Lambda Medical Ltd

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to safety risks.

This is the first assessment for this service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of Regulation 12 Safe care and treatment, Regulation 15 Premises and equipment and Regulation 17 Good governance.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety based on openness and honesty. Staff did not always demonstrate they investigated and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was an incident and investigation policy in place. The policy did not clearly outline how incidents should be reported and recorded, or how the severity of incidents should be classified. This was a risk that not all incidents would be reported and investigated to ensure improving the quality and safety of services.

We did not see evidence of incident reviews through team meeting minutes. There was no evidence of thematic analysis of incidents. However, leaders consistently told us they reviewed incidents through monthly senior leadership team meetings.

This policy identified the importance of incident reporting and investigation for organisational and wider learning.

Actions from incidents remained live on the electronic system until all actions had been completed. However, we did not see evidence of this within team meeting minutes.

A clear incident reporting and investigation process was verbally outlined by leaders. There was a bespoke electronic incident reporting system in place. Leaders who took responsibility for investigating incidents had received investigation training on a one-to-one basis with peers.

Staff gave examples of incidents that would be reported. Staff knew there was an electronic system for reporting incidents alongside speaking to members of the on-call senior leadership team.

There was a Duty of Candour Policy in place. This set out clear responsibilities and procedures in the event of any relevant safety incidents.

We were told learning from incidents was shared through a range of methods including team meetings, emails and direct to team through group messaging applications. Direct training would also be provided if this was identified as a requirement. Staff who had reported an incident could also access the incident outcomes on the system.

We heard examples of learning such as standardising the use of scoop straps following the identification of inconsistent practices amongst staff who also work at other organisations.

Leaders told us they would try to engage patients early on in investigation of incidents. There were no examples available at the time of inspection.

Staff used debriefs after emergency transfers including when transfers had gone well. Positive practice was shared amongst staff.

The service did not always establish and maintain safe systems of care. They did not always record peoples care needs. They made sure there was continuity of care, including when people moved between different services.

We reviewed patient transfer forms which were used for bookings and risk assessments. However, the layout of the forms did not clearly identify the risk assessment section or space to document risk management actions. Medical information was recorded which included information relating to medical conditions or infection prevention and control needs. Identified risks were not always formalised in a clear risk management plan. For example, one set of records did not detail clear mobility needs; mobility status was recorded as ‘required’ and ‘poor mobility’ was recorded against medical conditions. In 3 sets of records reviewed, mobility was recorded as “limited”. There was no documented evidence of these individuals’ mobility support needs being appropriately assessed or understood to ensure they could be safely supported by staff. There was a risk to patient safety if individual needs were not accurately understood and recorded at the time of booking.

We reviewed regulated activity carried out as part of private repatriation services. The service worked with patients and families to ensure they could meet their needs prior to accessing the service. Leaders planned ahead for transfers and ensured there had been communication with all agencies involved. Records reviewed evidenced that detailed information was collected regarding the patient history and reason for transfer, however there was no clear care plans for clinical interventions required on the journey. For example, we saw one journey took several hours by road, the notes completed during the journey demonstrated the patient received support and advice regarding management of pressure areas, such as repositioning. This was not, however, included in a care plan. Systems were not in place to ensure clear care plans were in place to appropriately manage risk and deliver safe.

When transferring to hospitals there was effective and early communication to ensure a hospital bed was available on the most appropriate ward. From arrival into the country and onwards transfer to hospital units there was regular communication with accepting hospitals. Staff worked closely with hospital bed managers to support admission directly to the most appropriate ward and avoid unnecessary transfer through the emergency departments.

Staff involved other health care providers when required and followed a Situation, Background, Assessment and Response (SBAR) format when handing care over to another healthcare provider.

The service did not always have clear policies to support working with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did share concerns appropriately.

Staff had access to a safeguarding policy and a safeguarding guidance policy. The safeguarding guidance policy was intended as a brief guide to operational actions required in the event of a safeguarding concern and referenced the overarching safeguarding policy.

Leaders were clear they may need access to local authority details in other areas of the country. There was a clear process for staff to be able to access additional contacts in other geographical areas.

There was a safeguard reporting procedure in place and displayed for staff to access.

