The Care Quality Commission
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North West Ambulance Service NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

12 April 2022 to 20 April 2022

During an inspection of Emergency and urgent care

The emergency and urgent care services serve more than 7.5 million people across the communities of Cumbria, Lancashire, Greater Manchester, Merseyside and Cheshire. The services respond to over one million emergency incidents each year; with the workforce providing pre-hospital care to patients in remote-rural and urban environments.

The trust’s vision is to be the best ambulance service in the UK, providing the right care, at the right time, in the right place; every time for patients accessing its emergency and urgent care (999) care service, non-emergency patient transport service and NHS 111 service. North West Ambulance Service NHS Trust (NWAS) provides 24 hours 7 days a week, emergency and urgent care services to those in need of emergency medical treatment and transport.

We carried out this short notice announced focused inspection of North West Ambulance Service emergency and urgent care between 12 and 14 April 2022. We had an additional focus on the emergency and urgent care pathway and carried out several inspections of services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.

As this was a focused inspection, and we did not look at every key line of enquiry, we did not re-rate the service this time. At our previous inspection in February 2020, we rated emergency and urgent care at the service as good overall. Responsive was rated as outstanding and the other key questions as good.

During this inspection we reviewed the emergency and urgent care services which include ambulance crews attending to 999 calls and the emergency operations centre which is the clinical hub which receives the 999 calls and dispatches vehicles. For both services we looked at elements of safety, effectiveness, caring, responsiveness and leadership of staff who were receiving and attending to 999 calls.

The trust employs around 6,300 staff in over 300 different roles and is supported by over 1,000 volunteers as members of its patient and public panel, volunteer car driver network and community first responder network. There are 3,686 staff employed in emergency and urgent care services, working across 103 ambulance stations. The service has 616 ambulance vehicles, including 481 emergency vehicles, 10 dedicated see and treat cars, 93 rapid response vehicles, 21 advanced paramedic vehicles and 11 community specialist response cars.

A summary of CQC findings on urgent and emergency care services in Cheshire and Merseyside (Liverpool, Knowsley and South Sefton).

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 Liverpool, Knowsley and South Sefton within the Cheshire and Merseyside ICS below: Cheshire and Merseyside (Liverpool, Knowsley and South Sefton)Provision of urgent and emergency care in Cheshire and Merseyside was supported by services, stakeholders, commissioners and the local authority. We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff had continued to work hard under sustained pressure across health and social care services.

Services had put systems in place to support staff with their wellbeing, recognising the pressure they continued to work under, in particular for front line ambulance crews and 111 call handlers. Staff and patients across primary care reported a preference for face to face appointments. Some people reported difficulties when trying to see their GP and preferred not to have telephone appointments. They told us that due to difficulties in making appointments, particularly face to face, they preferred to access urgent care services or go to their nearest Emergency Department. However, appointment availability in Cheshire and Merseyside was in line with national averages.

We identified capacity in extended hours GP services which wasn’t being utilised and could be used to reduce the pressure on other services. People and staff also told us of a significant shortage of dental provision, especially for urgent treatment, which resulted in people attending Emergency Departments. Urgent care services, including walk-in centres were very busy and services struggled to assess people in a timely way. Some people using these services told us they accessed these services as they couldn’t get a same day, face to face GP appointment. We found some services went into escalation. Whilst system partners met with providers to understand service pressures, we did not always see appropriate action taken to alleviate pressure on services already over capacity.

The NHS 111 service, which covered all of the North West area including Cheshire and Merseyside, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service.

Following initial assessment and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours (OOH) provider. We found some telephone consultation processes were duplicated and could be streamlined. At peak times, people were waiting 24-48 hours for a call back from the clinical assessment and out of hours services. We identified an opportunity to increase the skill mix in clinicians for both the NHS 111 and the clinical assessment service. For example, pharmacists could support people who need advice on medicines. Following our inspections, out of hours and NHS 111 providers have actively engaged and worked collaboratively to find ways of improving people’s experience by providing enhanced triage and signposting. People who called 999 for an ambulance experienced significant delays.

Whilst ambulance crews experienced some long handover delays at the Emergency Departments we inspected, data indicated these departments were performing better than the England average for handovers, although significantly below the national targets. However, crews found it challenging managing different handover arrangements at different hospitals and reported long delays. Service leaders were working with system partners to identify ways of improving performance and to ensure people could access appropriate care in a timely way. For example, the service worked with mental health services to signpost people directly to receive the right care, as quickly as possible.

The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure. We saw significant levels of demand on emergency departments which, exacerbated by staffing issues, resulted in long delays for patients. People attending these departments reported being signposted by other services, a lack of confidence in GP telephone appointments and a shortage of dental appointments. We inspected some mental health services in Emergency Departments which worked well with system partners to meet people’s needs. We found there was poor patient flow across acute services into community and social care services. Discharge planning should be improved to ensure people are discharged in a timely way. Staff working in care homes (services inspected were located in Liverpool and South Sefton)reported poor communication about discharge arrangements which impacted on their ability to meet people’s needs.

The provision of primary care to social care, including GP and dental services, should be improved to support people to stay in their own homes. Training was being rolled out to support care home staff in managing deteriorating patients to avoid the need to access emergency services. We found some examples of effective community nursing services, but these were not consistently embedded across social care. Staffing across social care services remains a significant challenge and we found a high use of agency staff. For example, in one nursing home, concerns about staff competencies and training impacted on the service’s ability to accept and provide care for people who had increased needs. We found some care homes felt pressure to admit people from hospital. Ongoing engagement between healthcare leaders and Local Authorities would be beneficial to improve transfers of care between hospitals and social care services.

In addition, increased collaborative working is needed between service leaders. We found senior leaders from different services sometimes only communicated during times of escalation.

A summary of CQC findings on emergency and urgent care services in Lancashire and South Cumbria.

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 Lancashire and South Cumbria below: Provision of urgent and emergency care in Lancashire and South Cumbria was supported by services, stakeholders, commissioners and the local authority.

We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff felt tired and continued to work under sustained pressure across health and social care. We found demand on urgent care services had increased. Whilst feedback on these services was mostly positive, we found patients were accessing these services instead of seeing their GP. Local stakeholders were aware that people were opting to attend urgent care services and were engaging with local communities to explore the reasons for this.

The NHS 111 service which covered all the North West area, including Lancashire and South Cumbria, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment, and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours providers. The NHS 111 service would benefit from a wide range of clinicians to be available such as dental, GP and pharmacists to negate the need for onward referral to other service providers.

People who called 999 for an ambulance experienced significant delays. Ambulance crews also experienced long handover delays at most Emergency Departments. Crews also found it challenging managing different handover arrangements. Some emergency departments in Lancashire and South Cumbria struggled to manage ambulance handover delays effectively which significantly impacted on the ambulance service’s ability to manage the risk in the community. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.

We saw significant delays for people accessing care and treatment in emergency departments. Delays in triage and initial treatment put people at risk of harm. We visited mental health services delivered from the Emergency Department and found these to be well run and meeting people’s needs. However, patients experienced delays in the Emergency Department as accessing mental health inpatient services remained a significant challenge. This often resulted in people being cared for in out of area placements.

We found discharge wasn’t always planned from the point of admission which exacerbated in the poor patient flow seen across services. Discharge was also impacted on by capacity in social care services and the ability to meet people’s needs in the community. We also found some patients were admitted from the Emergency Department because they couldn’t get discharged back into their own home at night.

Increased communication is needed between leaders in both health and social care, particularly during times of escalation when Local Authorities were not always engaged in action plans.

Summary of North West Ambulance Service NHS Trust

We did not rate this service at this inspection. The previous rating of good remains. We found:

  • The service was under significant and sustained pressure from demand with ambulances waiting on for handovers at emergency departments. The service was staffed sufficiently to meet the needs in most areas for planned levels of demand. However due to an increased number of callers to the 999 service and the increase in delayed handovers at emergency departments the service was unable to attend to all patients who needed an ambulance within the expected times. The service had taken action to manage the increasing the demand on the emergency and urgent care capacity by increasing the number of call handlers employed by the service and seeking aid from volunteer ambulance services and the military.
  • There was increased risk for patients who had long waits at emergency departments throughout the region, the system was pressured with hospitals unable to take patients due to the lack of capacity in emergency departments. Due to ambulance crews waiting outside emergency departments for handover this had increased the risk to patients in the community who were waiting on an ambulance which was either not able to be sent or was excessively delayed. Although the trust was performing in line with or better than the national average, the trust had reported incidents of patients who had come to harm due to delayed response times.
  • The trust was not meeting nationally set response time targets, this was due to the increased rate of calls many of which were in the highest risk category and the effect of delayed handovers on the service. The service was performing inline or better than the national average compared with other NHS ambulance trusts in all call categories apart from category 4.
  • There was evidence that staff were under high levels of stress since the start of the pandemic, this was seen to have had a negative effect on staffs’ mental and physical wellbeing. Staff told us they felt exhausted and demoralised however staff told us that they felt supported by their team and management and that they were proud to do their job. This pressure had been recognised by senior leaders for the trust who had made improvements on staff safety and placed increased emphasis on staff wellbeing.

