familycircumstances and communication needs.

• Patient information was stored in the driver’s cab out ofsight, respecting patient confidentiality.

• Records were held securely in the station office. Storagewas in locked filing cabinets and in a secure post boxand through password protected computer systems.

• We reviewed journey records for mental health patientsincluding patients detained under the Mental Health Act1983 going to or from mental health units.

• There was a Mental Health Act and conveyance policyand procedure in place which referred to thecompletion of patient report forms and mental healthconveyance risk assessment forms when transportingpatients with mental health disorders. We found patientreport forms were completed for these patients.

Safeguarding

• Reliable systems, processes and practices were not inplace to protect adults, children and young people fromavoidable harm and abuse. Although there weresafeguarding alert forms available for staff to completeto record safeguarding concerns, which were given tothe duty manager, we were not assured correctsafeguarding procedures were followed. We discussedwhat staff would do if they were informed of asafeguarding concern. We were informed they wouldcontact the hospital where the patient was transportedfrom and seek advice, and if required would contact thepolice. However, the four managers we spoke with werenot aware of their responsibility in making asafeguarding alert to the responsible local authoritysafeguarding team and were not aware of the legalrequirement to notify the CQC.

• There was a safeguarding policy in place which was lastupdated in April 2017. However, the policy was not up todate with current legislation and did not include the tencategories of abuse. Internal safeguarding policies werenot followed by staff.

• The provider had a policy relating to the use of restraintand informed us they do not use restraint. There was norecorded evidence to suggest staff had read the restraintpolicy and were aware of when to use restraint. We werenot assured that staff knew what restraint was and knewwhen to use it.

Mandatory training

• The service had a comprehensive mandatory trainingprogramme. The majority of mandatory training wasdelivered by e-learning and training in restraint wasdelivered face to face. All staff were required tocomplete and record their mandatory training.Examples of training included; safeguarding, infectioncontrol, patient handling, fire safety, data protection,sharps, hand hygiene, health and safety and equality acttraining. Additional training consisted of control andrestraint and handcuff training.

• We found that not all staff were up to date with theirmandatory training. For example, we found that out oftwenty five members of staff which also included thefive office staff, only two members of staff had receivedup to date training in safeguarding. The three membersof staff in the control room had not received up to datetraining. These staff were responsible for acting on anysafeguarding concerns reported to them by frontlinestaff. We spoke to one of the directors who was also oneof the control room staff. He informed us he had lastreceived training in safeguarding over a year ago. Theservice had appointed the registered manager as thesafeguarding lead who had completed online level threetraining in safeguarding. Although the safeguardingpolicy stated that ‘staff were required to receivemandatory training safeguarding refresher trainingbefore the renewal date on their certificates,

• Not all staff had completed basic life support training.Out of the twenty members of frontline staff, sevenmembers of staff had received up to date basic lifesupport training.

• Not all staff were up to date with training in restraint.Two members of staff involved in an incident where theyrestrained a patient did not receive training in controland restraint nearly a year after the incident.

• The service had an induction policy in place and wewere informed that staff completed an inductionprocess, upon commencing employment with theservice; we did not see completed induction documentsfor new members of staff. We were not assured that staffcompleted inductions.

• Patient transport services staff that drove the vehiclescompleted an in-house driving assessment oncommencement of employment and would undertake afurther assessment once they felt confident to transport




patients. The operations contract manager was theadministrator for the organisation’s driver training, andhad qualified in May 2016 with the Royal Society for thePrevention of Accidents.

• Although senior management were able to reviewrecords to see the training staff had completed andwhen training was due for renewal, we were not assuredthat this was taking place as a high proportion of stafftraining was out of date.

• Staff, who worked as mental health crews, did notreceive training in mental health awareness, mentalhealth legal frameworks, de-escalation, prevention andmanagement of violence and aggression and the use ofhandcuffs to equip them to work with and transportpatients with mental health needs.

Assessing and responding to patient risk

• Medical Response Services staff requested detailedinformation on risks posed when transporting patientsat the time of the booking. Basic risk assessmentscreening questions were asked at this time.

• When transporting patients the ambulance crew woulduse their first aid knowledge to assess if a patient’scondition was deteriorating.

• Records showed that in each case for mental healthpatients, risk assessments were completed by theorganisation requesting the transport. Information toevidence whether the patient was aware of the journey,current and past risks relating to physical and verbalaggression, the likelihood of the patient absconding orattempting to abscond, risks of self-harm and thecurrent presentation of the patient was given to staffprior to the journey taking place.

