You are here

Provider: North West Ambulance Service NHS Trust Requires improvement

Reports


Inspection carried out on 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


CQC inspections of services

Inspection carried out on 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