However:

  • The service was committed to improving the service which we saw at its digital and innovation station in Cumbria, this station had improvements made to it which would increase efficiency of crews and in turn increased the time ambulance crews were on the road. The service had also developed stations within the region known as ‘make ready stations’ these stations had external contractors who restocked ambulance vehicles after shifts ended which meant paramedic crews no longer had to work extra hours at the end of their shift getting an ambulance ready for the next crew.
  • Despite the immense pressure the service was experiencing we observed staff who were kind caring and compassionate to both patients and their colleagues. Patients we spoke with commented that the staff looked after them well and that they were doing a very difficult job.
  • The service was committed to working with trusts within the Integrated Care system (ICS) to reduce the number of patients coming to emergency departments and improving delayed handovers. Treatment pathways had been developed so that patients could be referred to same day emergency care (SDEC) and acute frailty units, this reduced the number of patients who needed to attend emergency departments.

How we carried out the inspection

For our emergency and urgent care inspection, we met with staff from across the whole organisation. We visited six ambulance stations across the North West region. We also visited the services new digital and innovation station, a medicines hub and saw plans for the services new make ready station in the region. We inspected ambulance vehicles (including emergency ambulances, rapid response vehicles and urgent care ambulances) across the service. We visited six acute hospital emergency departments.

We spoke with patients and their relatives during the inspection. We spoke with staff including senior paramedics, emergency medical teams, advanced paramedics, operational managers, sector managers, the strategic head, the head of service, the consultant paramedic, the medical director, director of quality and the director of operations.

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.

12 April 2022 to 20 April 2022

During an inspection of Emergency operations centre (EOC)

North West Ambulance Service NHS Trust serves more than 7.5 million people across the communities of Cumbria, Lancashire, Greater Manchester, Merseyside and Cheshire. The services respond to over one million emergency incidents each year; with the workforce providing pre-hospital care to patients in remote-rural and urban environments.

The trust’s vision is to be the best ambulance service in the UK, providing the right care, at the right time, in the right place; every time for patients accessing its urgent and emergency (999) care service, non-emergency patient transport service and NHS 111 service. North West Ambulance Service NHS Trust (NWAS) provides 24 hours, seven days a week, emergency and urgent care services to those in need of emergency medical treatment and transport.

We carried out this unannounced focused inspection of North West Ambulance service (NWAS) emergency operations centre between 11 and 14 April 2022. We had an additional focus on the urgent and emergency care pathway and carried out several inspections of other services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.

As this was a focused inspection, and we did not look at every key line of enquiry, we did not re-rate the service this time. At our previous inspection in February 2020 we rated emergency operations centres at the trust as good overall.

During this inspection we reviewed emergency and urgent care services (the ambulance crews responding to emergency 999 calls) and the emergency operations centres. For both services we looked at elements of the safety, effectiveness, caring, responsiveness and leadership of the staff and teams in the emergency operations centres, responding to 999 calls, and those supporting the emergency departments on site.

The trust employs around 6,300 staff in over 300 different roles and is supported by over 1,000 volunteers as members of its patient and public panel, volunteer car driver network and community first responder network. There are 3,686 staff employed in emergency and urgent care services, working across 103 ambulance stations. The service has 616 ambulance vehicles, including 481 emergency vehicles, 10 dedicated see and treat cars, 93 rapid response vehicles, 21 advanced paramedic vehicles and 11 community specialist response cars.

A summary of CQC findings on urgent and emergency care services in Cheshire and Merseyside (Liverpool, Knowsley and South Sefton).

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 Liverpool, Knowsley and South Sefton within the Cheshire and Merseyside ICS below: Cheshire and Merseyside (Liverpool, Knowsley and South Sefton)Provision of urgent and emergency care in Cheshire and Merseyside was supported by services, stakeholders, commissioners and the local authority. We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff had continued to work hard under sustained pressure across health and social care services.

Services had put systems in place to support staff with their wellbeing, recognising the pressure they continued to work under, in particular for front line ambulance crews and 111 call handlers. Staff and patients across primary care reported a preference for face to face appointments. Some people reported difficulties when trying to see their GP and preferred not to have telephone appointments. They told us that due to difficulties in making appointments, particularly face to face, they preferred to access urgent care services or go to their nearest Emergency Department. However, appointment availability in Cheshire and Merseyside was in line with national averages.

We identified capacity in extended hours GP services which wasn’t being utilised and could be used to reduce the pressure on other services. People and staff also told us of a significant shortage of dental provision, especially for urgent treatment, which resulted in people attending Emergency Departments. Urgent care services, including walk-in centres were very busy and services struggled to assess people in a timely way. Some people using these services told us they accessed these services as they couldn’t get a same day, face to face GP appointment. We found some services went into escalation. Whilst system partners met with providers to understand service pressures, we did not always see appropriate action taken to alleviate pressure on services already over capacity.

The NHS 111 service, which covered all of the North West area including Cheshire and Merseyside, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service.

Following initial assessment and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours (OOH) provider. We found some telephone consultation processes were duplicated and could be streamlined. At peak times, people were waiting 24-48 hours for a call back from the clinical assessment and out of hours services. We identified an opportunity to increase the skill mix in clinicians for both the NHS 111 and the clinical assessment service. For example, pharmacists could support people who need advice on medicines. Following our inspections, out of hours and NHS 111 providers have actively engaged and worked collaboratively to find ways of improving people’s experience by providing enhanced triage and signposting. People who called 999 for an ambulance experienced significant delays.

Whilst ambulance crews experienced some long handover delays at the Emergency Departments we inspected, data indicated these departments were performing better than the England average for handovers, although significantly below the national targets. However, crews found it challenging managing different handover arrangements at different hospitals and reported long delays. Service leaders were working with system partners to identify ways of improving performance and to ensure people could access appropriate care in a timely way. For example, the service worked with mental health services to signpost people directly to receive the right care, as quickly as possible.

The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure. We saw significant levels of demand on emergency departments which, exacerbated by staffing issues, resulted in long delays for patients. People attending these departments reported being signposted by other services, a lack of confidence in GP telephone appointments and a shortage of dental appointments. We inspected some mental health services in Emergency Departments which worked well with system partners to meet people’s needs. We found there was poor patient flow across acute services into community and social care services. Discharge planning should be improved to ensure people are discharged in a timely way. Staff working in care homes (services inspected were located in Liverpool and South Sefton)reported poor communication about discharge arrangements which impacted on their ability to meet people’s needs.

The provision of primary care to social care, including GP and dental services, should be improved to support people to stay in their own homes. Training was being rolled out to support care home staff in managing deteriorating patients to avoid the need to access emergency services. We found some examples of effective community nursing services, but these were not consistently embedded across social care. Staffing across social care services remains a significant challenge and we found a high use of agency staff. For example, in one nursing home, concerns about staff competencies and training impacted on the service’s ability to accept and provide care for people who had increased needs. We found some care homes felt pressure to admit people from hospital. On going engagement between healthcare leaders and Local Authorities would be beneficial to improve transfers of care between hospitals and social care services.

In addition, increased collaborative working is needed between service leaders. We found senior leaders from different services some times only communicated during times of escalation.

A summary of CQC findings on urgent and emergency care services in Lancashire and South Cumbria

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 Lancashire and South Cumbria below:

Provision of urgent and emergency care in Lancashire and South Cumbria was supported by services, stakeholders, commissioners and the local authority.

We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff felt tired and continued to work under sustained pressure across health and social care.

We found demand on urgent care services had increased. Whilst feedback on these services was mostly positive, we found patients were accessing these services instead of seeing their GP. Local stakeholders were aware that people were opting to attend urgent care services and were engaging with local communities to explore the reasons for this.

The NHS 111 service which covered all the North West area, including Lancashire and South Cumbria, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment, and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours providers. The NHS 111 service would benefit from a wide range of clinicians to be available such as dental, GP and pharmacists to negate the need for onward referral to other service providers.

People who called 999 for an ambulance experienced significant delays. Ambulance crews also experienced long handover delays at most Emergency Departments. Crews also found it challenging managing different handover arrangements. Some emergency departments in Lancashire and South Cumbria struggled to manage ambulance handover delays effectively which significantly impacted on the ambulance service’s ability to manage the risk in the community. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.

We saw significant delays for people accessing care and treatment in emergency departments. Delays in triage and initial treatment put people at risk of harm. We visited mental health services delivered from the Emergency Department and found these to be well run and meeting people’s needs. However, patients experienced delays in the Emergency Department as accessing mental health inpatient services remained a significant challenge. This often resulted in people being cared for in out of area placements.