• Ambulance crew had access to clinical advice from anon call member of staff or they would divert to ahospital. There was an escalation process in place forthe management of deteriorating patients. Theyinformed us they would stop the vehicle as soon as itwas safe to do so, call the control room for advice andinform the organisation where the patient was collectedfrom. They would then inform their managers andwould support the patient as best they could until helparrived.

Staffing

• The service employed twenty members of staff, twelveof which were permanent and eight of which were bankstaff. In addition there were five members of office andmanagement staff.

• Recruitment systems did not ensure that staff hadproper pre-employment checks prior to undertakingemployment. For example, proof of identification,references and qualifications were not sought for allstaff. We reviewed staff files. Out of the nine staff files wechecked, one member of staff did not have evidence onfile to ensure they had the right to work in the UK, fivemembers of staff did not have two references on file anddid not have a contract of employment on file.

• Fit and proper persons assessment were not robust.Both directors of the company did not undergorecruitment checks, although they both had aDisclosure and Barring Service check.

• All ambulance staff had valid enhanced Disclosure andBarring Service checks. We were able to see evidencethat a check with the service had been carried out priorto staff commencing duties, which involved accessingpatients and their personal and confidentialinformation. This protected patients from receiving careand treatment from unsuitable staff.

• The registered manager had a level three certificate infirst response emergency care and worked directly withpatients and crew staff as required.

• The service used computer programmes to assist withshift rosters to plan shifts. Shortfalls in cover were shownon this system and staff could request to workadditional shifts. The electronic rostering trackedsickness and holidays. If a short notice booking wasreceived, the service would not accept if they could notsupply two staff. We were informed that staff wereallocated time for rest and meal breaks.

• There was a process in place for the ambulance crewsout of hours and in case of emergencies. They had adirect number to the duty manager on call. Staff wespoke with knew how to escalate concerns whenworking out of hours.

Response to major incidents




• A major incident is any emergency that requires theimplementation of special arrangements by one or all ofthe emergency services and would generally include theinvolvement, either directly or indirectly, of largenumbers of people.

• As an independent ambulance service, the provider wasnot part of the NHS major incident planning. Howevermanagement staff informed us they would be utilisedwhen the NHS hospital trust had a major incident, totransport patients home.

• The provider assessed that current means ofcommunication for instance mobile phones, land linesand other telecommunication was robust enough toallow partner agencies to make contact during a majorincident.

Are patient transport services effective?

Evidence-based care and treatment

• Although the service had a set of up to date evidencebased policies and procedures in place, they were notused to guide staff in their daily work. For example, wefound the safeguarding policy had not been followed asan incident had not been reported to the localsafeguarding authority. Policies were accessible as ahard copy for staff to readily access and on thecomputer system.

• The policies and procedures referred to best practiceguidance including the department of health and theJoint Royal Colleges Ambulance Liaison Committee.

• Ambulance crew members carried their pocket bookwhich was based on guidance from the Joint RoyalColleges Ambulance Liaison Committee clinicalguidelines for pre-hospital care. Carrying a pocket bookwas in line with company policy.

• The NHS ambulance trust set or assessed patient’seligibility to travel on patient transport in line with theguidelines in the Department of Health ‘Eligibilitycriteria for patient transport services’ document. Theeligibility criteria were set nationally and it was theresponsibility of the providers booking patient transportto make sure it was used for patients who met thecriteria.

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. During the booking process, basic journeyinformation was gained regarding the collection addressand discharge destination.

• Staff did not transport a patient if they felt they were notequipped to do so, or the patient needed morespecialist care. The transport staff were not clinicallytrained, but did seek advice from clinical staff at thehospital as necessary or the manager on call for theservice. If a patient was observed or assessed as notwell enough to travel or be discharged from hospital,the ambulance care assistants made the decision not totake them.

• Where necessary, approved mental health professionalsor mental health staff accompanied patients withmental health needs on the journey to or betweenhospitals to ensure they were transported safely andaccording to their individual needs.

• If distance or rural journeys were scheduled, the journeywould be pre-planned with stops for toileting,refreshment food and drink. Ambulances held bottledwater to provide for patients as required during ajourney.

Response times and patient outcomes

• The provider did not benchmark and record the total ofjourneys they completed. We were not provided withinformation to identify the number of journeysundertaken in the reporting period September 2016 toSeptember 2017 and could not establish how manyrepatriations and private transfers took place.

• The provider collected and monitored the performanceof staff for the jobs that were assigned through the crewworksheets. Staff also called the control room to reportany difficulties, so the duty controller was always awareof what issues were causing a delay.

• The operations contract manager met with localcommissioners at least once a month. The provider hadagreed with their contractors to complete journeyswithin one hour. The management team informed usthat the service was currently answering calls within thedesired response times, although no formal monitoringwas taking place.

• Where booking staff recognised that they did not havethe staff capacity or vehicles at the correct locations to




accept a job, they would refuse it and could suggest thereferrer contact the local NHS ambulance service orother providers. The governance lead told us this rarelyhappened.

Competent staff

• Although, the service had an induction policy andprocedure, all staff had not completed an inductionprogramme that detailed the expectations andrequirements of the role, the company and policies andprocedures. The mandatory training followed theinduction, which all staff were not up to date with. Somestaff files contained certificates in restraint training,infection control and health and safety, but not all staffwere up to date with this training.

• Driver and Vehicle Licensing Agency checks werecompleted prior to commencement of employment.

• The service had no arrangements in place for ongoingchecks for driver competence, such as spot checks or‘ride outs’ by a driving assessor. The management teamtold us, that if they had a concern about the standard ofa crew member’s driving they would inform managers.Managers told us that any poor practice would beaddressed. Any additional staff training or refreshertraining may then be identified.

• Appraisals had been carried out for 16 out of the 25members of staff for 2015 to 2016. The service hadrecently introduced appraisals for staff. The governancemanager showed us all staff had been scheduled tocomplete appraisals in November 2017. Following theinspection the provider informed us that these hadbeen completed.

Coordination with other providers andmultidisciplinary working

• Staff at the local NHS hospital trust reported goodworking relationships with ambulance care assistants,managers and the operations assistant. We observedeffective co-operation between different providers tocoordinate patients’ transport around their care,treatment and discharge.

• We spoke with staff from the hospital discharge loungewho told us the service responded well to their requestsfor transport. They told us if they had any problems, theambulance crews were very responsive and alwaysprovided assistance upon request.

Access to information

• Information was obtained from hospital staff andentered onto the patient journey forms. These includedcollection times and addresses.

• A ‘live’ satellite navigation system was provided for staffto track the ambulance journeys to ensure vehicles werereaching jobs as requested. Staff confirmed this was aneffective system.

• Feedback from the hospital was that handoversbetween the ambulance and hospital staff weredetailed, professional and appropriate. Themanagement team reported they had a good workingrelationship with the hospital staff as generally visitedthe same wards and departments on a regular basis.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Not all staff had not received training in the MentalCapacity Act 2005 and the Deprivation of Libertystandards. One member of the management team hadcompleted training in mental capacity and the trainingwas via eLearning.

• Although there was a policy in place covering the MentalCapacity 2015, we did not see any evidence to suggestthat staff had read and understood the policy. We werealso not assured that staff understood the principles setout in the Mental Capacity Act. The organisation’s policystated that ‘if any person or carers refuse treatmentwhilst being transported to hospital, a vulnerableperson’s form must be completed and considerationmust be given to the patient’s mental capacity. Thepolicy was not followed by staff.

Are patient transport services caring?

We did not inspect this key question.

Are patient transport services responsiveto people’s needs?

Service planning and delivery to meet the needs oflocal people

• The main service was a patient transport services whichprovided non-emergency transport for patients whowere unable to use public or other transport due to their




medical condition. This included those attendinghospital, outpatient clinics, being discharged fromhospital wards or referrals from care homes and privateindividuals.

• The service had two core elements, pre-planned patienttransport services, and ‘ad hoc’ services to meet theneeds of patients. Workloads were planned around this.

• The service worked with the NHS Trust to support themto meet demand by having regular telephoneconversations. Medical Response Services couldrespond using four wheeled drive vehicles due tochanging weather conditions as required.

• Patient transport services were provided to a number ofNHS acute hospital trusts and Clinical CommissioningGroups. However, service level agreements were not inplace for non-emergency and non-clinical patienttransport. Journeys were provided on an ad hoc basis.The service supported hospital discharges across theWigan region.

• The managers worked a rota at the station andmanaged all bookings from 8am to midnight. Aftermidnight the office closed and the local NHS hospitaltrust allocated jobs directly to PTS crews who workedfrom 12am to 8am. This meant that if a call camethrough whilst on a journey, one PTS staff memberwould have to drive while the other staff member, whomay be with a patient, took the booking. We raisedconcern over this practice as taking bookings whilst withpatients did not ensure patient confidentiality and safepractice. We discussed the concerns with the registeredmanager and asked for additional staff members to beplaced on call immediately to take bookings aftermidnight, to ensure patient care was not compromised.Following the inspection we were informed that staffwere instructed not to take any booking calls if theywere in process of transporting a patient to ensure thepatient was their primary focus.

• On the day, bookings were responded to quickly viatelephone. For the ad hoc on the day bookings, officebased staff identified which drivers were available. Weobserved effective communication between drivers andoffice staff as part of service planning.

• All of the ambulances were equipped with trackingdevices. The service had the ability to monitor thelocations of its vehicles and to identify where they were.

• Meetings were held with senior managers andcommissioners of the service to ensure the provision ofthe service remained satisfactory.

Meeting people’s individual needs

• The ambulance care assistants ensured patients werenot left at home without being safe and supported.Some patients were discharged from hospital and had apackage of care to be arranged at home. If the supportperson or team had not arrived when the patient camehome, the ambulance care assistants called the hospitalto find out where they were. The patient would not beleft alone until either the care team arrived, or thepatient was safe in the care of their family or carer.

• Staff told us that at the time of booking the questionwas asked if the patient required a relative or carer tosupport them. Staff told us this service was put in placeto meet the patient’s individual needs and level of risk.This ensured that an appropriate vehicle was allocatedto ensure seating arrangements were suitable. Theprovider’s vehicles contained bariatric equipment totransfer patients who exceeded a certain weight. Staffconfirmed they were competent to use this equipment,which was generally planned in advance so staff wereaware of the patient’s needs.

• The governance manager told us translation serviceswere not currently available for patients whose firstlanguage was not English. However staff could accessgoogle translate via their phones.

• If distance or rural journeys were scheduled, the journeywould be pre planned with stops for toileting,refreshment food and drink. Ambulances held bottledwater to provide for patients as required during ajourney.

Access and flow

• Patients could access their care and treatment in atimely way. The provider was able to ensure thatresources were where they need to be at the timerequired. From taking a booking to providing theambulance service, the provider aimed to be therewithin the hour. This was monitored by the dutycontroller. Patients were advised if there was a delay.




• The service was available 24 hours a day. Patienttransport requests were received on an intermittentrather than a contractual basis and the serviceresponded at short notice. Long journeys or nighttransfers were required to be pre planned.

• If a journey was running late, the driver would ringahead to the destination with an estimated time ofarrival and keep the patient and the hospital informed.Any potential delay was communicated with patients,carers and hospital staff by telephone.

Learning from complaints and concerns

• Staff knew how to advise a patient if they wished tocomplain and written information of how to make acomplaint was present on the ambulances.

• The service had a system for handling, managing andmonitoring complaints and concerns. The policy wasupdated in April 2017 and outlined the process fordealing with complaints initially by local resolution andinformally. Where this did not lead to a resolution,complainants were given a letter of acknowledgementfollowed up by a further letter within 28 working days,once an investigation had been made into thecomplaint.

• The service had not received any complaints frompatients within the last 12 months.

Are patient transport services well-led?

Vision and strategy for this this core service

• A written statement of vision, strategy and guidingvalues had not been developed. The management teaminformed us their strategy was to stabilise, develop andsustain the business. They outlined they wanted toimprove staffing and the quality of the service providedand to provide the best possible service to patientsacross the country.

• Staff we spoke with told us they did not know what thevision and strategy for the service was.

• Managers had a good understanding of the commercialaspect of the patient transport services, ensuring theyremained competitive. This was demonstrated by theservice trying to secure new contracts.

Governance, risk management and qualitymeasurement

• There was no formal risk register in place at the time ofthe inspection and therefore we had no assurance thatrisks were being tracked, managed or mitigated. Theprovider was unaware of the high risk areas in theirservice due to a lack of audits.

• Internal audits looking at practices, system and processwere not completed by the service. Therefore, areas ofnon-compliance or areas for improvement were notidentified and action could not be taken to makeimprovements.

• We observed no evidence of governance meetingstaking place prior to the announcement of theinspection. Since the announcement two seniormanagement meetings had taken place in October andNovember 2017 to discuss operational issues.

Leadership / culture of service

• The leadership team consisted of the managing directorwho is the CQC registered manager, second director,office manager, operations contract manager and anoffice administrator. They were responsible for theplanning of the day to day work. Some of themanagement team also formed part of the operationalstaff for public events.

• The company structure was clear and showed clearroles and responsibilities within the senior managementteam. Staff knew which manager would provide themwith the necessary guidance and support.

• The managing director and the operations contractmanager went out on transfer cases as required. Thisallowed them to maintain their practice.

