Head Office

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question requires improvement due to risk monitoring processes requiring improvements to ensure patients' safety. At this assessment the rating has remained requires improvement. This was because the service did not always have effective governance to deliver consistent safe and high-quality care and their information governance processes required improvement. This meant the service management and governance was inconsistent.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The vision was to provide outstanding levels of service and putting patients at the heart of what they do.

The leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The service values were displayed in the transport office and included the provision of safe care, secure patient transport services for all, led by family values, by staff trained to a high standard and delivering a timely service.

Staff and managers we spoke with understood the challenges for people using the service and there was a culture of providing safe and secure transport services.

Staff could explain how they were working to deliver high-quality care. They spoke of teamwork, leadership support, good levels of training and a clear priority to meet the needs of individual patients.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. They demonstrated a good understanding and familiarity with the needs of patients who used their service. They had a good understanding of the services they managed and could explain clearly how the teams were working to provide high-quality care.

Leaders were visible in the service and approachable for patients and staff. Staff we spoke with told us they felt supported by managers and able to go to them should they need to. They told us that any issues were resolved quickly.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Results of feedback surveys were positive, with 99% of respondents describing the service as excellent or good.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. There were processes in place to discuss learning from feedback such as complaints. This included the use of scenario discussions to help identify opportunities for improvement.

Patients and staff could meet with service leads to discuss concerns and where appropriate external agencies were involved in this.

There was an up-to-date whistleblowing policy within the service, detailing the process for staff to follow if they needed to raise concerns. Staff we spoke with told us office staff and managers were approachable and open to their concerns and suggestions about the service. There was no specific staff survey process, although meetings were held where staff could share their views.

The evidence showed a good standard. The service valued diversity in their workforce. They demonstrated an inclusive and fair culture.

Because of the nature of the service all staff worked flexibly, agreeing to shifts at a suitable time for them. The service demonstrated a culture where diversity and inclusion are central to the operations of the service. We saw that 100% of staff had completed equality, diversity and inclusion (EDI) training.

Managers put reasonable adjustments in place for staff members to help them carry out their role. This included access to equipment and furniture adaptations as needed to meet individual staff needs.

The evidence showed some shortfalls. The service did not always have clear, systems of accountability or good governance. They did not always act on the best information about risk. However, service leads had made improvements around collating performance information.

Information governance systems did not ensure the confidentiality of patient records. The service used an instant messaging app for individual jobs, where communication was shared between crew and office staff about transportation details and included confidential patient information. We also were told patient records following an out of hours transfer were sometimes stored in the staff member’s home. This presented a risk to the confidentiality and secure storage of patient information it also meant there was no clear audit trail, reducing assurance that sensitive information was managed appropriately.

The service had a range of policies, covering all aspects of the service. However, during our site visit we saw the restraint policy was unclear about the specific observations to be carried out following restraint, including when a patient was transported following sedation. The policy did not include clear guidance on what observations should be carried out when sedation had been given. Following our assessment, the provider shared an updated restraint policy that included the observations to be carried out following restraint, including where patients had received sedation prior to the transport journey.

There were processes to manage individual patient risks and we saw completed individual patient risk assessments. However, during our on-site assessment leaders could not provide us with the full range of health and safety risk assessments about operational activities and there was no risk register held. Following our on-site visit, the provider shared risk assessments that included fire safety, manual handling, driver and journey assessment, lone working and control of substances hazardous to health (COSHH) risk assessments.

There were processes to manage service performance and quality. At our previous assessment we found the service did not have key performance indicators (KPIs) to monitor the quality of the service. At this assessment we found KPIs were in place to monitor quality. This included late versus on time pickups, cancelled journeys, use of restraint and other patient safety measures. KPI data was reviewed at management meetings to identify areas for improvement and any trends or themes indicated.

Staff had implemented recommendations from reviews of incidents and complaints. This included the identification and implementation of additional training.

The service had plans for emergencies and a business continuity plan.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Service leaders engaged with external stakeholders such as commissioning and referring services and the local council.

Patients and staff could give feedback to the service’s leadership, and this was listened to and action taken to improve where necessary. Leaders told us that while having regular staff meetings with all crew members was difficult, individual staff regularly attended the office and updates were shared. They also had the opportunity to share concerns or ideas about the service. Staff we spoke with told us they felt able to provide feedback and discuss issues with service leads.

The evidence showed a good standard. The service focused on continuous learning and improvement across the service.

Staff were given the time and support to develop opportunities for improvements. This included the time to attend debrief sessions and incident reviews to support the identification of learning and improvement.

We saw examples of investigations to identify learning from incidents and saw staff had been involved in this process. Real life scenarios were used to deliver training and encourage staff input into improving patient experience of the service.