We found discharge wasn’t always planned from the point of admission which exacerbated in the poor patient flow seen across services. Discharge was also impacted on by capacity in social care services and the ability to meet people’s needs in the community. We also found some patients were admitted from the Emergency Department because they couldn’t get discharged back into their own home at night.

Increased communication is needed between leaders in both health and social care, particularly during times of escalation when Local Authorities were not always engaged in action plans.

Summary of North West Ambulance Service NHS Trust

For the emergency operations centres we found:

We did not rate this service at this inspection. The previous rating of good remains. We found:

  • The service controlled infection risk well. Staff used equipment and control measures to prevent the spread of infection. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff undertook risk assessments as part of the 999 calls. Staff identified and acted quickly for patients at risk of deterioration or who were known to be deteriorating. 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. Managers regularly reviewed and adjusted staffing levels and skill mix and gave temporary staff a full induction.
  • The trust performed well in call answering times. The service monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide safe care and communicated effectively with other agencies.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service planned and worked to provide care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. Most people could access the service when they needed it, in line with national standards, and received the right care in a timely way.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for staff. Staff mostly felt respected, supported, and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear. Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events although the service was under significant pressure to manage the considerable increase in demand.

However:

  • There were known risks to patients when ambulance resources were not available to respond in a timely way. The trust was not able to resolve all these risks due to exceptional demand and ongoing resource issues.
  • Due to the increase in demand and the pressure on resources, the service was not always able to meet the needs of patients. Pressure from increased demand meant some patients waited too long for ambulances to be dispatched to them.

How we carried out the inspection

For our emergency operations centres inspection, we met with staff from across the whole organisation. We spoke with 22 staff including emergency medical advisors, emergency medical dispatchers, paramedics, advanced practitioners, service delivery managers, the strategic head of the emergency operations centre, the medical director, director of quality and the director of operations. We listened to ten calls coming into the service from the public and other healthcare professionals and heard how these were handled by the emergency medical dispatchers and clinical teams.

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.

25 February to 27 February 2020

During a routine inspection

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

25 February to 27 February 2020

During an inspection of Emergency and urgent care

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

  • There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs. The service was inclusive and took account of patients’ individual needs and preferences. This included patients living with dementia, a learning disability or patients with mental ill health. There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. 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. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, and gave patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. 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.

However;

  • The number of staff who completed safeguarding training did not meet trust targets.
  • The service did not consistently meet nationally agreed targets for response times. Performance against response times was monitored daily and remedial actions were in place to make improvements to the services.
  • The number of staff who completed appraisals did not meet trust targets.
  • Whilst staff had access to clinical contact shift supervision, there was inconsistency in how these were applied across the regional teams.

25 February to 27 February 2020

During an inspection of Emergency operations centre (EOC)

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Most mandatory training targets were on track to have been met by the financial year. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
  • Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients. They 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.
  • 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. People could access the service when they needed it and received care in a timely way.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. 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. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However

  • EOC staff did not always follow policies and procedures relating to the management of long-waiting and deteriorating patients in terms of re-assessing the need for triage.
  • Emergency call handlers did not always re-triage subsequent callers in line with the trust process.
  • Safeguarding training and staff appraisal compliance did not always meet trust targets.
  • Response times were slower than the England average in all months in the reporting period.
  • Not all staff received feedback from incidents they raised. There was not always up to date action plans relating to actions from incidents.

12 Jun to 5 Jul 2018

During a routine inspection

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

  • The trust had an up to date duty of candour policy and procedure. Records we reviewed confirmed that duty of candour was reflected in the trust’s duty of candour guidance, policies were cross referenced and the description of incidents that required duty of candour consideration had been updated following our inspection in 2016.
  • The service provided safe care and treatment. There were processes and staff followed them to lessen risks to patients, staff and the public.
  • Since the inspection in 2016, the trust had undertaken a review of how it responded to risk and how it prepared crews. The trust had strengthened and developed the Paramedic team lead structure to support and advise ambulance crews to recognise a deteriorating patient.
  • The trust met the fit and proper person’s requirement Regulation 5 of the Health and Social Care Act. This regulation ensures that directors of NHS providers are fit and proper to carry out this important role.
  • The trust ensured that there was sufficient staff on duty at all times; including sufficient numbers of clinical supervisors at the individual sites to ensure patient safety.
  • Innovation was encouraged and staff were supported to join national improvement groups to influence changes in protocols, processes, equipment and training. There were examples of innovative practice that were being incorporated into national practices.
  • Service provision, locations and vehicles, were planned to meet the needs of the local population. This was based on the need to respond to major incidents at government defined sites of strategic importance, major incidents in other areas of the NWAS geographical region and provide mutual aid to neighbouring ambulance trusts in a timely manner.
  • We were informed by senior management that staff were debriefed following a serious incident. For example, a serious road traffic collision with multiple victims. This usually took place at a hospital and was known as a ‘Hot debrief’. The discussion centre around what went well and what improvements could be made. This was confirmed by operational staff we spoke with across the trust.

However:

  • We found that there was a lack of adequate assurance that ensured an effective process for overseeing and monitoring compliance with infection prevention and control procedures was embedded across the trust.
  • Staff in areas of the trust were not always supported to access mandatory training, as defined by the provider as part of their role.
  • The trust had medicines policies in place and we viewed the medicines management procedures 2017 to 2019 which also contained the standard operating procedures for the management of all general medicines used by the trust however, we saw issues with patient group directives and conflicting information given to staff on administering certain drugs.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RX7/reports.

12 Jun to 5 Jul 2018

During an inspection of Emergency and urgent care

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

  • The service had a good network of staff who were adequately trained in safeguarding processes.
  • Staff told us they were always given time to make safeguarding referrals and were stood down to allow them to complete referrals.
  • We found good levels of cleanliness, hygiene and infection prevention and control (IPC) in NWAS ambulance stations and ambulances.
  • Ambulance crews had up to date satellite navigations and communication systems in their vehicles to guide crews to patient pickups and incidents.
  • The service had undertaken a full review of how it responded to risk and how it prepared crews. As well as using up to date clinical guidelines it has also developed new staffing structures in ambulance teams which provide support in responding to risk.
  • The trust had reviewed its staffing structure after our last inspection in 2016. In that inspection we found concerns about staffing mix as well as staffing capacity. We found significant steps had been taken to address shortfalls.
  • The trust had introduced new line management structures which had added Senior Paramedic Team Leaders (SPTLs) to support and advise ambulance crews.
  • Governance staff including a Clinical Quality Officer and a Corporate Consultant Paramedic ensure best practice is incorporated into staff and service guidelines.
  • Paramedics and emergency medical technicians had their driving licences checked annually by the trust. The Trust had a process in place to deliver required blue light driver check testing.

12 Jun to 5 Jul 2018

During an inspection of Emergency operations centre (EOC)

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

  • The service had a culture of reporting incidents, with staff knowing how to report an incident and having knowledge of the trust’s incident reporting processes. There was sharing of learning from incidents. This meant the service had improved opportunities to learn from incidents and improve patient safety.
  • The service ensured that there was sufficient staff on duty at all times. Including sufficient numbers of clinical supervisors at the individual sites to ensure patient safety.
  • The service ensured that the clinicians in the emergency operation centres held an appropriate level of safeguarding children training in line with national guidance.
  • The emergency operations centres had appropriate measures and systems in place to ensure service continuity in the event of a business continuity incident.
  • All emergency operations centre staff we met and observed consistently demonstrated compassion, kindness and respect towards callers and patients, including those in mental health crisis.
  • We observed positive examples of local leadership from the operating unit managers at all three operations centres. We saw that the leads of the service listened to staff and working to address concerns staff raised.
  • The trust has a working group designing a reporting mechanism, which will identify callers who have accessed the 999 systems at a set frequency. The trust leadership and operations centre managers are also currently working to produce a policy and procedure that will guide local managers through a consistent, safe and robust system of managing frequent callers.
  • We saw improvements since our last inspection. The trust has raised awareness among staff relating to the trust’s vision and strategy and how they can contribute to it.

However:

  • Turnaround rates were still proving problematic for the service, to try and improve turn round rates the trust has developed an Emergency Care Improvement Programme and is working with receiving trusts to try and improve this area.
  • In the Liverpool site the call-handling and dispatch rooms were located on two floors connected by a staircase. The urgent care desk and advanced paramedics, who provided support to the dispatchers, were in another part of the building. The building was visibly dated throughout; for example, there was staining on ceiling tiles in the corridors. We did however note that the development a new EOC building in Liverpool was well underway, although there was no definitive move in date at the time of inspection.

12 Jun to 5 Jul 2018

During an inspection of Resilience

We have not rated Resilience before. We rated it as good because:

The service provided safe care and treatment. There were processes and staff followed them to lessen risks to patients, staff and the public posed by the challenging environments and staff had to operate in. Staff followed national guidelines for the delivery of services and care and treatment.

The leadership of the service promoted a positive culture within the resilience service.