The safeguarding policy did not specify the level of safeguarding training staff required, However, the mandatory training policy identified that all staff carrying out ambulance duties should be compliant with level 2 Children and Adults safeguarding training, There was an additional requirement for frontline staff including technicians and paramedics to be trained to level 3 whilst the organisational aim was to have all staff trained at level 3 children and adults safeguarding regardless of role.

The safeguarding lead was trained to level 4 which was the correct level for the role.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. We heard an example of a recent safeguarding concern raised and appropriate support put in place.

Staff had access to a chaperone and transport of children policy. Staff understood the role of the chaperone.

All staff were DBS checked when they started working for the service. Staff did not go out on jobs before the checks were completed. The Recruitment Policy stated that risk assessments would be carried out where appropriate for any individuals who had any concerns identified on their DBS check. There were none at the time of assessment.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Leaders clearly described how the service ensured they had the right equipment and staffing to be able to manage and support people on longer journeys and to manage risks. However, we did not see consistently documented evidence of this in care records. The service worked with specialists to ensure specialist support could be provided when needed, for example, catheterised patients would not be transported for long journeys without a specialist clinician in attendance. These needs would be determined on an individual basis taking into account individual need and length of journey.

Staff were able to access advice and support in a prompt manner from senior leaders. There was a chaperone and transport of children policy in place. This outlined considerations when working with children and people with additional needs such as mental health or learning disability.

Leaders worked with patients, families and other healthcare providers to manage risk during transfers where patients had complex needs. For example, tracheostomy suctioning and management training had been provided prior to one transfer.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Vehicles were kept on a private road outside of the building. There was an extensive closed-circuit television (CCTV) system in place covering all ambulances and an onboard electronic safety system that would send alerts to managers should any part of the vehicle be tampered with, for example, petrol caps opened or windows moved without an authorised driver card being scanned on the dashboard.

At the time of inspection we identified some environmental risks within the building. For example, eroded concrete steps without hazard markings, poorly lit Control of Substances Hazardous to Health (COSHH) cupboard and damaged plastic cladding behind the mop store with sharp edges. Action was taken immediately following inspection including putting hazard marking on the steps, making safe the plastic cladding and ensuring working light bulbs within the COSHH cupboard. We also highlighted the COSHH cupboard was unlocked with keys in the lock. We were informed this was for access during inspection. Immediately following inspection the security of the cupboard was upgraded to allow only electronic key card access by authorised staff.

There were clearly defined cleaning stations with colour coded mop system and mop head supplies in place. There was a sluice and separate handwashing sink, however, these were located at the back of the building requiring buckets to be carried through the building and past reception area out to the vehicles. This created a hazard whilst carrying water buckets through the building. This risk had not been identified on the risk register.

We saw electrical safety checks were completed.

A full range of serviced fire extinguisher types were available at appropriate locations through the site.

We reviewed a fire risk assessment. Not all risks and controls had been identified. There was clear signage for the fire exit at the front of the building through the main entrance door. However, we observed during inspection a back storage room that had no fire exit leading outwards. The only escape route was to the front of the building. There were flammable oxygen cylinders stored between the back room and the front exits. We were not assured that all risks had been identified, considered and mitigated.

Equipment and stock was stored across 3 areas. Some areas housed clinical and non-clinical stocks together. On the day of inspection there was no clearly identified stock inventory or audit system. Stock was replenished based on a visual review of when stocks looked to be getting low. However, immediately following onsite inspection feedback, the provider put an electronic inventory system in place with Quick Response (QR) codes allowing staff to sign stock out and support an improved stock management and re-ordering system.

There was a digital vehicle log in place for crews to record faults. We checked 3 vehicles during inspection. All vehicles were noted as ready for use. Policy stated a vehicle daily inspection should be completed prior to each shift commencing. Staff stated they carried out inspections.

There was a clear vehicle servicing policy in place. At the time of the onsite inspection the provider was unable to provide service history for vehicles as this was kept by the mechanic company. Immediately following the inspection an improved process for ensuring oversight of vehicle maintenance was put in place by the provider. This included QR codes for staff to review the most recent MOT and servicing of a vehicle along with an alerting system for leaders.

The ambulance station was an active working space with joint entry to training rooms and areas for equipment storage. Access was controlled through staff access cards. Comprehensive security arrangements were in place within the building.

Comprehensive electronic safety systems were in place regarding vehicle use. For example, only assigned staff would be able to access vehicle keys from the locked box once their card had been activated to do so; alerts would notify the manager when blue lights were activated including on which vehicle with which driver. This meant the leadership team could review appropriate use of blue lights at the time, however, this was not recorded as a formal audit.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited to a staff bank and were able to book shifts as jobs were made available. Staffing requirements for each job was determined on an individual basis according to the nature of the job. Staff experience would be considered along with number of staff required. Leaders told us they had sufficient staff on the bank to fulfil all jobs taken on.

Leaders were aware that many staff had additional jobs elsewhere. There was a system in place to flag when staff booked multiple shifts within 12 hours of each other. This allowed leaders to work with staff to ensure they had sufficient breaks between jobs.

A member of the senior leadership team was on call or included within the staffing for each job.

All staff underwent a standard induction process. This included relevant individual checks, mandatory training followed by clinical skills, competency sign off and mentored shifts. All staff had access to a scope of practice for their individual role. Newly qualified staff were allocated a mentor.

Staff had annual performance reviews and ongoing opportunities for continuing professional development (CPD). If poor staff performance was identified, this was dealt with appropriately in a supportive way.

Driver checks were undertaken at the point of employment and annually thereafter. Driver assessments were carried out at regular intervals. Emergency response ambulance driver training was completed by staff.

Checks were carried out on all staff members each time a shift was booked. Staff were only accepted on the shift if mandatory training was compliant. Staff were able to check their own training on the electronic platform and leaders would receive alerts three months, two months and one month before training was due to expire. If any staff training expired the system was set up to block them from requesting any shifts.

A comprehensive list of mandatory training was provided within the mandatory training policy. However, this did not detail the frequency of training required. Additional training was supported and the provider aimed to achieve a workforce of skilled staff above the recognised requirements for the industry, for example, staff were all being supported to achieve advanced life support (ALS) in addition to basic life support (BLS).

There was a recognition of prior learning policy. This ensured learning achieved in other external roles could be transferred with suitable evidence of completion.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff maintained equipment and kept it clean. However, vehicles were cleaned whilst parked on the roadside outside of the building. At the time of inspection we noted available space for cleaning within the ambulance station contained other pieces of equipment. There was a risk of soiling vehicles during cleaning whilst on the roadside.

Vehicles were taken out of service if waiting for a deep clean following repairs or infection incidents.

Cleaning guidance for staff was visible on site and hourly cleaning check records were kept up to date.

There was a clear cleaning schedule for ambulances, including deep cleans every 6 weeks. At the time of inspection, the registered manager reviewed each vehicle record individually to check deep cleans were up to date. Dates were recorded however, the cleaning records were held by the cleaning company. Following the inspection, changes were made to ensure that full cleaning records for deep cleans were available to the provider. Stickers were also added to the inside of each vehicle and clearly stated when the next deep clean was due.

At the end of each shift staff were allocated time to complete the routine cleaning processes. All crews were trained in this process. Vehicle cleaning checklists were completed digitally and uploaded to an internal system for management oversight. If crews identified additional deep cleans were required after jobs as directed by the ambulance cleaning policy, for example, risk of norovirus infection, they notified leaders and were able to lock the keys out of use until the deep clean had taken place. The vehicle would be recorded as out of action until the deep clean was completed.

Sharps bins were used in accordance with guidance. The infection prevention and control (IPC) policy outlined the procedure for safe use in line with national guidance.

Staff had access to personal, protective equipment (PPE). The IPC Policy outlined clear guidance for use of PPE.

Staff adhered to infection control principles, including handwashing. We reviewed hand hygiene audits for the past 6 months. Audits were completed on each day the service carried out active work. The audits demonstrated consistent compliance with no repeated areas of concern within the audit. However, the IPC Policy did not state the frequency audits should be carried out or audit compliance targets.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was a medicines management policy in place. At the time of inspection this policy focussed on the management of medications within the emergency and urgent care service provided. There was not a separate part to the policy outlining management of medications for patient transport services. Following inspection we were provided with an updated policy to reflect a clear process for signing patient medication in and out and ensuring storage within sealed tamper proof packaging.

There was access to sealed tamperproof bags and lockable cabinets for storage at the time of inspection