Lancashire HQ

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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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

This is the first assessment for this service. We rated the safe key question as inadequate. This meant people were not always safe and protected from avoidable harm.

The service was in breach of legal regulation relating to governance.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was an adverse incident policy in place. Incidents were included as a standard agenda item on monthly board meeting agendas. However, there was a lack of clarity among staff and within policy regarding reporting of incidents. The policy stated that incident report forms were available in each ambulance or on request via email. We did not see evidence of forms available. We saw that there was an incident reporting form available on the service’s electronic devices. The policy did not refer to the electronic incident reporting system. We did not see any guidance regarding how to report incidents electronically. There were no examples of incidents that should be reported.

We were told that no incidents had been reported in the past year. However, we were told that on two occasions in the past year restraint had been used. We also saw patient records from two journeys evidencing the use of restraint. The incident policy referred to a reportable adverse incident as ‘any incident, near miss, occurrence or incident that could result in harm, injury...to a patient’. We were not

assured that all occurrences that could result in harm were reported according to the service’s policy. We were therefore, also not assured that any learning or reflection would take place following incidents. The registered manager was asked about what would be reported as an incident and advised that this might include harm to staff. Systems were not operating effectively to ensure the risks were assessed, monitored and improved in relation to ensuring the health, safety and welfare of service users and others whom may be at risk.

The service had a Duty of Candour Policy.

The service did not work well with people and health system partners to establish and maintain safe systems of care. Staff did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

There was an established referral process using an electronic system whereby available jobs would be viewed and tenders would be placed for jobs. Key risk information was included on the referral form by the referring organisation. This was reviewed by the provider prior to accepting jobs.

We were told that a dynamic risk assessment would be completed at the point of transfer of a patient into the care of the ambulance service. We saw risk assessment paperwork that allowed for documentation of changes in risk since the information was initially provided by the referring agency. This also included checking of service user’s belongings.

We understood that transport provision was available for patients detained under the Mental Health Act 2007 (MHA 2007) or informal patients. Not all leaders were clear on the difference. We were not assured that pathways of care were clear or differentiated according to different service user needs.

We heard that paperwork requiring transportation with the service user would be locked in the ambulance. We did not see clear evidence of how or where this paperwork would be stored during journeys.

There was a journey log that was used to record details of the journey including any detail that may be required to be handed over to the receiving organisation.

There was a record keeping policy in place. However, we did not see detailed guidance on maintaining care records, for example, completion of sections within the risk document or journey log.

We saw evidence of communication between the provider and other organisations in carrying out transfer jobs to ensure smooth transitions.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff did not 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 not share concerns quickly and appropriately.

The registered manager was the named safeguarding lead. The safeguarding lead had not completed level 4 safeguarding training. However, the operations director did have level 4 safeguarding training.

We reviewed the safeguarding policy. This included a section regarding referrals, however did not set out a clear process, for example, stated ‘referrals should be made to social services or the police by phone’. There was a second section titled ‘referrals’ relating to patients with mental health conditions. This referenced patients’ calling ambulances for emergency care. It was unclear how this section related to the work of the Lancashire ambulance service provision.

There was no clarity regarding the clear responsibilities for notification of safeguarding incidents where there were joint working arrangements with other organisations, for example, where an escort from another organisation was present.

The registered manager was unable to locate contact details for local authorities to which any safeguard referrals would be made. The policy referenced a flow chart for referral management. The flow chart was not included in the policy. We were not assured that there was a clear understanding of safeguarding roles and processes within the carrying out of the regulated activity.

At the time of the inspection no safeguarding referrals had been made.

Staff understood what to report as safeguard concerns.

The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were reviewed on receipt of documentation completed by the organisation requesting ambulance transport. We heard that dynamic risk assessments were completed at the point of meeting a patient. We saw dynamic risk assessment forms, however, we did not see evidence of detail recorded on the forms. We did not hear any examples of how individual risks were or might be considered to ensure that a balanced and proportionate approach to risk was taken.

The service had a mental health policy which outlined the role of de-escalation in supporting people to manage risk.

We reviewed two sets of patient notes where restraint had been used. We did not see any evidence regarding the rationale for restraint or whom had made the decision for restraint, for example, the referring organisation or the provider.

We saw that rigid handcuffs and soft cuffs were available for use. We did not see any detailed operating procedure or guidance to support decision making for use of these restraints. We were not assured that the service always took a proportionate approach to imposing restrictions on people.

There was a ‘De-escalation: Principles and Guidance including restraint document’ available. It was not clear that this document related solely to the work of the Lancashire Ambulance Provider or to the wider mental health care sector.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

There was a fleet management policy in place. This set out responsibilities for vehicle maintenance and repairs. There was a vehicle inspection and maintenance record chart visible for all staff. This demonstrated that all vehicles were serviced and maintained appropriately.

There was an identified local mechanic for servicing of vehicles and emergency call outs. However, this was not a formally agreed arrangement for emergency call outs.

There was a separate locked unit for storage of cleaning materials and equipment. There was a locked COSHH cupboard.

The service did not make sure there were enough qualified, skilled and experienced staff. Staff did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We reviewed some staff files of those who undertook regulated activity and found errors or omissions in all files including unclear DBS status, no proof of identity, no proof of right to work in the UK, no references or work history. This was not in line with the provider’s own recruitment policy.

We were told that one member of staff had a positive DBS disclosure and a risk assessment had been completed. We saw no evidence of any risk assessment in the files that were reviewed. We reviewed the staff files audit sheet and did not see reference to an additional risk assessment.

We were not assured that conflicts of interest were managed appropriately by the provider. We noted that appraisals had been undertaken in the previous 12 months but noted that one had been completed by the staff member’s spouse.

We noted that driving assessments had been completed but these had been assessed by other members of staff who had been assessed themselves as competent by the same person. We were not assured of a robust quality assurance system.

We noted that staff had also provided references for each other which did not provide assurance.

We saw that driving licence checks were being completed every three months, this had been changed from 12 months following an issue with a former member of staff.

The induction policy set out timescales for completion of an induction. The induction training requirements in this policy did not make reference to specific mental health awareness training or understanding of the role of transport services under the Mental Health Act 1983. However, the Training and Development Policy did include mental health and capacity.

The Training and Development Policy listed training elements and stated that some were added for roles within mental health transport. There was no clear definition regarding the specific requirements for staff working in the mental health transport provision as opposed to the providers other non-regulated activity. We were not assured that the induction and subsequent training was tailored specifically to the mental health transport activity carried out.

There was no detail in the Training and Development Policy regarding frequency of each area of training , however, there was a separate document that detailed this.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was a document entitled Infection, Prevention and Control Procedures. This set out appropriate procedures for situations that might arise.

An infection, prevention and control audit took place on a six monthly basis. We reviewed three audits and saw confirmation of regular checks on completion of cleaning schedules.

Staff carried individual hand gel dispensers. We were told hand gel would be provided for others travelling within the ambulances.

We were told that all vehicles were cleaned between patients and at the end of every shift. A vehicle checklist would be completed at the start of every shift.

All vehicles were serviced and deep cleaned every six weeks.

All vehicles appeared clean and with no issues found.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

There service had a medication management policy. This policy identified that for the regulated activity of mental health transport services the staff were not permitted to administer any form of medication. The service did not transport patients whilst under sedation. There was a check box for this on the dynamic risk assessment form.

Staff told us that if medication needed transporting with patients, it would be stored securely in a pharmacy bag with a tag and signed in to staffs’ possession. However, there was no guidance in the medication management policy for situations that may require transportation of medications with patients.