Innovation was encouraged and staff were encouraged were to join national improvement groups to influence changes in protocols, processes, equipment and training. There were examples of innovative practice, that were being incorporated into national practices.

There was effective collaborative working between trust staff and partner agencies to manage local, regional and national risks. This ensured paramedic care and treatment was available in a timely manner, to patients in challenging circumstances, such as major incidents and mass casualty incidents.

Training provision met the national guidelines. Staff were highly skilled in delivery paramedic care in a safe manner to patients in challenging and dangerous environments.

The service, location and vehicles, was planned to meet the needs of the local population. This was based on the need to respond to major incidents at government defined sites of strategic importance, major incidents in other areas of the NWAS geographical region and provide mutual aid to neighbouring ambulance trusts in a timely manner.

To Be Confirmed

During a routine inspection

The North West Ambulance Service (NWAS) NHS Trust is one of 10 ambulance trusts in England and provides emergency medical services across the North West region, which has a population of around 7, 052,000 million people. The trust employs 5,409 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across the North West.

The trust has 109 ambulance stations distributed across the region, three emergency operations centres,one support centre, three patient transport service control rooms, and two Hazardous Area Response Team (HART) buildings (one being shared with Merseyside Fire & Rescue).

The trust also provides, along with Urgent Care and out of hours partners, the NHS 111 Service for the North West Region. Operating from five sites across the North West, in Greater Manchester, Merseyside and Lancashire and Cumbria.

We last inspected this trust between 19 and 22 August 2014 for the announced element of the inspection, and the unannounced inspection visits took place on 26 and 27 September 2014. As the first ambulance trust inspected under the new model, the trust was not rated as part of this inspection. Additionally the 111 service was not inspected at the time of this previous inspection. We told the trust that they must make improvements to:

  • Review the process for pre-alerting hospital accident and emergency departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.
  • Make sure that emergency operations centre staff across all three emergency operation centres (EOCs) are consistently identifying and recording incidents as appropriate.
  • Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.
  • Improve access to clinical supervision for all clinical staff.
  • Review medicines formulary guidance issued to front-line staff to make sure it is current.
  • Ensure that all staff are receiving the mandatory training necessary for their role.
  • Ensure that all staff across all divisions are consistently receiving appraisals.

Before carrying out this inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the Ambulance Service. These included clinical commissioning groups (CCGs); NHS Improvement and the local Healthwatch.

We carried out our announced focused inspection of NWAS between 23 and 26 May 2016, with an unannounced inspection taking place on 6 June 2016. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected three core services:

  • Emergency Operations Centres
  • Urgent and Emergency Care
  • Patient Transport Services

We also inspected the NHS 111 service provision during this inspection.

Our key findings were as follows:

Leadership and Culture

  • There were regional variations in the culture both across the trust as a whole and within regions. Staff in some areas felt very positive about the culture, but in other areas they felt there was a high degree of pressure and that focus was on performance targets rather than care for patients.
  • The Chief Executive Officer had recently commenced in a substantive post on 10 May 2016, following a period of covering the post as an interim, from March 2016.
  • The urgent and emergency care service has had a clinical leadership model in place since 2012, with more focus on clinical quality than was previously the case. The leadership model includes a Consultant Paramedic in each area and advanced paramedics in each sector. The structure has been reviewed recently and the operational and clinical team leader roles are in the process of being merged.
  • Staff reported that the new clinical leadership structure with senior paramedics assuming a combined management and clinical leadership role was a positive development. This change had been well received as it provided clearer lines of reporting and less confusion, at the stations where it had already been implemented.
  • Staff felt that leadership from heads of service was strong and visible. Heads of service and sector managers had been supported to develop their leadership skills with attendance at higher education courses.
  • In Liverpool many of the staff said that staff morale was affected by the building which was cramped with teams located in different rooms.

Staffing

  • There were staff vacancies across all areas of the urgent and emergency care service and the overall vacancy rate was 5.7%.
  • Staff vacancy rates in North Cumbria were the highest in the trust with 35 vacancies, which represented 20%. The paramedic vacancy rate in this area was 16.7%. One of the initiatives to manage this deficit was the employment of paramedics from other countries. Two paramedics from Europe had worked in Cumbria for some time. The trust had employed 35 new European paramedics in Greater Manchester at the time of the inspection. There were plans to recruit a further 36 with 24 of these being appointed to North Cumbria.
  • A high proportion of vacancies related to band five paramedics. A total of 15.7% whole time equivalent (WTE) posts for this role were vacant at the time of our inspection across all areas. This reflected a national shortage of paramedics. Eight seven paramedics had been recruited between 1 April 2016 and June 2016.
  • The staff turnover rate for the 2015/16 period for the service was 7.2%. The trust was looking at new ways to recruit paramedics to fill these vacancies. This included progression programmes for their EMT staff and also international recruitment. The trust’s human resources department was working with managers on developments to improve the retention in Cumbria where rates were higher at 11%. This included the consideration of relocation packages.

Records

  • Information relating to patients’ care and treatment was recorded on patient record forms (PRFs) which were paper based forms in a duplicate book. This meant the ambulance service could maintain their own record and also supply one copy to the hospital or patient, depending on whether the patient was conveyed to hospital. They also had one copy without patient identifiable information to use for audit purposes.
  • We reviewed 236 PRFs within urgent and emergency care. We saw that, in 218 of these cases, the records were completed in legible handwriting, were signed and dated and the history of the patient incident, treatment provided, medicines administered, assessments of pain and observations were completed.
  • There was a limited amount of free text space available to record a full history and clinical assessment. If there was not enough space to complete all details, a second PRF would be completed. Some staff felt a continuation sheet would be beneficial but others told us there was enough space to document all necessary details.

Governance and Risk Management

  • The quality committee met every two months and discussed areas, such as risk and mitigation, safeguarding, response times, complaints, incidents, medicine management, infection prevention, quality improvement and National Ambulance Clinical Quality Indicators. This meant that the executive team only got oversight on these quality areas every two months.
  • Due to the length of time it took the trust to investigate and conclude serious incidents, the board did not have a full overview of the reporting and monitoring of serious incidents. This meant there was no monitoring of how quickly serious incidents were reported, timescales for investigations and how quickly actions were implemented following the outcome of the investigation. Serious incidents regularly took longer than the 60 day timeframe (set by NHS England in the serious incident framework) to investigate and conclude.
  • There was a trust-wide risk register in place which recorded all operational risks with a score of 12 and above. There was evidence that the register was reviewed and updated regularly. However, there were some improvements required. In particular, some risk descriptions did not clearly describe the risk; some of the information recorded under controls and assurance were not actually controls or sources of assurance; there was no target rating for risks on the risk register, meaning it was unclear what level of risk the trust was aiming for, and there were a number of risks without actions identified to mitigate the identified risk. Additionally a significant number of risks had been on the risk register for a number of years with little evidence of progress or impact being reported. In addition local risk registers were not totally aligned to the trust wide risk register.

We saw several areas of outstanding practice including:

  • The Hazardous Area Response Teams (HART) in both Manchester and Merseyside were delivering an excellent service to patients. They were proactive in their approach to gaining new skills and forging relationships with other emergency services, to ensure the smooth running of rescues in difficult areas. Their co location with the fire service training headquarters in Merseyside afforded them and all NWAS staff excellent and unique training opportunities. This ensured that they were equipped to deal with and manage a wide range of hazardous emergencies and undertaken formalised de briefs in a multidisciplinary manner.
  • The service had community care pathway designed to share information across services and ensure ambulance clinicians were aware of pre-existing care plans for patients being managed by community services. This included when it was most appropriate for patients to be treated at home, involving other professionals or conveyed to an alternative care setting than an emergency department. This was also supported in some areas by the long term conditions teams based at local hospital trusts.
  • The community engagement manager was in the process of implementing an electronic application initiative called ‘Good SAM’. This application could be downloaded onto mobile devices and alerts users who have been vetted and checked to a nearby cardiac arrest. Through this initiative the manager had also mapped all defibrillators in the North West area and from August 2016, this information would be available to call centre staff so that they could direct members of the public attending cardiac arrests to these devices.
  • All staff we observed were exceptionally caring in their approach and went above and beyond their duty to provide compassionate, supportive care.

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

Importantly, the trust must:

Trust wide

  • Ensure the consent policy and guidance on mental capacity assessments issued to staff is in line with the Mental Capacity Act (2005) code of practice.
  • Ensure they are compliant with the fit and proper person regulation when appointing both executive and non-executive directors.
  • Ensure the complaints policy reflects timescales for investigations and ensure complainants are given information in relation to how to take action if they are not satisfied with how the trust has managed the complaint.

In Urgent and Emergency Care:

  • The service must ensure staff are given adequate opportunities to report incidents and safeguarding issues.
  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy.
  • The service must ensure all staff receive the required level of mandatory training.
  • The service must ensure that all staff receive the required level of mandatory safeguarding training and ensure that there is a mechanism to check that staff have completed this training.
  • The service must ensure all community first responders have the required level of training to undertake their role including how to recognise and act on safeguarding issues.
  • The service must ensure that vehicle log books are completed fully and that checks undertaken by managers reflect the true content of the log books.
  • The service must ensure that all equipment used in the delivery of patient care is subject to the appropriate and required checks, including that held by the community first responders.
  • The service must ensure that vehicles receive deep cleaning when required.
  • The service must ensure that controlled drugs are stored, managed and checked in line with trust policy and national legislation.
  • The service must ensure that all staff involved in the administration of medical gases, for example Entonox, have received the required level of training to ensure they are competent to undertake this duty.
  • The service must ensure there are adequate numbers of suitably qualified staff deployed in all areas.
  • The service must ensure that all policies used in the delivery of patient care are reviewed and updated at the frequency required.
  • The service must ensure that patients have timely access to care and treatment in line with national targets.
  • The service must ensure all staff received their annual appraisal.
  • The service must ensure all staff have received the required level of training to ensure they are able to exercise their duties in line with the Mental Capacity Act (2005).
  • The service must ensure that the consent policy and guidance on mental capacity assessments issued to staff is in line with the Mental Capacity Act (2005) code of practice.
  • The service must ensure that there is specialist equipment and training for staff to safely manage the care of bariatric patients.
  • The service must ensure that staff received back up when requested in a timely way.
  • The service must ensure that risks are appropriately documented, reviewed and updated.
  • The service must ensure that any allegations of bullying are taken seriously and managed appropriately with support provided to the staff involved.
  • Ensure that departmental risk registers are kept up to date and reviewed appropriately.
  • Ensure that processes are robust and effective in relation to Safeguarding processes and procedures.
  • Ensure compliance with the fit and proper person regulation.

In Emergency Operations Centres:

  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy and ensure all staff have received appropriate training on the incident reporting system.
  • The service must ensure there are robust processes for sharing lessons learned from incidents and complaints with staff across the three sites.
  • The service must ensure that all safeguarding concerns are reported in line with the NWAS policy and must improve staff awareness of the safeguarding policy.
  • The service must ensure all staff receive their annual appraisal.
  • Ensure that risk registers clearly document short and long term risks local to each emergency operations centres (EOC) site as well as to the EOC service as a whole, including control measures that have been identified and implemented, and planned review dates.
  • Ensure the clinical escalation plan is reviewed and updated.

In Patient Transport Services:

  • The trust must ensure that investigation reports fully reflect the actions taken during an investigation and provide a summary of the root cause of the incident and the lessons learned, in line with trust policy.
  • The trust must ensure patient information is kept confidential. The management of patient information provided to volunteer drivers did not promote confidentiality.
  • The service must finalise its existing PTS structure and quality reporting framework to ensure that there is a clear oversight of escalation and monitoring of governance, risks and performance of the service.

In addition, the trust should:

Trust wide:

  • Continue to monitor staffing levels and recruit sufficient frontline paramedic and other staff to meet patient safety and operational standards requirements.
  • Review the duty of candour policy and ensure it fully reflects the regulation.

In Urgent and Emergency Care:

  • The service should consider implementing systems to ensure that feedback from incidents and investigations is consistent and accessible to all staff including community first responders.
  • The service should ensure that communication aids for patients with visual or mental capacity impairments are available.
  • The service should consider providing training to all frontline staff on the duty of candour and their responsibilities in relation to this.
  • The service should consider ensuring that staff with level three safeguarding training are available for staff to access for advice and guidance.
  • The service should consider providing training on key safeguarding subjects which crews may come across such as female genital mutilation, radicalisation recognition and human trafficking.
  • The service should consider implementing a system to ensure the key codes to access keys in the ambulance stations are changed regularly.
  • The service should ensure that all records are completed fully and legibly.
  • The service should consider implementing a system by which all staff members creating a written record of patient care can sign the relevant sections patient record.
  • The service should consider ways to improve staff compliance with the use of patient pathways and care bundles.
  • The service should ensure that patients can be provided if necessary with information on how to feedback about the service.
  • The service should ensure that complaints are dealt with consistently and in line with trust policy.
  • The service should ensure that staff are aware of the trust vision and values.
  • The service should consider implementing a more consistent way of monitoring of performance and quality across the regions.
  • The service should improve staff engagement and address areas of low morale.

In Emergency Operations Centres:

  • Improve EOC staff’s skills in managing calls from children or from people who may have mental health problems, those who may be in crisis, and those living with dementia or learning disabilities.
  • Improve communication across all EOC teams, including those working night shift patterns, of changes to procedures or announcements.
  • Improve accessibility, and readability, of information transferred by the system to the EOC from NHS111, including the reduction of duplication of information.
  • Raise awareness among all EOC staff on the trust’s vision and strategy and how they can contribute to it.
  • Consider how the environment at the Liverpool site can be improved, including what reasonable adaptations may be needed for staff who have reduced mobility.
  • Review the policy for deploying the HART team and how it reflects the way in which the triage and dispatch system operates in practice.
  • Review the use of the MPDS system in terms of the tools not being available when a second follow-up call is made.
  • Review the Mental Capacity Act (2005) training for all staff.

In Patient Transport Services:

  • The trust should consider facilitating ambulance crews to meet regularly to ensure new developments and lessons learned from local, trust wide and national incidents can be shared and discussed.
  • The trust should explore that all recorded safeguarding incidents have been appropriately referred and that PTS staff are aware of what constitutes abuse or neglect and that they are all clear about the referral process.
  • The trust should review the staff training requirements for the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) guidelines to provide a common understanding of how patients are cared for in accordance with their best interests.
  • The trust should review its process for maintaining all vehicles in good visual repair and that rusty items are replaced as quickly as possible.
  • The trust should review its process for reviewing and updating policies and procedures as appropriate.
  • The trust should review the process for ensuring that DNACPR documentation travelling with the patient is in the appropriate format.
  • The trust should review the process for responding to and investigating complaints to improve the timeliness of this procedure.
  • The trust should review its process for including operational issues within a strategic overview or central risk register related to internal risks.
  • The trust should review its PTS operating model to produce a formal vision and strategy for PTS linked to the overarching organisation vision and strategy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

23-27 May 2016

During a routine inspection

The North West Ambulance Service (NWAS) NHS Trust is one of 10 ambulance trusts in England and provides emergency medical services across the North West region, which has a population of around 7 million people. The trust employs 5162 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across the North West.

The trust has 109 ambulance stations distributed across the region, three emergency operations centres, one support centre, three patient transport service control centres, and two Hazardous Area Response Team (HART) buildings (one being shared with Merseyside Fire & Rescue).

The trust also provides, along with Urgent Care and out of hours partners, the NHS 111 Service for the North West Region. Operating from five sites across the North West, in Greater Manchester, Merseyside and Lancashire and Cumbria.

We last inspected this trust between 19 and 22 August 2014 for the announced element of the inspection, and the unannounced inspection visits took place on 26 and 27 September 2014. As the first ambulance trust inspected under the new model, the trust was not rated as part of this inspection. Additionally the 111 service was not inspected at the time of this previous inspection. We told the trust that they must make improvements to:

  • Review the process for pre-alerting hospital accident and emergency departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.
  • Make sure that emergency operations centre staff across all three emergency operation centres (EOCs) are consistently identifying and recording incidents as appropriate.
  • Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.
  • Improve access to clinical supervision for all clinical staff.
  • Review medicines formulary guidance issued to front-line staff to make sure it is current.
  • Ensure that all staff are receiving the mandatory training necessary for their role.
  • Ensure that all staff across all divisions are consistently receiving appraisals.

Before carrying out this inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the Ambulance Service. These included clinical commissioning groups (CCGs); Monitor and the local Healthwatch.

We carried out our announced focused inspection of NWAS between 23 and 26 May 2016, with an unannounced inspection taking place on 6 June 2016. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected three core services:

  • Emergency Operations Centres
  • Urgent and Emergency Care
  • Patient Transport Services

We also inspected the NHS 111 service provision during this inspection.

Our key findings were as follows:

Leadership and Culture

  • There were regional variations in the culture both across the trust as a whole and within regions. Staff in some areas felt very positive about the culture, but in other areas they felt there was a high degree of pressure and that focus was on performance targets rather than care for patients.
  • The Chief Executive Officer had recently commenced in a substantive post on 10 May 2016, following a period of covering the post as an interim, from March 2016.
  • The urgent and emergency care service was moving towards a clinical leadership model, with more focus on clinical quality and a reduction in operational management. This leadership model included a consultant paramedic for the region and advanced paramedics in each sector. An increase in the number of senior paramedics and decrease in assistant operations managers was planned.
  • Staff reported that the new clinical leadership structure with senior paramedics assuming a combined management and clinical leadership role was a positive development. This change had been well received as it provided clearer lines of reporting and less confusion, at the stations where it had already been implemented.
  • Staff felt that leadership from heads of service was strong and visible. Heads of service and sector managers had been supported to develop their leadership skills with attendance at higher education courses.
  • In Liverpool many of the staff said that staff morale was affected by the building which was cramped with teams located in different rooms.

Staffing

  • There were staff vacancies across all areas of the urgent and emergency care service and the overall vacancy rate was 5.7%.
  • Staff vacancy rates in North Cumbria were the highest in the trust with 35 vacancies, which represented 20%. The paramedic vacancy rate in this area was 16.7%. One of the initiatives to manage this deficit was the employment of paramedics from other countries. Two paramedics from Europe had worked in Cumbria for some time. The trust had employed 35 new European paramedics in Greater Manchester at the time of the inspection. There were plans to recruit a further 36 with 24 of these being appointed to North Cumbria.
  • A high proportion of vacancies related to band five paramedics. A total of 16.2% whole time equivalent (WTE) posts for this role were vacant at the time of our inspection across all areas. This reflected a national shortage of paramedics.
  • The staff turnover rate for the 2015/16 period for the service was 7.2%. The trust was looking at new ways to recruit paramedics to fill these vacancies. This included progression programmes for their EMT staff and also international recruitment. The trust’s human resources department was working with managers on developments to improve the retention in Cumbria where rates were higher at 11%. This included the consideration of relocation packages.

Records

  • Information relating to patients’ care and treatment was recorded on patient record forms (PRFs) which were paper based forms in a duplicate book. This meant the ambulance service could maintain their own record and also supply one copy to the hospital or patient, depending on whether the patient was conveyed to hospital. They also had one copy without patient identifiable information to use for audit purposes.
  • We reviewed 236 PRFs within urgent and emergency care. We saw that, in 218 of these cases, the records were completed in legible handwriting, were signed and dated and the history of the patient incident, treatment provided, medicines administered, assessments of pain and observations were completed.
  • There was a limited amount of free text space available to record a full history and clinical assessment. If there was not enough space to complete all details, a second PRF would be completed. Some staff felt a continuation sheet would be beneficial but others told us there was enough space to document all necessary detail. Paramedics on the Manchester urgent care desk completed patient review forms for each patient seen. These records were posted into a locked cabinet in the office and were collected once a month to be stored securely elsewhere in the trust. The urgent care desk team did not have access to the cabinet and, as such, we were unable to review any of these records. This meant there was a risk these records could not be accessed urgently if required.

Governance and Risk Management

  • The quality committee met every two months and discussed areas, such as risk and mitigation, safeguarding, response times, complaints, incidents, medicine management, infection prevention, quality improvement and National Ambulance Clinical Quality Indicators. This meant that the executive team only got oversight on these quality areas every two months.
  • The board did not have an overview of the reporting and monitoring of serious incidents. This meant there was no monitoring of how quickly serious incidents were reported, timescales for investigations and how quickly actions were implemented following the outcome of the investigation. Serious incidents regularly took longer than the 60 day timeframe (set by NHS England in the serious incident framework) to investigate and conclude.
  • There was a trust-wide risk register in place which recorded all operational risks with a score of 12 and above. There was evidence that the register was reviewed and updated regularly. However, there were some improvements required. In particular, some risk descriptions did not clearly describe the risk; some of the information recorded under controls and assurance were not actually controls or sources of assurance; there was no target rating for risks, meaning it was unclear what level of risk the trust was aiming for, and there were a number of risks without actions identified to mitigate the identified risk. Additionally a significant number of risks had been on the risk register for a number of years with little evidence of progress or impact being reported. In addition local risk registers were not totally aligned to the trust wide risk register.

We saw several areas of outstanding practice including:

  • The Hazardous Area Response Team (HART) teams in both Manchester and Merseyside were delivering an excellent service to patients. They were proactive in their approach to gaining new skills and forging relationships with other emergency services, to ensure the smooth running of rescues in difficult areas. Their co location with the fire service training headquarters in Merseyside afforded them and all NWAS staff excellent and unique training opportunities. This ensured that they were equipped to deal with and manage a wide range of hazardous emergencies and undertaken formalised de briefs in a multidisciplinary manner.
  • The service had community care pathway designed to share information across services and ensure ambulance clinicians were aware of pre-existing care plans for patients being managed by community services. This included when it was most appropriate for patients to be treated at home, involving other professionals or conveyed to an alternative care setting than an emergency department. This was also supported in some areas by the long term conditions teams based at local hospital trusts.
  • The community engagement manager was in the process of implementing an electronic application initiative called ‘Good SAM’. This application could be downloaded onto mobile devices and alerts users who have been vetted and checked to a nearby cardiac arrest. Through this initiate the manager had also mapped all defibrillators in the North West area and from August 2016, this information would be available to call centre staff so that they could direct members of the public attending cardiac arrests to these devices.
  • All staff we observed were exceptionally caring in their approach and went above and beyond their duty to provide compassionate, supportive care.

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

Importantly, the trust must:

In Urgent and Emergency Care:

  • The service must ensure staff are given adequate opportunities to report incidents and safeguarding issues.
  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy.
  • The service must ensure all staff receive the required level of mandatory training.
  • The service must ensure that all staff receive the required level of mandatory safeguarding training and ensure that there is a mechanism to check that staff have completed this training.
  • The service must ensure all community first responders have the required level of training to undertake their role including how to recognise and act on safeguarding issues.
  • The service must ensure that vehicle log books are completed fully and that checks undertaken by managers reflect the true content of the log books.
  • The service must ensure that all equipment used in the delivery of patient care is subject to the appropriate and required checks, including that held by the community first responders.
  • The service must ensure that vehicles receive deep cleaning when required.
  • The service must ensure that controlled drugs are stored, managed and checked in line with trust policy and national legislation.
  • The service must ensure that all staff involved in the administration of medical gases, for example Entonox, have received the required level of training to ensure they are competent to undertake this duty.
  • The service must ensure there are adequate numbers of suitably qualified staff deployed in all areas.
  • The service must ensure that all guidelines and policies used in the delivery of patient care are reviewed and updated at the frequency required.
  • The service must ensure that patients have timely access to care and treatment in line with national targets.
  • The service must ensure all staff received their annual appraisal.
  • The service must ensure all staff have received the required level of training to ensure they are able to exercise their duties in line with the Mental Capacity Act (2005).
  • The service must ensure that the consent policy and guidance on mental capacity assessments issued to staff is in line with the Mental Capacity Act (2005) code of practice. The service must ensure there is specialist equipment and training for staff to safely manage the care of bariatric patients.
  • The service must ensure that staff received back up when requested in a timely way.
  • The service must ensure that risks are appropriately documented, reviewed and updated.
  • The service must ensure that any allegations of bullying are taken seriously and managed appropriately with support provided to the staff involved.
  • Ensure that departmental risk registers are kept up to date and reviewed appropriately.
  • Ensure that processes are robust and effective in relation to safeguarding processes and procedures.
  • Ensure compliance with the fit and proper person regulation.

In Emergency Operations Centres:

  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy and ensure all staff have received appropriate training on the incident reporting system.
  • The service must ensure there are robust processes for sharing lessons learned from incidents and complaints with staff across the three sites.
  • The service must ensure that all safeguarding concerns are reported in line with the NWAS policy and must improve staff awareness of the safeguarding policy.
  • The service must ensure all staff receive their annual appraisal.
  • Ensure that risk registers clearly document short and long term risks local to each emergency operations centres (EOC) site as well as to the EOC service as a whole, including control measures that have been identified and implemented, and planned review dates.

In Patient Transport Services:

  • The trust must ensure that investigation reports fully reflect the actions taken during an investigation and provide a summary of the root cause of the incident and the lessons learned, in line with trust policy.
  • The trust must ensure patient information is kept confidential. The management of patient information provided to volunteer drivers did not promote confidentiality.
  • The service must finalise its existing PTS structure and quality reporting framework to ensure that there is a clear oversight of escalation and monitoring of governance, risks and performance of the service.

In addition, the trust should:

In Urgent and Emergency Care:

  • The service should consider implementing systems to ensure that feedback from incidents and investigations is consistent and accessible to all staff including community first responders.
  • The service should ensure that communication aids for patients with visual or mental capacity impairments are available.
  • The service should consider providing training to all frontline staff on the duty of candour and their responsibilities in relation to this.
  • The service should consider ensuring that staff with level three safeguarding training are available for staff to access for advice and guidance.
  • The service should consider providing training on key safeguarding subjects which crews may come across such as female genital mutilation, radicalisation recognition and human trafficking.
  • The service should consider implementing a system to ensure the key codes to access keys in the ambulance stations are changed regularly.
  • The service should ensure that all records are completed fully and legibly.
  • The service should consider implementing a system by which all staff members involved in the care of the patient can sign for the care they have delivered.
  • The service should consider ways to improve staff compliance with the use of patient pathways and care bundles.
  • The service should ensure that patients can be provided if necessary with information on how to feedback about the service.
  • The service should ensure that complaints are dealt with consistently and in line with trust policy.
  • The service should ensure that staff are aware of the trust vision and values.
  • The service should consider implementing a more consistent way of monitoring of performance and quality across the regions.
  • The service should improve staff engagement and address areas of low morale.

In Emergency Operations Centres:

  • Improve EOC staff’s skills in managing calls from children or from people who may have mental health problems, those who may be in crisis, and those living with dementia or learning disabilities.
  • Improve communication across all EOC teams, including those working night shift patterns, of changes to procedures or announcements.
  • Improve accessibility, and readability, of information transferred by the system to the EOC from NHS111, including the reduction of duplication of information.
  • Raise awareness among all EOC staff on the trust’s vision and strategy and how they can contribute to it.
  • Consider how the environment at the Liverpool site can be improved, including what reasonable adaptations may be needed for staff who have reduced mobility.
  • Review the policy for deploying the HART team and how it reflects the way in which the triage and dispatch system operates in practice.
  • All patient records made by the paramedics on the Manchester urgent care desk should be made accessible to relevant staff, as required.
  • Review the use of the MPDS system in terms of the tools not being available when a second follow-up call is made.
  • Review the Mental Capacity Act (2005) training for all staff.

In Patient Transport Services:

  • The trust should ensure all staff have timely access to a computer in order to submit electronic incidents or safeguarding referrals.
  • The trust should consider facilitating ambulance crews to meet regularly to ensure new developments and lessons learned from local, trust wide and national incidents can be shared and discussed.
  • The trust should explore that all recorded safeguarding incidents have been appropriately referred and that PTS staff are aware of what constitutes abuse or neglect and that they are all clear about the referral process.
  • The trust should review the staff training requirements for the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) guidelines to provide a common understanding of how patients are cared for in accordance with their best interests.
  • The trust should review its process for maintaining all vehicles in good visual repair and that rusty items are replaced as quickly as possible.
  • The trust should review its process for reviewing and updating policies and procedures as appropriate.
  • The trust should consider implementing regular refresher driving courses or skills checks for PTS drivers.
  • The trust should review the process for ensuring that DNACPR documentation travelling with the patient is in the appropriate format.
  • The trust should review the process for responding to and investigating complaints to improve the timeliness of this procedure.
  • The trust should review its process for including operational issues within a strategic overview or central risk register related to internal risks.
  • The trust should review its PTS operating model to produce a formal vision and strategy for PTS linked to the overarching organisation vision and strategy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

19-22 August and 26-27 September 2014

During a routine inspection

North West Ambulance Service NHS Trust has been selected as the first ambulance trust to be inspected under the Care Quality Commission’s revised inspection approach.

It is one of 10 ambulance trusts, five of which are foundation trusts. It is in the process of applying to become a foundation trust.

The announced inspection took place between 19 and 22 August 2014, and the unannounced inspection visits took place on 26 and 27 September 2014.

As the first ambulance trust inspected under the new model, we did not provide ratings for this trust.

The trust operates a 111 service. This was not looked at as a part of this inspection.

Our key findings were as follows:

The service was clinically led and focused on patients and outcomes.

The trust was only achieving one of the three key response time targets in 2014/15; although it did achieve all key national ambulance targets 2013/14.

Systems, processes and practices were used to keep people safe from harm.

The ambulance service used evidence-based computer systems to support decision making when the public called 999. Special patient notes were held on the system to support and inform decisions.

The trust had clinicians based in its three emergency operations centre however they were used effectively in Manchester.

Paramedics used a Paramedic Pathfinder tool (Pathfinder allowed staff to transfer patients to the correct pathways using known clinical guidance to determine the correct treatment) to ensure that patients received care in the most appropriate setting.

The patient transport services provided transport for people who met the eligibility criteria.  These were people who needed to be taken to hospital for a planned appointment and who were unable to make their own way to hospital because of clinical or medical needs.

The trust’s leadership team had a clear vision that was freely quoted by many staff. It was underpinned by a strategy to make the trust one that provides not just a good service but a great one. The trust had a system to communicate its messages via different media such as notice boards, bulletins and emails. However some staff cited lack of time, lack of face to face meetings and lack of access to emails to be able receive those messages.

Overall, staff felt supported and well equipped to carry out their duties. It was compulsory for advanced paramedics to have a Master’s qualification; operational managers were encouraged to partake in Chartered Management Institute schemes. Some staff expressed concerns that they had not received the training they needed to manage obstetric emergencies, although mandatory training included an obstetric update.  

There was a procedure for staff to report this colleagues’ poor practice and staff were encouraged not to tolerate this.

There were challenges in the delivery of the patient transport services. However, there was a commitment to this service and recognition that it was part of the future plans for the trust.

Staff treated patients and their families and carers in a caring manner with dignity and respect, and valued them as individuals. We observed exemplary care being given across the whole trust.

We saw several areas of outstanding practice including:

Numerous examples where staff showed a caring, committed and compassionate manner, despite the situation or the environment they were in, or the challenges they faced.

Patients who called more than twice in 7 days or 4 times in 28 days were recognised as ‘frequent callers’. The trust had a ‘frequent callers’ team that liaised with the caller, their GP and other social care providers to ensure that the person’s health and social care needs would be met by the right provider.

Clinical staff performance was monitored and all paramedics’ results were published within the team. Each paramedic had a unique identifying number so only they would know which results related to their performance. This meant they could compare their performance against their colleagues without knowing which results related to whom.

‘Prevent’ is part of the UK government’s counter-terrorism strategy known as CONTEST, which aims to reduce the risk to the UK and its interests overseas from terrorism. At the time of our inspection, 55% of staff had completed their training.

Emergency Medical technicians in order to progress to paramedics they’ve had to apply to a University to undertaken the Paramedic Diploma which meant that they had to leave the trust. Recently, a trial had been undertaken for them to enhance their level of education to the point where they can apply to the trust’s own internally sponsored Paramedic course.

The trust showed commitment to ongoing education and development of their staff at all levels. It appointed one of the first consultant paramedics back in 2008 and was focused on ensuring that staff were equipped to carry out their roles.

The commitment and enthusiasm for the use of volunteer community first responders and their support was evident. They received a comprehensive 6-month package of training, and then continuing training and support.

The trust had developed a process for responding to calls when a patient had already been seen by ambulance staff within the previous 24 hours. These calls were automatically flagged and referred to the clinical governance team who then immediately reviewed these incidents to understand and share any learning from these incidents.

The purpose-built emergency operations centre at Parkway in Manchester provided a good working environment and a positive atmosphere to work within.

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

Getting the most appropriate vehicle to the patient (a key objective for ambulance services) is known as ‘best allocation’ and the trust aimed to achieve this target 60% of the time. However, this had only been achieved in 40% of cases from July to September 2014. It varied but was around 40% for the trust.

The service took a high number of patients to hospital when alternative services may have been more appropriate in meeting their needs. The trust was the worst performing nationally in this area. Less than 4% of calls to the trust were closed with telephone advice.

Some staff raised concerns that they did not have access to pain relief medication for children experiencing significant pain. The issue had been raised with senior staff who were in the process of addressing it.

Pulse oximeters (which check the oxygen levels in blood streams) with probes suitable for children were not available to all staff at all times.

There were some areas within the trust where staff had not had appraisals and regular communication was not taking place.

Importantly, the trust must:

Review the process for pre-alerting hospital accident and emergency (A&E) departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.

Make sure that emergency operations centre staff across all three EOCs are consistently identifying and recording incidents as appropriate.

Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.

Improve access to clinical supervision for all clinical staff.

Review medicines formulary guidance issued to front-line staff to make sure it is current.

Ensure that all staff are receiving the mandatory training necessary for their role.

Ensure that all staff across all divisions are consistently receiving appraisals.

The trust should :

Assess the impact and mitigate of any identified risks by call-handling staff not accessing clinical advice, in contrast to regular clinical advice being sought by Manchester Parkway call-handling staff.

Assess the impact and mitigate associated risks of non-clinical staff re-triaging calls.

Ensure measures in action plans are SMART (specific, measurable, achievable, realistic and timed), in the Broughton emergency operations centre.

Audit and assess individual call-handling performance at all emergency operations centres.

Assess and implement measures to improve performance for the proportion of calls closed with telephone advice when clinically appropriate.

Review the adoption of the urgent disconnect policy at all emergency operations centres.

Assess and implement measures to improve performance against the national target for the percentage of calls abandoned before being answered.

Share learning and good practice across emergency operations centres.

Review the system for managing controlled drugs at ambulance stations to ensure that they are managed appropriately.

Review systems to assess if access to new stocks of controlled drugs in rural areas can be improved.

Evaluate the availability of training and opportunities for career progression for emergency medical technicians across the trust.

Assess and implement measures to improve performance against the 40-minute transfer target for transport services patients having haemodialysis or cancer treatment.

Ensure that the public know how to complain should they wish to.

Improve complaint response times.

Ensure that the various communication media that the trust employs be supported to be effective by the ability of staff to access them in both time and physical access, recognising the geographical spread of the trust.

Consider bringing forward the programme to provide a new Emergency Operations Centre ( EOC) at Elm House Liverpool or consider renting purpose built accommodation

Re-examine and improve basic cleaning processes for ambulances such as standards for replacement of mop heads and processes for replenishing buckets containing cleaning fluids

Instigate team meetings or training in specialist subjects, such as the Mental Capacity Act 2005 or deprivation of liberty safeguards for Liverpool Elm House EOC staff.

Develop a system for EOC staff to deal with requests for information from the police.

Call-taking and dispatch staff arranged call-backs to Green 3 and 4 calls (non-life threatening) that had passed the expected response time, in order to explain delays and check for any deterioration in the patient. This was organised in an ad hoc way and sometimes overlapped with call-backs undertaken by staff at the urgent care desk. Set up a process to undertake this is a systematic way.

Improve the frequency of face-to-face interactions between managers and staff ensure that team meetings take place on a regular basis.

Professor Sir Mike Richards

Chief Inspector of Hospitals

​November 2014

19-22 August and 26-27 September 2014

During a routine inspection

North West Ambulance Service NHS Trust has been selected as the first ambulance trust to be inspected under the Care Quality Commission’s revised inspection approach.

It is one of 10 ambulance trusts, five of which are foundation trusts. It is in the process of applying to become a foundation trust.

The announced inspection took place between 19 and 22 August 2014, and the unannounced inspection visits took place on 26 and 27 September 2014.

As the first ambulance trust inspected under the new model, we did not provide ratings for this trust.

The trust operates a 111 service. This was not looked at as a part of this inspection.

Our key findings were as follows:

The service was clinically led and focused on patients and outcomes.

The trust was only achieving one of the three key response time targets in 2014/15; although it did achieve all key national ambulance targets 2013/14.

Systems, processes and practices were used to keep people safe from harm.

The ambulance service used evidence-based computer systems to support decision making when the public called 999. Special patient notes were held on the system to support and inform decisions.

The trust had clinicians based in its three emergency operations centre however they were used effectively in Manchester.

Paramedics used a Paramedic Pathfinder tool (Pathfinder allowed staff to transfer patients to the correct pathways using known clinical guidance to determine the correct treatment) to ensure that patients received care in the most appropriate setting.

The patient transport services provided transport for people who met the eligibility criteria.  These were people who needed to be taken to hospital for a planned appointment and who were unable to make their own way to hospital because of clinical or medical needs.

The trust’s leadership team had a clear vision that was freely quoted by many staff. It was underpinned by a strategy to make the trust one that provides not just a good service but a great one. The trust had a system to communicate its messages via different media such as notice boards, bulletins and emails. However some staff cited lack of time, lack of face to face meetings and lack of access to emails to be able receive those messages.

Overall, staff felt supported and well equipped to carry out their duties. It was compulsory for advanced paramedics to have a Master’s qualification; operational managers were encouraged to partake in Chartered Management Institute schemes. Some staff expressed concerns that they had not received the training they needed to manage obstetric emergencies, although mandatory training included an obstetric update.  

There was a procedure for staff to report this colleagues’ poor practice and staff were encouraged not to tolerate this.

There were challenges in the delivery of the patient transport services. However, there was a commitment to this service and recognition that it was part of the future plans for the trust.

Staff treated patients and their families and carers in a caring manner with dignity and respect, and valued them as individuals. We observed exemplary care being given across the whole trust.

We saw several areas of outstanding practice including:

Numerous examples where staff showed a caring, committed and compassionate manner, despite the situation or the environment they were in, or the challenges they faced.

Patients who called more than twice in 7 days or 4 times in 28 days were recognised as ‘frequent callers’. The trust had a ‘frequent callers’ team that liaised with the caller, their GP and other social care providers to ensure that the person’s health and social care needs would be met by the right provider.

Clinical staff performance was monitored and all paramedics’ results were published within the team. Each paramedic had a unique identifying number so only they would know which results related to their performance. This meant they could compare their performance against their colleagues without knowing which results related to whom.

‘Prevent’ is part of the UK government’s counter-terrorism strategy known as CONTEST, which aims to reduce the risk to the UK and its interests overseas from terrorism. At the time of our inspection, 55% of staff had completed their training.

Emergency Medical technicians in order to progress to paramedics they’ve had to apply to a University to undertaken the Paramedic Diploma which meant that they had to leave the trust. Recently, a trial had been undertaken for them to enhance their level of education to the point where they can apply to the trust’s own internally sponsored Paramedic course.

The trust showed commitment to ongoing education and development of their staff at all levels. It appointed one of the first consultant paramedics back in 2008 and was focused on ensuring that staff were equipped to carry out their roles.

The commitment and enthusiasm for the use of volunteer community first responders and their support was evident. They received a comprehensive 6-month package of training, and then continuing training and support.

The trust had developed a process for responding to calls when a patient had already been seen by ambulance staff within the previous 24 hours. These calls were automatically flagged and referred to the clinical governance team who then immediately reviewed these incidents to understand and share any learning from these incidents.

The purpose-built emergency operations centre at Parkway in Manchester provided a good working environment and a positive atmosphere to work within.

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

Getting the most appropriate vehicle to the patient (a key objective for ambulance services) is known as ‘best allocation’ and the trust aimed to achieve this target 60% of the time. However, this had only been achieved in 40% of cases from July to September 2014. It varied but was around 40% for the trust.

The service took a high number of patients to hospital when alternative services may have been more appropriate in meeting their needs. The trust was the worst performing nationally in this area. Less than 4% of calls to the trust were closed with telephone advice.

Some staff raised concerns that they did not have access to pain relief medication for children experiencing significant pain. The issue had been raised with senior staff who were in the process of addressing it.

Pulse oximeters (which check the oxygen levels in blood streams) with probes suitable for children were not available to all staff at all times.

There were some areas within the trust where staff had not had appraisals and regular communication was not taking place.

Importantly, the trust must:

Review the process for pre-alerting hospital accident and emergency (A&E) departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.

Make sure that emergency operations centre staff across all three EOCs are consistently identifying and recording incidents as appropriate.

Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.

Improve access to clinical supervision for all clinical staff.

Review medicines formulary guidance issued to front-line staff to make sure it is current.

Ensure that all staff are receiving the mandatory training necessary for their role.

Ensure that all staff across all divisions are consistently receiving appraisals.

The trust should :

Assess the impact and mitigate of any identified risks by call-handling staff not accessing clinical advice, in contrast to regular clinical advice being sought by Manchester Parkway call-handling staff.

Assess the impact and mitigate associated risks of non-clinical staff re-triaging calls.

Ensure measures in action plans are SMART (specific, measurable, achievable, realistic and timed), in the Broughton emergency operations centre.

Audit and assess individual call-handling performance at all emergency operations centres.

Assess and implement measures to improve performance for the proportion of calls closed with telephone advice when clinically appropriate.

Review the adoption of the urgent disconnect policy at all emergency operations centres.

Assess and implement measures to improve performance against the national target for the percentage of calls abandoned before being answered.

Share learning and good practice across emergency operations centres.

Review the system for managing controlled drugs at ambulance stations to ensure that they are managed appropriately.

Review systems to assess if access to new stocks of controlled drugs in rural areas can be improved.

Evaluate the availability of training and opportunities for career progression for emergency medical technicians across the trust.

Assess and implement measures to improve performance against the 40-minute transfer target for transport services patients having haemodialysis or cancer treatment.

Ensure that the public know how to complain should they wish to.

Improve complaint response times.

Ensure that the various communication media that the trust employs be supported to be effective by the ability of staff to access them in both time and physical access, recognising the geographical spread of the trust.

Consider bringing forward the programme to provide a new Emergency Operations Centre ( EOC) at Elm House Liverpool or consider renting purpose built accommodation

Re-examine and improve basic cleaning processes for ambulances such as standards for replacement of mop heads and processes for replenishing buckets containing cleaning fluids

Instigate team meetings or training in specialist subjects, such as the Mental Capacity Act 2005 or deprivation of liberty safeguards for Liverpool Elm House EOC staff.

Develop a system for EOC staff to deal with requests for information from the police.

Call-taking and dispatch staff arranged call-backs to Green 3 and 4 calls (non-life threatening) that had passed the expected response time, in order to explain delays and check for any deterioration in the patient. This was organised in an ad hoc way and sometimes overlapped with call-backs undertaken by staff at the urgent care desk. Set up a process to undertake this is a systematic way.

Improve the frequency of face-to-face interactions between managers and staff ensure that team meetings take place on a regular basis.

Professor Sir Mike Richards

Chief Inspector of Hospitals

​November 2014