• We saw records which showed that some crew hadadditional qualifications and had developed theirleadership skills. The managing director had completeda First Response Emergency Care level threequalification and operations contract manager hadcompleted a qualification to administer driving trainingto the staff team.

• Staff team meetings were not held. There were limitedopportunities for staff to make suggestions on how theorganisation could improve the services.

• The managing director told us learning was cascaded tostaff. All staff members had a work email account. Theservice had introduced a bulletin which was printed andplaced in the staff pigeon hole, informing staff ofdevelopments with the service and practice issues. Thefirst bulletin was published in November 2017.




• We saw information that showed us the directors hadnot been appointed in line with the fit and properperson requirements. Although both directors of thecompany had a Disclosure and Barring Service checkthey did not undergo another recruitment checks.Checks on the directors’ qualifications, competence,skills and experience were not completed. Proof ofidentity, a full employment history, information aboutany physical or mental health conditions relevant to aperson’s capability were not in place.

Public and staff engagement

• The service’s publicly accessible website containedinformation for the public in relation to what the servicewas able to offer.

• The provider informed us they had not completed anypatient surveys and were introducing these. Theprovider’s website had opportunities for the public togive feedback about the service.

• Staff were able to access information such as policiesand procedures electronically and duty rotas.

Innovation, improvement and sustainability

• There was genuine positivity about the future of theservice with a hope and plans to help the serviceexpand.

• Senior managers considered the sustainability of theservice during contract negotiations.




Areas for improvement

Action the hospital MUST take to improve

• The provider must ensure staff receive the appropriatetraining, to enable them to carry out the duties theyare employed to perform. This includes safeguardingtraining that is relevant and at a suitable level for theirrole, updated at appropriate intervals and enablesthem to recognise different types of abuse and theways they can report concerns.

• The provider must ensure they have robustsafeguarding procedures and processes that makesure the patients are protected.

• The provider must ensure that staff undergo checksprior to undertaking employment to ensure they onlyemploy 'fit and proper' staff who are able to providecare and treatment appropriate to their role.

• The provider must ensure systems and processes arein place to implement the statutory obligations of Dutyof candour and ensure all staff are trained andunderstand it.

• The provider must have effective governance,including assurance and auditing systems orprocesses.

• The provider must ensure that directors undergochecks prior to undertaking employment to ensurethey are ‘fit and proper’ to undertake their role.

Action the hospital SHOULD take to improve

• The provider should ensure that all learning fromincidents is shared to prevent them from occurringagain to ensure the safety of people using the service.

• The provider should that there is a system in place toassess, monitor and improve the quality and safety ofthe services provided.

• The provider should introduce team meetings.• The provider should review its process for operational

issues within a strategic overview or central riskregister.

• The provider should introduce infection preventioncontrol audits.

• The provider should develop a vision and strategy forthe service and ensure this is embedded across theorganisation.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


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

Regulated activity


Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation 17: Good governance. Care QualityCommission Regulations 2014 (Part 3)

How the regulation was not being met:

The provider had not ensured that there was effectivegovernance, including a risk register, assurance andauditing systems or processes in place. These mustassess, monitor and drive improvement in the qualityand safety of the services provided.

This was breach of regulation

Regulation 17(2) (a)

Regulated activity



Regulation 18 HSCA (RA) Regulations 2014 Staffing

Regulation 18: Staffing

Care Quality Commission Regulations 2014 (Part 3)


The provider had not ensured staff has received thatappropriate training, to enable them to carry out theduties they are employed to perform and receivedsafeguarding training that is relevant and at a suitablelevel for their role, updated at appropriate intervals andenabled them to recognise different types of abuse andthe ways they can report concerns.


Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Regulation 18 (2)(a)

Regulated activity



Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

Regulation 13:Safeguarding service users from abuseand improper treatment



The provider had not ensured they had robustsafeguarding procedures and processes that made surethe patients were protected.


Regulation 13 (2)

Regulated activity



Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

Regulation 19: Fit and proper persons employed



The provider had not ensured staff had had preemployment checks completed prior to undertakingemployment including fit and proper personsassessments.

This was breach of regulation:

Regulation 19 (2)(a)(b)(3)(a)(b)

Regulated activity

Regulation

Regulation

Regulation






Regulation 5 HSCA (RA) Regulations 2014 Fit and properpersons: directors

Regulation 5: Fit and proper persons: Directors



The provider had not ensured directors had satisfied therequirements of the regulation.

This was a breach of regulation:

Regulation 5 (3)(a)(b)(d)(e)




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