Kernow Ambulance Service

Kernow Ambulance Service is based in the South West of England and provides transport for mental health patients throughout the UK and Europe. There is one depot located in Bodmin. The service is provided for people between the ages of 14 and 65 and includes individuals with various mental health issues and learning disabilities.

The service held an agreement with an NHS purchasing and supply alliance to provide non-emergency patient transfer services which include qualified staff and secure transport.

Kernow Ambulance Service is registered with the CQC to provide the regulated activity:

• Patient transport services, triage and medical advice provided remotely

We inspected this service using our comprehensive inspection methodology. The announced part of the inspection on the 24th October 2017 along with a further announced visit on the 1st November 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, 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 complied with the Mental Health Act 1983 and 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 good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas where the service provider needs to improve:

• There was no relationship between the management of incidents and risks. Incidents were not used to identify, control, or measure risk related to patient safety. The review of incidents involving violence and aggressive behaviour was not scrutinised to identify learning and potential changes to practice.
• Patient documentation when mechanical restraint was used was not consistent and there was no recorded rationale, escalation and de-escalation plan for each patient. Where behaviour is deemed to present risk to the individual or those providing care, restraint may be used to restrict a persons free movement. The restraint may be physical, where the individual is held by others, or mechanical which describes the use of devices such as harnesses or hand cuffs. The provider could not assure themselves that staff only used physical and mechanical restraints as a last resort and in line with best practice.
• Mental capacity was not consistently considered and recorded as part of a patient’s health status.
• Thorough risk assessments for patients were not consistently undertaken to safeguard the health, safety, and wellbeing of the patient for every transfer. The provider could not evidence appropriate steps to mitigate or remove any risks identified through this process.
• The provider could not evidence sufficient numbers of staff, who had the correct competencies and experience were identified for each journey.
• The provider did not ensure that policies and practices reflected the current legislation and any associated codes of practice.
• The provider could not evidence for longer distance journeys that risk assessments in relation to health, safety, and wellbeing of patients or staff had been conducted.
• There were no clear processes for the disposal of clinical waste including contaminated linen and bodily fluids; there were no audits regarding hand hygiene or infection control.
• The provider did not ensure recruitment processes and practices were in keeping with regulation requirements.
• The provider did not have a major incident policy.
• The provider did not have any clinical audit programme or evaluation of processes to identify where improvement could be made. Information was not collected to provide key performance indicators and the provider confirmed they did not monitor response times and patient outcomes.
• Kernow Ambulance management communicated with other services when needed but did not meet regularly with other providers who used their services to assure the quality of the service.
• Kernow Ambulance management did not have agreed safety practices with providers who used their services.
• Clinical governance arrangements did not underpin quality and safety across all areas of the business. Systems or processes were not established and operated effectively to ensure all areas of clinical risk were monitored and reviewed to improve quality and safety for patients and staff. We found no assurance framework which monitored compliance to standard operating procedures or evidence the safe introduction of new practice.
• The provider did not have any formalised systems to challenge decisions or have an independent overview of the service. The registered manager also provided clinical leadership, but did not receive any clinical or peer supervision to help them stay up to date with current practice.

However, we also found areas of good practice:

• The environment of the depot was clean, secure and suitable for safe storage of ambulances and equipment.
• Infection control practices were documented within local procedures and understood by staff; practices were in accordance with the provider policy.
• Kernow Ambulance Service offered an induction programme and mandatory training for all staff.
• Procedures were in place to safeguard children, adolescents, and adults from abuse.
• Staff had the right skills and knowledge to do their jobs. An induction was provided for all staff. Staff received an appraisal to identify learning needs, and a plan was created to support staff to develop their practice.
• During the inspection we were not able to observe any patient journeys or direct patient care; however staff told us how patient care was their priority. People’s individual needs and preferences were central to the delivery of the service.
• For patients who were not detained under the Mental Health Act 1983, their understanding and involvement was recorded. Staff told us they provided support to the patient with the aim of reducing distress and any associated negative behaviour.
• The providers had a shared vision for the service and an agreement about scope of development. The management team were accessible to receive calls, manage bookings and respond to queries.
• The service was operational 24 hours a day, seven days a week, allowing direct contact with the management team, including out of hours.
• Patient and staff feedback was encouraged and was under further development.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, to help the service improve. We issued the provider with two requirement notices and one warning notice that affected patient transport services.  Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals