All inspections: London Ambulance Service NHS Trust

We carried out this unannounced focused inspection as part of our review of north east London’s urgent and emergency care services.

We inspected the Emergency Operations Centre (EOC) against our NHS Ambulance Services - system resilience focussed inspection framework.

The London Ambulance Service NHS Trust (LAS) is the only NHS provider trust to serve the whole of London and its population. They cover an area of 620 square miles, answer around two million 999 calls a year and crews attend more than 3000 emergencies a day. They are the busiest ambulance service in the country and one of the busiest in the world.

We carried out this unannounced inspection in December 2021. As this was a focussed inspection, and we did not look at every question in our key lines of enquiry, we did not re-rate the service this time. The previous rating for the EOC of ‘Requires Improvement’ remains.

A summary of CQC findings on urgent and emergency care services in Northeast London.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Northeast London below:

Northeast London

Provision of urgent and emergency care in north east London was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area is complex, made up of a large number of health and social care providers. We did not inspect all providers within the system and did not inspect any GP services.

We undertook these inspections during the COVID-19 pandemic; the pandemic had put significant pressure on health and social care services and the staff working within them. Despite the challenging circumstances, we found examples of staff working in partnership. For example, there was good engagement between service leaders to understand the impact of demand on different services and to discuss opportunities to signpost patients to services under less pressure.

However, system wide collaboration was needed to alleviate the pressure and risks to patient safety identified in the emergency department we inspected.

We were told there were capacity issues, especially in primary care, resulting in delays for patients trying to access urgent care or patients being signposted from 111 to acute services. We were told appointments for out of hours GPs were often unavailable. We observed patients queuing to access both the urgent treatment centre and emergency department and were told patients attended these services due to an inability to access their own GP. This put additional demand on the hospital and caused further delays in patients accessing treatment.

In addition, there had been an increase in the number of 111 calls from patients requiring dental treatment and patients reported a local reduction in dental providers accepting new patients.

We identified an opportunity for more effective integration between the 999 and the integrated urgent care (IUC)111 service; the call system for the 999 service was unable to electronically send information to the 111 service if it was decided the caller did not meet the criteria for an ambulance. The caller was asked to redial 111. In contrast, 111 were able to communicate directly with 999 if they felt their caller required an ambulance.

We inspected one emergency department in NE London and found that local services did not always work together to reduce attendances or the length of stay in the emergency department. This resulted in situations of overcrowding, compromised infection control and extended waits for treatment, which impacted on outcomes for patients. The ambulance service had commenced daily calls with system partners to try and reduce ambulance handover delays and to monitor demand across NE London.

We identified a lack of collaborative working and poor communication between an emergency department and the co-located urgent treatment centre resulting in delays for people accessing services. Different digital operating systems within these services did not promote effective communication or integration between services and were a limiting factor in how services could work collaboratively to deliver safe, effective and timely patient care. These issues resulted in people being sent from the urgent treatment centre to the emergency department without an effective referral mechanism and meant they experiences further delays whilst in another queue to be assessed.

We found examples of delays in discharge from acute medical care impacting on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews and prolonged waits in the Emergency Department due to the lack of bed capacity. We also found patients in the emergency department for whom a decision to admit had been made; however, they were still waiting in excess of 24 hours before being transferred to a bed on the ward. These delays exposed people to a risk of harm.

We identified a significant number of patients unable to leave hospital to return to their own home or move into community care. This was due to a number of complex reasons including delays in the provision of care packages due to lack of availability, a lack of residential and/or nursing care beds and because of a shortage of social care staff and the impact of vaccination as a condition of deployment. We were told that Local Authorities were working to increase capacity in social care and that they regularly met with system partners to discuss the provision of urgent and emergency care in London; however, the impact on patient flow through urgent and emergency care pathways remained a significant challenge across NE London. Increased collaboration and support from system partners was required to manage the risk being held in the emergency department we inspected.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

For our emergency operations centre inspection, we talked with 10 call handlers, four dispatchers, two CHUB clinicians, a paramedic member of the HEMS team, two advanced paramedics specialising in critical and urgent care respectively and two student paramedics. We interviewed three of the trust’s senior operational managers and executives. After the inspection we requested further information and documents from the trust.

Summary of this service

The service was under immense and sustained pressure from call demand, with increased numbers of ambulances being held at Emergency Departments (ED), resulted in less capacity to respond to calls. The service was staffed and resourced safely to meet people’s needs in most areas for commissioned and planned levels of demand. However, the recent significant rise in numbers of callers to 999, and the inability to release ambulances from emergency departments meant the service was unable to reach all patients who needed an ambulance safely and effectively much of the time. Incidents of exceptional demand was occurring on most days, and staff told us that this was becoming unsustainable for the service. Staffing levels had been increased to deal with some of the anticipated rise in demand, however this was not able to keep in line with the increased demand on the service. Additional recruitment was underway to mitigate this.

Some of the EOC staff described feeling exhausted, demoralised and stressed at times by the job with the current pressures. This was recognised and acknowledged by the senior management and the executive team at the trust. Staff remained as positive as they could and we saw and heard how this helped in their response to callers.

The service had not fully implemented and enforced national guidelines relating to COVID-19 screening and social distancing within the workplace.

However:

Despite the pressure faced we heard EOC staff treat patients with compassion and kindness. They respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Our rating of the trust stayed the same. We rated it as good because:

There were enough front-line ambulance staff to care for patients and keep them safe. Staff had training in the key skills needed for their role. Most staff understood how to protect patients from abuse and managed their safety well. Managers monitored the effectiveness of the service and made sure staff were competent in their roles.
The services-controlled infection risks and followed professional practices with this regard. Staff understood their duty to raise concerns and report incidents and near misses. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff assessed risks to patients, acted on them and kept good care records of treatment and care provided. Information was shared where required in a safe manner with other health agencies. Staff provided good care and treatment, gave patients pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers and helped patients and their carers find further information and to access community and advocacy services.
There were systems to alert staff to specific safety or clinical needs of a person using the service and to provide additional support. Steps were taken to respond to capacity issues by transferring calls between sites.
Services were available seven days a week. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service engaged well with patient groups and the wider community to plan and manage services and all staff were committed to improving services continually.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Most staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.
Leaders used a range of monitoring tools to measure performance and achievement of national targets. Action was taken where improvements were needed. Complaints were responded to in line with the trust’s standards.
The service promoted equality and diversity in daily work and provided opportunities for career development. There was a general culture of inclusivity and of teamwork across services.

However:

Despite the trust having increased the staffing in the Emergency Operations Centres, there was a lack of consistency in staffing levels and the rota system was unreliable. This impacted on staff’s ability to respond to incoming telephone calls to the Emergency Operations Centres. Temporary agency staff used in IUC did not always have the required level of skill needed to provide a responsive service to callers. The availability of clinical advisors in the EOC impacted on staff’s ability to get advice as quickly as needed.
The incident reporting culture had continued to improve and there was evidence of improvements made as a result of learning from such events. There was however, some variation in EOC staffs understanding and use of the incident reporting process. Although learning from incident review processes was communicated in several ways, staff working in EOC and the IUC reported not having time to read some communications and therefore, were not aware of some updates.
Although mandatory safety training rates had improved since the last inspection, some expected targets had not been met. Staff working in EOC had educational breaks built into their shifts but reported not having enough time to update themselves or complete on-line learning.
Line managers in EOC and IUC were not always assessing their staff’s competencies following the completion of mandatory training and regarding expected practices within their roles. There were gaps in some of the role specific training of IUC staff.
Although appraisal rates had improved in EOC, some staff did not have the opportunity to have feedback on their performance through supervision or an annual review.
Whilst staff had access to policies, procedural guidance and other useful information, where updates to these resources was required, action had not always been taken to do this. However, we saw systems had been put in place to address this area as soon as the matter was brought to the executive’s attention.
Although the trust had done work to improve safety and security, some areas and vehicles were still not secured to a consistent standard. The provision of equipment had improved to front line vehicles and staff, there were some items which remained less available or were not yet provided and some items had passed the expiry date. This was like our previous findings.
The stock rotation of some locally managed medicines and consumables needed to be tightened to ensure out of date stock was identified and removed.
The servicing of vehicles was not always happening in a timely way causing reduced availability to staff.
Although people could access the service when they needed it, there were regular delays in responding to initial telephone calls made by the public to the EOC.
Team meetings did not routinely take place for the sharing of information and one-to-one meetings were cancelled in IUC due to demands on the service. Opportunities were sometime missed to help staff understand the priorities of the service and what was being done to manage these and other issues.
Several staff in EOC were not fully aware of the trust’s vision or how they could contribute to its achievement. Senior leaders were not as visible and approachable as staff expected, although the executive team had carried out several staff engagement activities to address this.

Our rating of this service went down. We rated it as requires improvement because:

The service did not have always have enough staff working within both EOC’s.
Not all staff understood how to protect patients from abuse. However, the service worked well with other agencies when abuse was highlighted.
The design, maintenance and use of facilities, premises and equipment did not always keep staff safe.
Staff did not always have opportunity to learn from incidents and managers did not always ensure actions from patient safety incidents were implemented and monitored.
Managers did not always appraise staff’s work performance and did not always hold supervision meetings with them to provide support and development.
At the time of inspection, staff did not always have access to updated policies.
Staff did not always feel leaders understood and managed the priorities and issues the service faced. Leaders were not always visible and approachable in the service for staff.
The service did not always operate effective governance processes. Staff were clear about their roles and accountabilities but did not always have regular opportunities to meet, discuss and learn from the performance of the service.

However:

All those responsible for delivering care worked together as a team to benefit patients.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
It was easy for people to give feedback and raise concerns about care received.
Staff were overwhelmingly positive about the culture within both EOC’s and the inclusivity of the organisation.
The trust employed a mental health nurse (RMN) who was available within EOC to offer support and guidance to staff on matters relating to patients experiencing mental ill health.

Our rating of this service stayed the same. We rated it as good because:

Risk assessments were undertaken for each patient. Risks were managed well.
Mandatory training was provided in key skills and most completed it as required.
Patients who were at risk of deterioration where quickly identified and managed accordingly.
On the whole the service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Records were clear and up-to-date, we found they were stored securely and were easily available.

Patient safety incidents were managed well. Staff understood their responsibility with regards to incident reporting. Incidents were investigated and learning was shared with staff.

All patients were partners in their care, they were supported by staff to understand their treatment and to make decisions about their care.

Patients were provided with information on how to make healthier lifestyle choices.

Staff were supported by clinical experts who gave advice to ensure patients received the correct treatment and care.
Date was used by the service to analyse how it was performing. Data was accessible to staff when it was needed.

However

Security at station was still an issue, stations and vehicles were left unlocked. Certain pieces of equipment were routinely not available for staff to use as part of their daily work.
Fleet staff did not receive training in the new ambulance vehicles the service were introducing to the fleet.
The storage of medicines in kit bags needed to improve. The stock rotation of some consumables needed to be tightened to ensure out of date stock was identified and removed.
The trusts policies and procedures were not always updated in a timely manner.

Managers were not always visible and approachable for staff and patients. Staff were not always supported by managers to develop their skills.

The inspection of London Ambulance Service headquarters commenced on 20 November, and was unannounced.

The inspection was prompted in part by notification of an incident, which is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risks around the security of ambulance stations, vehicles, and equipment. This inspection examined those risks.

We did not re-rate this service following the inspection.

We found:

The safeguarding of vulnerable children had not been fully considered. As a result, external safeguarding agencies had not been notified of potential safeguarding matters.
The timeframe for contacting individuals as part of the investigation was limited, which made the communication with persons affected less likely to be achieved.
The trust had not notified the disclosure and barring service (DBS) of the individual involved in the incident.
At the time of our inspection a security alert had not been sent to independent ambulance services to notify them of the incident.
Immediate changes to the processes and systems within the Emergency Operations Centre had been made to help reduce the risk of the incident happening again; however, these changes had not been fully communicated and they had not been embedded in practice.
Operational pressures often meant staff did not always make the relevant checks within the central support unit, when booking call signs onto the system.
Security of ambulances, vehicle keys and some areas within ambulance stations was not sufficient.
There was no firm guidance as to how long an ambulance vehicle could be left unattended before being collected.
The checking of staffs’ compliance with current and new practices was not sufficiently strong.

However:

Stakeholders and key partners were notified as soon as the incident was identified. The trust worked collaboratively with other agencies, and kept them informed of progress on actions arising from the incident review.
The investigative process was conducted in accordance with professional guidance, and within the boundaries of limitations made by a separate police matter.
The duty of candour had been considered and acted upon in accordance with the trusts policy and regulation.
Immediate actions had been taken to mitigate future risks, and the trust had developed a detailed action plan to improve the security of vehicles. This was continuously reviewed and monitored for progress.

Our rating of the trust improved. We rated it as good because:

We rated safe in the emergency operations centre (EOC) and well-led in emergency and urgent care (EUC) as requires improvement. We rated caring as outstanding in the EUC. In both EOC and EUC we rated effective and responsive as good. Well-led was rated as good in EOC. In rating the trust, we took into account the current ratings of the Emergency Preparedness Resilience and Response service and 111 services, which were not inspected this time.
We rated well-led for the trust overall as good.
At this inspection we found the trust had made significant improvements, in particular and of note were those related to well-led.

Staff provided care and treatment based on national guidance and evidence. They cared for patients with compassion, involved patients and those close to them in decisions about their care and treatment, and provided emotional support.
There were appropriate methods and processes to respond and manage risks to patients. Staff understood their roles and responsibilities in relation to safeguarding vulnerable adults and children.
Staff knew how to report incidents; managers shared learning from incidents and the trust carried out detailed investigations, feeding back to patients and families where appropriate.
The trust set quality performance targets, and reviewed these regularly against internal and external targets. The trust had governance, risk management, and quality measures to improve patient care, safety, and their outcomes.
During our previous inspection in February 2017 we reported on a computer aided dispatch (CAD) outage on New Year’s Eve 2017. However, the trust had reviewed the resilience and robustness of the system. The systems processes had been improved, although more work was planned.

There was good local leadership at both Waterloo and Bow emergency operations centre. The service had developed a five year strategy for emergency operations. There was an inclusive and constructive working culture within EOC services.
Senior managers had identified risks to the retention of call taking and dispatch staff. Work was in progress on an enhanced pay package for these staff grades.
Services were planned to meet local needs, and managers monitored the effectiveness of care and treatment through local and national audits.
The trust managed complaints and ensured staff had opportunities to learn from when things went wrong.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. This was an improvement since our last inspection.

However:

The EOC had regular periods where they were not able to meet the required number of planned staffing hours. There was poor retention of new dispatch and call taking staff, and staff turnover rates were above the trust’s target.
From April 2017 to October 2017, only 44% of staff working within the emergency operations centre at the trust had received an appraisal; this did not meet the trust target of 85%.
Mandatory safety training compliance rates did not meet the trust targets for some subjects.
From August 2017 the percentage of abandoned calls was higher than the England average.
Between November 2017 and January 2018 call answering times were below the England average. However, as the new ambulance response programme (ARP) measures were only introduced to London Ambulance Service (LAS) in November 2017, there was only three months of data available.
Managers told us there was very little time available for managerial tasks due to operational demands.

Our rating of this service improved. We rated it as good because:

There were much stronger governance arrangements in place compared to our findings at the last inspection. The trust had taken action on key areas of concern we had raised, and were continuously focussed on quality, patient safety, risks, and performance.
The reporting of low level incidents had improved and generally staff were more engaged with reporting incidents of all levels. There was more oversight at a local level and managers were able to assess themes and trends associated to their sectors. This meant they were able to take actions and share learning to staff.
The management of medicines had continued to improve on our findings of the 2017 inspection. New style drug rooms were being installed which meant tighter controls for the tracking and tracing of medicines.
Infection control prevention (IPC) practices had improved and there were more robust quality assurance processes regarding the monitoring and management of IPC.
The trust had more effective processes for managing risks. At a local level, managers were more empowered to oversee and manage their risks.
There was better scrutiny at a local level for staff mandatory training and staff were taking greater responsibility for completing the required training subjects.
Equipment availability had improved, and there were better systems for the supply and maintenance of equipment.
Major incidents were managed well. There were systems in place to ensure effective command and control protocols were followed by staff.
The trust performed well for the majority of patient outcomes. The trust had effective systems to monitor and take action to improve patient outcomes.
The trust had worked hard to implement the ambulance response programme (ARP). Initial performance information showed the trust was ranked fourth out of ten acute ambulance trusts, within the short space of time they had been adhering to the new standards.
There was access to professional expertise and clinical guidance. Support was available to frontline staff through suitably experienced specialists, such as mental health nurses and a maternity consultant midwife.
Staff provided excellent care to patients. We observed numerous occasions when staff went beyond their call of duty to ensure patients were cared for in a compassionate, kind, and dignified manner.
There were stronger quality measures in place at a local level, with greater oversight of performance and areas for improvements. Action was taken to address any shortcomings in a measured and responsive way.
Through the hospital handover project, the trust had lead on introducing ways of improving patient access and flow during patient handover at hospitals.

However:

At a local level, managers were unhappy with the clarity of their role and the extra workload they had received. The clinical team leaders (CTL) were still unhappy with the unclear boundaries within their role. This had not improved since our last inspection.
Local managers felt pressurised and on occasions harassed by the ‘middle management’ tier of the organisation.
Some staff were not happy with the way in which their managers addressed sickness and absence. They felt the approach to the trust policy was punitive. This had not improved since our last inspection.
Staff told us they did not have sufficient time to make the necessary vehicle checks at the start of their shift. This had not improved since our last inspection. The majority of staff were unhappy with the late finishing of their duties. They frequently ran late at the end of their shifts.
Patients had limited access to the appropriate mental health facilities and for the majority of cases; patients were conveyed to emergency departments. Although, this was beyond the control of the trust, this placed immense pressure on staff and was not always in the best interests of patients.
Hospital handover delays meant ambulances were ‘stacked’ at hospitals awaiting the receiving trust staff to accept and take over the care of the patient. As a result, ambulance staff were not able to respond to patient calls made during this time.
Complaints were not always dealt within the local time frame.

London Ambulance Service NHS Trust covers the capital city of the United Kingdom, over an area covering approximately 620 square miles. The service is provided to a population of around 8.6 million people, and over 30 million annual visitors. London Ambulance Service NHS Trust (LAS) was established in 1965 from nine previously existing services, and became an NHS Trust on 1 April 1996.

The trust provides an emergency and urgent care (EUC) service to respond to 999 calls, which are received and managed by the trusts emergency operations centre (EOC). Staff working in EOC provide clinical advice over the telephone, and dispatch emergency vehicles where required. The LAS also provides resilience and hazardous area response teams (HART), which all NHS organisations have been required to have since April 2013. LAS plays a crucial role in the national arrangements for emergency preparedness, resilience and response,(EPRR), contributing to a co-ordinated and planned response to major incidents through the local health resilience partnerships (LHRPs). There are two LAS Hazardous Area Response Team (HART), one based in Hounslow and the other in Tower Hamlets. In addition, LAS provides a patient transport services (PTS).

Services are managed from the trust’s main headquarters in Waterloo, and annexes in Bow and Pocock Street .

The trust also offers the following services: First Aid Training to organisations and the public, and Community First Responders (volunteers trained by LAS to provide life-saving treatment).

The trust uses a command and control Computer Aided Dispatch (CAD) system to manage all calls into the Emergency Operations Centre. In the year 2015-2016, LAS received 1.86 million 999 calls into its two operations centres.

The trust had previously been inspected in June 2015, where we rated Emergency and Urgent Care (EUC) and Resilience Planning as inadequate. The Emergency Operations Centre was rated as requires improvement. A follow up inspection undertaken in August 2016 found progress had been made with regard to the requirements we had set out in a warning notice issued as a result of the June 2015 inspection. We did not rate the August 2016 inspection because we did not consider all of the key lines of enquiry due to the focused approach of the inspection.

We inspected LAS as part of our planned, comprehensive inspection programme. Our inspection took place on 7, 8 & 9 February 2017, with unannounced visits on 17,24 & 25 February 2017. We looked at three core services: access via Emergency Operations Centres (EOC), EUC, and the Emergency Preparedness, Resilience and Response (EPRR), which included its two hazardous area response teams (HART). The 111 service provided by the trust had been inspected recently, and we did not inspect the patient transport services on this occasion. The commercial training services were not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC).

During the inspection we visited ambulance premises as well as hospital locations in order to speak to patients and staff about the ambulance service.

Overall, we rated this trust as requires improvement.

We rated the trust as being good for providing care which was effective and responsive to the needs of the population it serves. We rated safety and the well-led domain as requires improvement.

People reported and we observed staff go the extra mile. There were examples when people reported the care they received exceeded their expectations.

There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who used the service, those close to them and staff was strong, caring and supportive. Staff recognised and respected the totality of people’s needs. They always took people’s personal, cultural, social and religious needs into account. For these reasons, we rated the trust outstanding for the caring domain.

Our key findings were as follows:

Safety:

Whilst there had been improved mechanisms for identifying, reporting and investigating incidents, there remained a level of inconsistency in staffs perception of what constituted an incident and the reporting of such in all three services. As a result the trust was not always able to capture important data, which could identify trends and common themes across the organisation.
Learning from incidents had improved but, was happening in an ad-hoc way, and as a result was not not yet fully embedded in practice across all areas of the service. Whilst the executive team had clear methods for communicating learning, staff reported they did not always have time to read updates.
Mandatory safety training for non-clinical staff was not meeting the trusts own targets, and as a result, there was a risk of staff not being updated with regard to the latest safety practices.
The systems and processes for safeguarding people who were vulnerable as a result of their circumstances were clearly set out, and staff we spoke with were aware of safeguarding and how to recognise and report abuse or neglect.
Infection prevention and control measures had been established. Despite this, standards of compliance with protocols varied across the organisation. This was compounded further by the lack of staff awareness of standards, possibly attributed to non-completion of required training, and a lack of basic essential items to support practices.
A number of ambulance vehicles needed internal repair, which prevented a good level of cleanliness from being achieved.
There was some inconsistency in undertaking the required safety checks of vehicles and equipment, some of which was attributed to time factors at the start of shifts.

Significant improvement in medicine management had been achieved over the past few months. There remained an issue related to the tracking and tracing of medicines, which was still not sufficiently robust with regard to safe storage and tracking.

Whilst significant work had been undertaken to increase front-line ambulance staff, we were not assured all ambulance crew were allocated to response vehicles appropriately. Inexperienced crew were sometimes paired together and solo first responders were not always paramedics. As a result patient care and treatment was delayed when backup support was required.

Patient records provided detailed information to support handover at local hospitals, as well as an audit trail from call handler on-wards. Records were accurately kept and stored securely.

Effective:

Significant improvements had been made in Emergency Preparedness Resilience and Response, demonstrated through staff adherence with its agreed formal framework, and compliance with national standards. Response times to incidents classified as a HART response had been met.
Staff ensured patients consented to treatment and care where able, and recognised where the best interests of the patient had to be considered where the situation indicated a response from staff without formal consent.
Staff had good induction procedures and access to training. The trust was supporting staff to enhance their roles through additional responsibilities and expanded roles, such as clinical team leader and advanced paramedic practitioner. The introduction of the in-house academy provided an opportunity for staff to progress to the paramedic role.
Staff were supported to access training and development opportunities, and had their skills and competencies assessed. The performance review of staff through an annual appraisal levels had improved, although the completion rates did not yet meet the trust target.
Staff used evidence-based guidance to ensure patients were appropriately assessed, risks were identified and managed. The provision of care, advice and treatment reflected national clinical and medical guidance standards. For example, there were pathways of care to assess and respond to deteriorating patients. These included suspected stroke, chest pain, and trauma.

However,

The trust was not meeting the national performance targets for highest priority calls attended to by emergency and urgent care crew. Although outside factors of handover delays at emergency departments, and increased activity contributed towards this, patient safety was at risk due to delayed treatment and non-conveyancing to hospital.

The EUC ambulance crews experienced significant problems with handover delays at hospitals, resulting in stacked ambulances and crew being unable to attend emergency calls.

Many staff did not have a clear understanding of the Mental Health Act. Although this had improved for staff working in emergency 999 services.

Caring:

Staff across all services were caring, compassionate and treated patients with dignity and respect the majority of time.

Patients who spoke with us were very positive about the service they received and the way they were treated by staff. Formal written information from patients to the trust demonstrated high levels of satisfaction.

The emotional needs of patients and their relatives were addressed by staff providing information, treatment and care. Staff used a range of skills to provide empathy, support and reassurance when dealing with patients who were anxious or distressed.

Ambulance staff explained treatment and care options in a way which patients were able to understand, and involved them and their relatives in decisions about whether it was appropriate to take them to hospital or not.

Call handlers took their time to provide information and advice in a manner which was understood. They were patient, respectful and kind.

Patients could receive advice from experts and clinicians in order to manage their own health. Clinicians provided information to patients about managing worsening symptoms and were able to advise patients of alternative services, such as non-emergency services, their GP or local urgent care centres.

A small number of ambulance crew who were waiting with patients to hand them over to nursing staff in emergency departments did not on occasion demonstrate considered attention to the patient.

Responsive:

There was effective and collaborative working between emergency operations centres, ambulance crews and the resilience staff, as well as external agencies. The services were co-ordinated to support seamless care, admission avoidance and alternative care pathways.

The service was able to cope with different levels of demand, and was accessible via a number of routes. Systems for reporting to the National Ambulance Resilience Unit (NARU) and NHS England about the Hazardous Area Response Teams capacity had improved; formal arrangements were in place to report staffing on a shift by shift basis to NARU.

Patients with complex needs could be met by the staff, and they had access to an interpretation service when required.

However,

Attendance rates for equality, diversity and human rights training was relatively low.

There was more work to do in relation to developing a comprehensive business continuity plan, which would include all aspects of service delivery, including control services demand management systems, and rolling out the business impact assessment procedure to all part of the service. It was estimated this would be completed within 12-24 months.

The complaints process was clearly defined and the process for responding to complaints was robust. There was however, limited evidence of learning from complaints and concerns.

Well-led:

The governance arrangements were much stronger and organised in a manner which enabled better scrutiny and oversight. There was greater recognition, management and recording of risks at departmental level and information was communicated via various committees upwards to the trust board. There remained deviation from local trust policies in how risks migrated to the trust-wide risk register. Further, developments were required in terms of understanding and operating of the board assurance framework.

The trust had a clinical strategy, which took into account growing demand and increased activity. This was linked to quality plans, designed to improve clinical outcomes.

There was a clear governance structure with accountable roles for staff and managers in each area of the service. This included the use of a framework to manage risks and provide quality assurance. Managers and their staff were more familiar with local risk registers, and generally knew the key risks to the service.

Service quality was measured through monthly staff key performance indicators (KPI), management meetings, and reports to the board. Work was also in progress on a comprehensive review the trust’s major incident processes and IT systems.

There had been a shift in the culture across all areas, and generally staff were positive about working for LAS, although there was recognition that work still needing to be done to develop this further and maintain momentum.

Staff morale in both Waterloo and Bow EOCs had significantly improved since the trust’s previous inspection in June 2015. There remained variations in staff morale in ambulance stations, which was linked to varied leadership styles.

The trust recognised more work needed to be done to reduce the disconnect between the executive team and frontline staff. Staff reported not feeling fully engaged with the trust’s strategy, vision, and core values. Further, they were unsettled with the constant changes within the executive team, and were seeking more stability.

Staff did not feel fully consulted and engaged in the trust change agenda and reported the trust leadership as having a top down managerial approach. Remoteness of ambulance stations further added to the feeling of disconnection.
Staff reported rarely receiving a rest break. This meant they could work 12 hour shifts without having adequate rest. The lack of sufficient rest breaks posed a health and safety risk to staff, which had been recognised by the executive team.
Although the trust were in the process of reviewing current rosters and breaks, the current system was a contentious issues among staff. Staff told us there was an inconsistent and inflexible approach across the organisation and this was a source of frustration with them. Additionally, there was variation in how sickness absence was managed at departmental level, which caused a degree of unrest.
The trust had placed a great deal of emphasis on tackling bullying and harassment, despite this there remained a perception from some staff of issues remaining of this nature, and of discrimination. The variation in the local management of stations was linked to this.

We saw several areas of outstanding practice including:

We observed staff behaviours and heard staff interactions, which demonstrated outstanding care and treatment to patients, and their relatives. Staff were committed to the provision of a compassionate and caring service towards patients, and treated patients and callers on line and at the scene with dignity and respect.

The trust had employed mental health nurses at their clinical hub to provide expert opinion and assistance to frontline staff when they treated patients with mental health concerns.

A maternity education programme and maternity pre-screening tools and action plans had ensured staff were able to respond to and support maternity patients.

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

Importantly, the trust must:

Take action to improve staff uptake of mandatory training subjects, including safeguarding vulnerable people and infection prevention and control. The recording of such training must be more efficient and subject to scrutiny.

In addition the trust should:

Continue to develop a culture which empowers staff to recognise and report incidents. This should include reporting of low harm and near-miss incidents.
The trust needs to do more to ensure they meet the national performance targets for highest priority calls.
Improve the oversight and management of infection prevention and control practices. This includes ensuring consistent standards of cleanliness in the ambulance stations, vehicles and staff adherence to hand hygiene practices.

Further improve the provision and monitoring of essential equipment availability for staff at the start of their shift.

Ensure continued monitoring and improvements are made in medicine management, so that safety procedures are embedded in everyday practice, and are sustained by staff.

Make sure the skills matrix is more robustly used to ensure ambulance personnel are appropriately allocated, taking into account individual qualifications, experience and capabilities.

Continue to work with staff to address the issues related to rosters, rest breaks, sickness and absence. Actions taken should demonstrate a fair and consistent approach to managing the demands of the service, along with the health and safety of staff.

Ensure sufficient time is factored into the shift pattern for ambulance crews to undertake their daily vehicle checks within their allocated shift pattern.

Ensure there are ongoing robust plans to tackle handover delays at hospitals.

Identify further opportunities for the executive team to increase their engagement with staff, to ensure the strategy and vision is embedded in their culture, and that the views of staff are heard.

Review the leadership and management styles of key staff with responsibility for managing emergency and urgent care ambulance crews.
Continue to build on the programme of work to improve the culture around perceived bullying and harassment. Push forward with the measures it has identified and already established to increase a more diverse and representative workforce with greater numbers of black and minority ethnic staff.

On the basis of the findings of this inspection, it is my recommendation that the trust remain in special measures. I am hopeful that the trust will be able to deliver the necessary improvements and we will return to the trust in the near future to check progress. In particular, the leadership team is very new. As long as this has become properly established I am confident that we will be able to recommend that the trust should exit special measures within a few months.

Professor Sir Mike Richards

Chief Inspector of Hospitals

London Ambulance Service NHS Trust covers the capital city of the United Kingdom, over an area covering approximately 620 square miles. The service is provided to a population of around 8.6 million people, and over 30 million annual visitors. London Ambulance Service NHS Trust (LAS) was established in 1965 from nine previously existing services, and became an NHS Trust on 1 April 1996.

The trust provides an emergency and urgent care (EUC) service to respond to 999 calls, which are received and managed by the trusts emergency operations centre (EOC). Staff working in EOC provide clinical advice over the telephone, and dispatch emergency vehicles where required. The LAS also provides resilience and hazardous area response teams (HART), which all NHS organisations have been required to have since April 2013. LAS plays a crucial role in the national arrangements for emergency preparedness, resilience and response,(EPRR),contributing to a co-ordinated and planned response to major incidents through the local health resilience partnerships (LHRPs). There are two LAS Hazardous Area Response Team (HART), one based in Hounslow and the other in Tower Hamlets. In addition, LAS provides a patient transport services (PTS).

Services are managed from the trust’s main headquarters in Waterloo, and annexes in Bow and Pocock Street. The trust also offers the following services: First Aid Training to organisations and the public, and Community First Responders (volunteers trained by LAS to provide life-saving treatment).

The trust uses a command and control Computer Aided Dispatch (CAD) system to manage all calls into the Emergency Operations Centre. In the year 2015-2016, LAS received 1.86 million 999 calls into its two operations centres.

The trust had previously been inspected in June 2015, where we rated Emergency and Urgent Care (EUC) and Resilience Planning as inadequate. The Emergency Operations Centre was rated as requires improvement. A follow up inspection undertaken in August 2016 found progress had been made with regard to the requirements we had set out in a warning notice issued as a result of the June 2015 inspection. We did not rate the August 2016 inspection because we did not consider all of the key lines of enquiry due to the focused approach of the inspection.

We inspected LAS as part of our planned, comprehensive inspection programme. Our inspection took place on 7, 8 & 9 February 2017, with unannounced visits on 17, 24 & 25 February 2017. We looked at three core services: access via Emergency Operations Centres (EOC), EUC, and the Emergency Preparedness, Resilience and Response (EPRR), which included its two hazardous area response teams (HART). The 111 service provided by the trust had been inspected recently, and we included the ratings from that inspection in our overall aggregation of the service.

We did not inspect the patient transport services on this occasion. The commercial training services were not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC)

During the inspection we visited ambulance premises as well as hospital locations in order to speak to patients and staff about the ambulance service.

Overall, we rated this trust as requires improvement.

We rated the trust as being good for delivering an effective and responsive service to the needs of the population it serves.

We rated safety and the well-led domain as requires improvement.

People reported and we observed staff go the extra mile. There were examples when people reported the care they received exceeded their expectations.

There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who used the service, those close to them and staff was strong, caring and supportive. Staff recognised and respected the totality of people’s needs. They always took people’s personal, cultural, social and religious needs into account. For these reasons, we rated the trust outstanding for the caring domain.

Our key findings were as follows:

Safety:

• Whilst there had been improved mechanisms for identifying, reporting and investigating incidents, there remained a level of inconsistency in staffs perception of what constituted an incident and the reporting of such in all three services. As a result the trust was not always able to capture important data, which could identify trends and common themes across the organisation.

• Learning from incidents had improved but, was happening in an ad-hoc way, and as a result was not not yet fully embedded in practice across all areas of the service. Whilst the executive team had clear methods for communicating learning, staff reported they did not always have time to read updates.

• Mandatory safety training was not meeting the trusts own targets, and as a result, there was a risk of staff not being updated with regard to the latest safety practices.

• The systems and processes for safeguarding people who were vulnerable as a result of their circumstances were clearly set out, and staff we spoke with were aware of safeguarding and how to recognise and report abuse or neglect.

• Infection prevention and control measures had been established. Despite this, standards of compliance with protocols varied across the organisation. This was compounded further by the lack of staff awareness of standards, possibly attributed to non-completion of required training, and a lack of basic essential items to support practices.

• A number of ambulance vehicles needed internal repair, which prevented a good level of cleanliness from being achieved.

• There was some inconsistency in undertaking the required safety checks of vehicles and equipment,some of which was attributed to time factors at the start of shifts.

• Significant improvement in medicine management had been achieved over the past few months. There remained an issue related to the tracking and tracing of medicines, which was still not sufficiently robust with regard to safe storage and tracking.

• Whilst significant work had been undertaken to increase front-line ambulance staff, we were not assured all ambulance crew were allocated to response vehicles appropriately. Inexperienced crew were sometimes paired together and solo first responders were not always paramedics. As a result patient care and treatment was delayed when backup support was required.

• Patient records provided detailed information to support handover at local hospitals, as well as an audit trail from call handler on-wards. Records were accurately kept and stored securely.

Effective:

• Significant improvements had been made in Emergency Preparedness Resilience and Response, demonstrated through staff adherence with its agreed formal framework, and compliance with national standards. Response times to incidents classified as a HART response had been met.

• Staff ensured patients consented to treatment and care where able, and recognised where the best interests of the patient had to be considered where the situation indicated a response from staff without formal consent.

• Staff had good induction procedures and access to training. The trust was supporting staff to enhance their roles through additional responsibilities and expanded roles, such as clinical team leader and advanced paramedic practitioner. The introduction of the in-house academy provided an opportunity for staff to progress to the paramedic role.

• Staff were supported to access training and development opportunities, and had their skills and competencies assessed. The performance review of staff through an annual appraisal levels had improved, although the completion rates did not yet meet the trust target.

• Staff used evidence-based guidance to ensure patients were appropriately assessed, risks were identified and managed. The provision of care, advice and treatment reflected national clinical and medical guidance standards. For example, there were pathways of care to assess and respond to deteriorating patients. These included suspected stroke, chest pain, and trauma.

However,

• The trust was not meeting the national performance targets for highest priority calls attended to by emergency and urgent care crew. Although outside factors of handover delays at emergency departments, and increased activity contributed towards this, patient safety was at risk due to delayed treatment and non-conveyancing to hospital.

• The EUC ambulance crews experienced significant problems with handover delays at hospitals, resulting in stacked ambulances and crew being unable to attend emergency calls.

• Many staff did not have a clear understanding of the Mental Health Act. Although this had improved for staff working in emergency 999 services.

Caring:

• Staff across all services were caring, compassionate and treated patients with dignity and respect the majority of time.

• Patients who spoke with us were very positive about the service they received and the way they were treated by staff. Formal written information from patients to the trust demonstrated high levels of satisfaction.

• The emotional needs of patients and their relatives were addressed by staff providing information, treatment and care. Staff used a range of skills to provide empathy, support and reassurance when dealing with patients who were anxious or distressed.

• Ambulance staff explained treatment and care options in a way which patients were able to understand, and involved them and their relatives in decisions about whether it was appropriate to take them to hospital or not.

• Call handlers took their time to provide information and advice in a manner which was understood. They were patient, respectful and kind.

• Patients could receive advice from experts and clinicians in order to manage their own health. Clinicians provided information to patients about managing worsening symptoms and were able to advise patients of alternative services, such as none-emergency services, their GP or local urgent care centres.

• A small number of ambulance crew who were waiting with patients to hand them over to nursing staff in emergency departments did not on occasion demonstrate considered attention to the patient.

Responsive:

• There was effective and collaborative working between emergency operations centres, ambulance crews and the resilience staff, as well as external agencies. The services were co-ordinated to support seamless care, admission avoidance and alternative care pathways.

• The service was able to cope with different levels of demand, and was accessible via a number of routes. Systems for reporting to the National Ambulance Resilience Unit (NARU) and NHS England about the Hazardous Area Response Teams capacity had improved; formal arrangements were in place to report staffing on a shift by shift basis to NARU.

• Patients with complex needs could be met by the staff, and they had access to an interpretation service when required.

However,

• Attendance rates for equality, diversity and human rights training was relatively low.

• There was more work to do in relation to developing a comprehensive business continuity plan, which would include all aspects of service delivery, including control services demand management systems, and rolling out the business impact assessment procedure to all part of the service. It was estimated this would be completed within 12-24 months.

• The complaints process was clearly defined and the process for responding to complaints was robust. There was however, limited evidence of learning from complaints and concerns.

Well-led:

• The governance arrangements were much stronger and organised in a manner which enabled better scrutiny and oversight. There was greater recognition, management and recording of risks at departmental level and information was communicated via various committees upwards to the trust board. There remained deviation from local trust policies in how risks migrated to the trust-wide risk register. Further, developments were required in terms of understanding and operating of the board assurance framework.

• The trust had a clinical strategy, which took into account growing demand and increased activity. This was linked to quality plans, designed to improve clinical outcomes.

• There was a clear governance structure with accountable roles for staff and managers in each area of the service. This included the use of a framework to manage risks and provide quality assurance. Managers and their staff were more familiar with local risk registers, and generally knew the key risks to the service.

• Service quality was measured through monthly staff key performance indicators (KPI), management meetings, and reports to the board. Work was also in progress on a comprehensive review the trust’s major incident processes and IT systems.

• There had been a shift in the culture across all areas, and generally staff were positive about working for LAS, although there was recognition that work still needing to be done to develop this further and maintain momentum.

• Staff morale in both Waterloo and Bow EOCs had significantly improved since the trust’s previous inspection in June 2015. There remained variations in staff morale in ambulance stations, which was linked to varied leadership styles.

• The trust recognised more work needed to be done to reduce the disconnect between the executive team and frontline staff. Staff reported not feeling fully engaged with the trust’s strategy, vision, and core values. Further, they were unsettled with the constant changes within the executive team, and were seeking more stability.

• Staff did not feel fully consulted and engaged in the trust change agenda and reported the trust leadership as having a top down managerial approach. Remoteness of ambulance stations further added to the feeling of disconnection.

• Staff reported rarely receiving a rest break. This meant they could work 12 hour shifts without having adequate rest. The lack of sufficient rest breaks posed a health and safety risk to staff, which had been recognised by the executive team.

• Although the trust were in the process of reviewing current rosters and breaks, the current system was a contentious issues among staff. Staff told us there was an inconsistent and inflexible approach across the organisation and this was a source of frustration with them. Additionally, there was variation in how sickness absence was managed at departmental level, which caused a degree of unrest.

• The trust had placed a great deal of emphasis on tackling bullying and harassment, despite this there remained a perception from some staff of issues remaining of this nature, and of discrimination. The variation in the local management of stations was linked to this.

We saw several areas of outstanding practice including:

• We observed staff behaviours and heard staff interactions, which demonstrated outstanding care and treatment to patients, and their relatives. Staff were committed to the provision of a compassionate and caring service towards patients, and treated patients and callers on line and at the scene with dignity and respect.

• The trust had employed mental health nurses at their clinical hub to provide expert opinion and assistance to frontline staff when they treated patients with mental health concerns.

• A maternity education programme and maternity pre-screening tools and action plans had ensured staff were able to respond to and support maternity patients.

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

Importantly, the trust must:

• Take action to improve non-clinical staff uptake of mandatory training subjects, including safeguarding vulnerable people and infection prevention and control. The recording of such training must be more efficient and subject to scrutiny.

In addition the trust should:

• Continue to develop a culture which empowers staff to recognise and report incidents. This should include reporting of low harm and near-miss incidents.

• The trust needs to do more to ensure they meet the national performance targets for highest priority calls.

• Improve the oversight and management of infection prevention and control practices. This includes ensuring consistent standards of cleanliness in the ambulance stations, vehicles and staff adherence to hand hygiene practices.

• Further improve the provision and monitoring of essential equipment availability for staff at the start of their shift.

• Ensure continued monitoring and improvements are made in medicine management, so that safety procedures are embedded in everyday practice, and are sustained by staff.

• Allocate ambulance personnel appropriately, taking into account individual qualifications, experience and capabilities.

• Continue to work with staff to address the issues related to rosters, rest breaks, sickness and absence. Actions taken should demonstrate a fair and consistent approach to managing the demands of the service, along with the health and safety of staff.

• Ensure sufficient time is factored into the shift pattern for ambulance crews to undertake their daily vehicle checks within their allocated shift pattern.

• Ensure there are ongoing robust plans to tackle handover delays at hospitals.

• Identify further opportunities for the executive team to increase their engagement with staff, to ensure the strategy and vision is embedded in their culture, and that the views of staff are heard.

• Review the leadership and management styles of key staff with responsibility for managing emergency and urgent care ambulance crews.

• Continue to build on the programme of work to improve the culture around perceived bullying and harassment. Push forward with the measures it has identified and already established to increase a more diverse and representative workforce with greater numbers of black and minority ethnic staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We undertook a follow up inspection of London Ambulance Services NHS Trust (LAS) on 2 and 3 August 2016, in relation to the warning notice issued under section 29A of The Health and Social Care Act 2008 on 1 October 2015.

This inspection focused on issues raised in the warning notice, those being:

Insufficient numbers of appropriately trained frontline paramedic staff.
Shortage of paramedic and technician staff for the Hazardous Area Response Team (HART)
Medicine management was not in line with Human Medicines Regulations 2012 and recommended guidelines.
Lack of effective governance in mitigating staff and patient risks.

We visited the trusts headquarters in Waterloo, London, stations in Fulham, Newham and Waterloo, and the Hazardous Area Response Team (HART) in Cody Road, East London. We also visited the central stores in Deptford.

Our key findings were as follows:

The trust had made significant progress with recruitment of frontline staff, with over 700 new staff recruited within the last year.
Staffing figures provided to us indicated significant improvement compared to our findings on the previous inspection. Staffing levels had increased, with 3,050 whole time equivalent (WTE) staff, with frontline accounting for 2,856 and central operations 193.
The National Ambulance Resilience Unit’s (NARU) HART interoperability standard number 12 was being met at the time of this return visit, with six staff able to respond to a HART call at any one time.
LAS had 85 HART staff, 42 on each site, plus one additional staff member to cover training, holiday, and absence.
In instances where two HART teams were not available, notification was made to the London Fire Brigade and Metropolitan Police Service, and systems were established to comply with NARU protocols.
The organisation was working with a workforce optimisation company to review HART rosters as a means of maximising cover.
As part of the trusts five year strategic plan, recruitment plans included annual recruitment campaigns to attract paramedics from inside and outside the European Union, and from other ambulance services. Apprenticeship schemes for London were also being discussed.
A new electronic reporting system had been set up but, had yet to be fully embedded within the organisation. However, the trust had seen an increase of both patient and staff incidents being reported onto the system in June 2016, compared to the previous two months.
Staff were not always being encouraged to report incidents by their managers and this had an effect on local risks registers, and the extent to which problems were being monitored and assessed. For example, not all staff reported shortages of drug packs through the incident reporting system. Therefore, information that would help escalate issues to the appropriate places was not always captured.
Staff we spoke with knew how to report incidents but they reported that they sometimes did not have sufficient time to do so. Staff did not want to report incidents at the end of a full shift in their own time.
We were told that governance was not yet ‘living and breathing’ in the organisation. Although senior staff were said to be more open to listening and considering ideas, and were more understanding, they were not always able to respond proactively to these.
There was a variation in the way stations were managed, in terms of organisation and maintenance and attention to communications.
Although there had been acknowledgment of issues identified around medicine management, limited action had been taken, which had undermined the improvement process. Staff told us the paper based system was seen as open to failure and if more detailed thought had been placed at the start of the process, a better outcome may have been achieved.
The Quality Improvement Programme (QIP) showed there were plans to roster administrative time during staff shifts to assist them with reporting incidents.
The London Ambulance Service special measures stocktake in May 2016 recognised their system of tracing and tracking medicines given to patients was ineffective and risky.
Checks were not made to see if medicines were given to patients, after they were removed from paramedic drug packs. These included oral morphine solution and diazepam injections.
Staff reported to us they often had shortages of drug packs due to the lack of tracking where drug packs were.
Every drug pack had a unique number that could be tracked, but no audits had been done to check the location and number of packs actually in circulation.
Distribution of drug packs was a concern at Whipps Cross and Walthamstow, as they were last on the distribution list and packs had often run out by then.
Staff we spoke with told us the management of medicines had improved. We observed Morphine was now locked in secure storage units and the passcode was now changed every three months.
Ambulance staff we spoke with informed us the team leaders checked controlled medicines and it was the staff on shifts responsibility to sign medicines in and out. The signing out of non-controlled drugs took time, and often drug packs were being taken without a sign out. The trust informed us staff were required to document the individual drug pack number on the dispatch summary/roadworthy check sheet (LA1) for each shift. Furthermore, the drug pack number would then be expected to be recorded on the patient report form, if the pack had been opened and drugs administered.
Stocks of medicine drug packs were expected to be checked weekly but, there was a reliance on staff honesty and this sometimes led to gaps in the system, where checks had not been undertaken.
There had been improved management of medical gases, yet there was no effective system of tracking cylinders. They could identify if a cylinder had gone missing via a unique pin number at corporate level, but not the location it was lost or stolen from.
There was a one-year medicine management improvement plan, which involved the development of a clinical strategy. This would incorporate the medicine management strategy. The quality improvement plan update for medicines management in July 2016, indicated phase one of improvements were completed with phase two in progress.
The trust was advertising for a full time pharmacist. One of their first objectives would then be to finalise the strategy.
A Quality Improvement Programme (QIP) was launched in January 2016 in response to concerns raised by the CQC. Issues being addressed included, staffing levels, medicines management, and governance.
Staff we spoke with of all grades, told us they had a lot of respect for the chief executive, and they were visible. We were told each executive had an area they were responsible for, which in turn made them more visible to staff. For example, the director of operations was responsible for delivering patient facing services, EOC, 111, HART and tactical response.
We were told by a senior staff member that engagement with staff was much improved but there were still areas which required attention with respect to the physical environment especially the two call centres.
The trust had focused on bullying and harassment, with workshops, and holding conversations instead of resorting to formal processes. Senior staff, including station managers and team leaders had attended the courses, and frontline staff were aware of the workshops. Ambulance staff reported feeling able to report a matter if necessary, and they would be taken seriously, and have their confidentiality respected.
The bullying and harassment workshops had been attended by 490 staff.
A lead director was in post, with a specific remit for overseeing the commitment to reducing bullying and harassment within the organisation. Incident response officers were available to respond to issues raised by individuals.
However, the NHS staff survey 2015, found the trust’s worst performing areas, included staff experience of bullying and harassment and not knowing who the senior managers were. These two areas were highlighted as concerns during our last inspection.
Local risk registers were not always updated to reflect current issues, for example, the lack of drug packs at stations. However, the trust risk register acknowledged this was a high risk.
Staff told us they had a greater awareness of risk registers, including having these at departmental, divisional, and corporate levels.
The Emergency Operations Centre (EOC) had clearer defined programmes for the improvement of operations. More work was needed to achieve this, and the trust recognised this was a long term plan with goals set for March 2017.
Surgeries were held in June 2016 for staff to engage in discussion for improvement. Issues raised included, concerns on roster reviews and lack of facilities.

There remained areas of poor practice where the trust needs to make further improvements.

Importantly, the trust must:

Implement an effective system that checks or monitors medicines removed from paramedic or general drug packs in order to assess if these were given to patients or otherwise used. These medicines include oral morphine solution and diazepam injections.
Ensure a robust system of checks and audits are set up to trace, and track transactions of medicines removed from paramedic drug packs, which have been administered to patients.

In addition the trust should:

Assess and monitor staffs adherence with procedures for reporting the shortage of drug packs through their incident reporting process.
Develop local risk registers so these reflect the shortages, and thereby enable management to monitor and assess the extent of the problem.
Have effective management systems and processes at their Deptford stores to monitor and control drug pack provision and availability. Establish a robust medical gas cylinders tracking system.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The London Ambulance Service NHS Trust (LAS) is one of 10 ambulance trusts in England providing emergency medical services to the whole of Greater London, which has a population of around 8.6 million people. The trust employs around 4,251 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across London.

The main role of LAS is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received by the emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. Other services provided by LAS include patient transport services (PTS) for non-emergency patients between community provider locations or their home address; NHS 111 non-emergency number for urgent medical help and/or advice which is not life-threatening; and resilience services which includes the Hazardous Area Response Team (HART).

Our announced inspection of LAS took place between 1 to 5 and 17 and 18 June 2015 with unannounced inspections on 12, 17 and 19 June 2015. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected four core services:

Emergency Operations Centres
Urgent and Emergency Care
Patient Transport Services
Resilience planning including the Hazardous Area Response Team:

We did not inspect the NHS 111 service provision during this inspection.

Overall, the trust was rated as Inadequate. Caring was rated as Good. Effective, and responsive were rated as Requires improvement. Safe and Well-led was rated as Inadequate.

Our key findings were as follows:

The trust was making efforts to recover from a decline in performance which had worsened in late 2014. At the time of our inspection the interim chief executive was appointed substantively to the post. This was seen as a positive move by many front line staff to assist stability. There had been two previous chief executives in post or appointed since 2012.
The trust was operating with a shortage of trained paramedics in the light of a national shortage and due to paramedics leaving its service for a number of reasons including better pay elsewhere. It had conducted recruitment of paramedics from as far afield as Australia and New Zealand to combat this.
We had significant concerns about a reported culture of bullying and harassment in parts of the trust. The trust had commissioned an independent report into this which it had received in November 2014. However this was only presented to the trust board in June 2015.
We had similar concerns about the trust's provision and use of HART paramedics and the trust's ability to meet the requirements of the National Ambulance Resilience Unit (NARU).
The trust had been facing increased contractual competition for its patient transport services (PTS) leading to a diminishing workload. It was trialling a new non-emergency transport service (NET) which had begun in September 2014.
During our inspection we found staff to be highly dedicated to and proud of the important work they were undertaking.At the same time they were open and honest about the challenges they were facing daily.They were largely supportive of their immediate managers but found some senior managers and executives and board members to be remote and lacking an understanding of the issues they were experiencing.

We saw several areas of good practice including:

The trust's intelligence conveyancing system to help prevent overload of ambulances at any particular hospital emergency department.
Good levels of clinical advice provided to frontline staff from the trust's clinical hub.
We observed staff to be caring and compassionate often in very difficult and distressing circumstances.
The percentage of cardiac patients receiving primary angioplasty was 95.8% against an England average of 80.7%
Good multi-disciplinary working with other providers at trust and frontline staff levels.

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

Importantly, the trust must:

develop and implement a detailed and sustained action plan to tackle bullying and harassment and a perceived culture of fear in some parts.
recruit sufficient frontline paramedic and other staff to meet patient safety and operational standards requirements.
recruit to the required level of HART paramedics to meet its requirements under the National Ambulance Resilience Unit (NARU) specification.
improve its medicines management including:
formally appoint and name a board director responsible for overseeing medication errors and formally appoint a medication safety officer.
review the system of code access arrangements for medicine packs to improve security.
set up a system of checks and audit to ensure medicines removed from paramedic drug packs have been administered to patients.
set up control systems for the issue and safekeeping of medical gas cylinders.
improve the system of governance and risk management to ensure that all risks are reported, understood, updated and cleared regularly.
address under reporting of incidents including the perceived pressure in some departments not to report incidents.

In addition the trust should:

review and improve trust incident reporting data.
ensure all staff understand and can explain what situations need to be reported as safeguarding.
review the use of PGDs to support safe and consistent medicines use.
improve equipment checks on vehicles and ensure all equipment checks are up to date on specific equipment such as oxygen cylinders.
ensure sufficient time for vehicle crews to undertake their daily vehicle checks.
ensure consistent standards of cleanliness of vehicles and instigate vehicle cleanliness audits.
set up learning to ensure all staff understand Duty of Candour and their responsibilities under it.
ensure adequate and ready provision of protective clothing for all ambulance crews.
ensure equal provision of ambulance equipment across shifts.
improve the blanket exchange system pan London to prevent re-use of blankets before cleaning.
ensure full compliance with bare below the elbow requirements.
review and improve ambulance station cleaning to ensure full infection, prevention and control in the buildings and in equipment used to daily clean ambulances.
set up a system of regular clinical supervision for paramedic and other clinical staff.
ensure all staff have sufficient opportunity to complete their mandatory training, including personal alerts and control record system.
increase training to address gaps identified in the overall skill, training and competence of HART paramedics.
review staff rotas to include time for meal breaks, and administrative time for example for incident reporting.
review patient handover recording systems to be more time efficient.
provide NICE cognitive assessment training for frontline ambulance staff.
improve training for staff on Mental Capacity Act assessment.
ensure all staff receive annual appraisals.
review development opportunities for staff.
improve access to computers at ambulance stations to facilitate e-learning and learning from incidents.
review maintenance of ambulances to ensure all are fully operational including heating etc.
review arrangements in the event of ambulances becoming faulty at weekends.
review and improve patient waiting times for PTS patients.
ensure PTS booking procedures account for the needs of palliative care patients.
develop operational plans to respond to the growing bariatric population in London.
review operational guidelines for managing patients with mental health issues and communicate these to staff.
ensure better public and staff communication on how to make a complaint including provision of information in emergency and non emergency ambulances.
communicate clearly to all staff the trust's vision and strategy.
develop a long term strategy for the (Emergency Operations Centres (EOCs).
increase the visibility and day to day involvement of the trust executive team and board across all departments.
review trust equality and diversity and equality of opportunity policies and practice to address perceptions of discrimination and lack of advancement made by trust ethnic minority staff and staff on family friendly rotas.
review the capacity and capability of the trust risk and safety team to address the backlog of incidents and to improve incident reporting, investigation, learning and feedback the trust and to frontline staff.

The above list is not exhaustive and the trust should study our reports in full to identify and examine all other areas where it can make improvements.

On the basis of this inspection I have recommended that the trust be placed in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The London Ambulance Service NHS Trust (LAS) is one of 10 ambulance trusts in England providing emergency medical services to the whole of Greater London, which has a population of around 8.6 million people. The trust employs around 4,251 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across London.

The main role of LAS is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received by the emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. Other services provided by LAS include patient transport services (PTS) for non-emergency patients between community provider locations or their home address; NHS 111 non-emergency number for urgent medical help and/or advice which is not life-threatening; and resilience services which includes the Hazardous Area Response Team (HART).

Our announced inspection of LAS took place between 1 to 5 and 17 and 18 June 2015 with unannounced inspections on 12, 17 and 19 June 2015. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected four core services:

Emergency Operations Centres
Urgent and Emergency Care
Patient Transport Services
Resilience planning including the Hazardous Area Response Team:

We did not inspect the NHS 111 service provision during this inspection.

Overall, the trust was rated as Inadequate. Caring was rated as Good. Effective and Responsive were rated as Requires Improvement. Safe and Well-led were rated as Inadequate.

Our key findings were as follows:

The trust was making efforts to recover from a decline in performance which had worsened in late 2014. At the time of our inspection the interim chief executive was appointed substantively to the post. This was seen as a positive move by many front line staff to assist stability. There had been two previous chief executives in post or appointed since 2012.
The trust was operating with a shortage of trained paramedics in the light of a national shortage and due to paramedics leaving its service for a number of reasons including better pay elsewhere. It had conducted recruitment of paramedics from as far afield as Australia and New Zealand to combat this.
We had significant concerns about a reported culture of bullying and harassment in parts of the trust. The trust had commissioned an independent report into this which it had received in November 2014. However this was only presented to the trust board in June 2015.
We had similar concerns about the trust's provision and use of HART paramedics and the trust's ability to meet the requirements of the National Ambulance Resilience Unit (NARU).
The trust had been facing increased contractual competition for its patient transport services (PTS) leading to a diminishing workload. It was trialling a new non-emergency transport service (NET) which had begun in September 2014.
During our inspection we found staff to be highly dedicated to and proud of the important work they were undertaking. At the same time they were open and honest about the challenges they were facing daily.They were largely supportive of their immediate managers but found some senior managers and executives and board members to be remote and lacking an understanding of the issues they were experiencing.

We saw several areas of good practice including:

The trust's intelligence conveyancing system to help prevent overload of ambulances at any particular hospital emergency department.
Good levels of clinical advice provided to frontline staff from the trust's clinical hub.
We observed staff to be caring and compassionate often in very difficult and distressing circumstances.
The percentage of cardiac patients receiving primary angioplasty was 95.8% against an England average of 80.7%
Good multi-disciplinary working with other providers at trust and frontline staff levels.

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

Importantly, the trust must:

Develop and implement a detailed and sustained action plan to tackle bullying and harassment and a perceived culture of fear in some parts.
Recruit sufficient frontline paramedic and other staff to meet patient safety and operational standards requirements.
Recruit to the required level of HART paramedics to meet its requirements under the National Ambulance Resilience Unit (NARU) specification.
Improve its medicines management including:
Formally appoint and name a board director responsible for overseeing medication errors.
Review the system of code access arrangements for medicine packs to improve security.
Set up a system of checks and audit to ensure medicines removed from paramedic drug packs have been administered to patients.
Set up control systems for the issue and safekeeping of medical gas cylinders.
Improve the system of governance and risk management to ensure that all risks are reported, understood, updated and cleared regularly.
Ensure staff report all appropriate incidents and are always encouraged to do so.

In addition the trust should:

Review and improve trust incident reporting data.
Ensure all staff understand and can explain what situations need to be reported as safeguarding.
Review the use of PGDs to support safe and consistent medicines use.
Improve equipment checks on vehicles and ensure all equipment checks are up to date on specific equipment such as oxygen cylinders.
Ensure sufficient time for vehicle crews to undertake their daily vehicle checks.
Ensure consistent standards of cleanliness of vehicles and instigate vehicle cleanliness audits.
Set up learning to ensure all staff understand Duty of Candour and their responsibilities under it.
Ensure adequate and ready provision of protective clothing for all ambulance crews.
Ensure equal provision of ambulance equipment across shifts.
Improve the blanket exchange system pan London to prevent re-use of blankets before cleaning.
Ensure full compliance with bare below the elbow requirements.
Review and improve ambulance station cleaning to ensure full infection, prevention and control in the buildings and in equipment used to daily clean ambulances.
Set up a system of regular clinical supervision for paramedic and other clinical staff.
Ensure all staff have sufficient opportunity to complete their mandatory training, including personal alerts and control record system.
Increase training to address gaps identified in the overall skill, training and competence of HART paramedics.
Review staff rotas to include time for meal breaks, and administrative time for example for incident reporting.
Review patient handover recording systems to be more time efficient.
Provide NICE cognitive assessment training for frontline ambulance staff.
Improve training for staff on Mental Capacity Act assessment.
Ensure all staff receive annual appraisals.
Review development opportunities for staff.
Improve access to computers at ambulance stations to facilitate e-learning and learning from incidents.
Review maintenance of ambulances to ensure all are fully operational including heating etc.
Review arrangements in the event of ambulances becoming faulty at weekends.
Review and improve patient waiting times for PTS patients.
Ensure PTS booking procedures account for the needs of palliative care patients.
Develop operational plans to respond to the growing bariatric population in London.
Review operational guidelines for managing patients with mental health issues and communicate these to staff.
Ensure better public and staff communication on how to make a complaint including provision of information in emergency and non emergency ambulances.
Communicate clearly to all staff the trust's vision and strategy.
Develop a long term strategy for the Emergency Operations Centres (EOCs).
Increase the visibility and day to day involvement of the trust executive team and board across all departments.
Review trust equality and diversity and equality of opportunity policies and practice to address the perception by ethnic minority staff of discrimination and lack of career advancement and by frontline staff that rotas are not family-friendly .
Review the capacity and capability of the trust risk and safety team to address the backlog of incidents and to improve incident reporting, investigation, learning and feedback the trust and to frontline staff.

The above list is not exhaustive and the trust should study our reports in full to identify and examine all other areas where it can make improvements.

On the basis of this inspection I have recommended that the trust be placed in special measures.

London Ambulance Service NHS Trust

All Inspections

6 December 2021

During an inspection of Emergency operations centre (EOC)

2nd, 3rd, 6th, 7th September 2019

During a routine inspection

2nd, 3rd, 6th, 7th September 2019

During an inspection of Emergency operations centre (EOC)

2nd, 3rd, 6th, 7th September 2019

During an inspection of Emergency and urgent care

20th & 21st November 2018

During an inspection looking at part of the service

5 to 22 March 2018

During a routine inspection

5 to 22 March 2018

During an inspection of Emergency operations centre (EOC)

5 to 22 March 2018

During an inspection of Emergency and urgent care

7-9 February and 17 24-25 February 2017

During a routine inspection

7-9 February and 17 24 25 February 2017

During a routine inspection

Professor Sir Mike Richards

2 and 3 August 2016

During an inspection looking at part of the service

Professor Sir Mike Richards

1-5;17-18 June 2015.Unannounced visits on 12,17,19 June 2015

During a routine inspection

Chief Inspector of Hospitals

1-5; 17-18 June 2015. Unannounced visits on 12, 17, 19 June 2015.

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals