Lancashire HQ

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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.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation relating to requirements of registered managers and governance.

This service scored 39 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff did not understand the challenges and the needs of people and their communities.

The registered manager was not able to provide a clear description of the vision and strategy for the service. There was no clear understanding of the role and purpose of

the mental health transport service. There was limited understanding of the needs of patients who may be accessing the service. For example, there was a lack of clarity regarding the difference between detained and informal patients.

The Governance Policy set out the responsibility of the operations manager in preparing, involving others in the preparation and the presentation of the strategic plan to the board. We asked for the strategy and vision. This was not provided.

We reviewed the providers website. This included ‘our mission’. The mission referred to filling the gap and providing emergency response in joint collaboration with partners and commissioners to find solutions for people at the right time. This was not reflected in the providers policies and procedures. We were not assured that there was a clear strategy and vision for the service.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager had spent limited time working within the mental health setting, citing experience as primarily in the non-regulated work that the provider also carried out.

The registered manager did not demonstrate a detailed background knowledge and understanding of the context and needs of people experiencing mental health difficulties.

We saw evidence of limited understanding of the specific role of the mental health transport service. For example, limited understanding of the difference between civil and criminal powers of restraint, limited knowledge of the Mental Health Act and restrictive practices within this and the specific roles and remit of ambulance transport staff. This was evidenced through review of the De-escalation, Control and Restraint policy.

We heard limited understanding of the difference between patients who were formally detained under sections of the Mental Health Act 2007 and those who were informal. Staff told us that in some circumstances mental health practitioners from partner organisations would travel with patients. However, there were no clearly documented pathways or guidance set out for working with patients in differing circumstances and with differing legal boundaries.

There was a lack of oversight of processes and training requirements to ensure delivery of safe care within the context of mental health transport.

We were not assured that leaders were clear on their responsibilities in ensuring appropriate policies and procedures were in place to meet the specific requirements of the service.

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

The service consisted of a small team who felt they could communicate with each other openly and honestly.

There was a whistleblowing policy in place. This included reference to staff taking concerns up with appropriate external organisations should they not feel the internal route was appropriate. However, the registered manager was not clear at the time of inspection what route staff may use should they not feel comfortable to raise concerns internally.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The Employee Handbook stated that the provider was committed to fair treatment of all employees regardless of background. The provider followed guidance set out by the Disability and Equalities Act 2010 when carrying out recruitment.

The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We reviewed the providers policies. There was no consistent approach to naming the policies, for example the risk register document appeared to contain elements of policy. There was no consistent evidence regarding the review of the last policy. There was no evidence that policies were updated in line with changes in practice, for example the Adverse Incident Policy did not reference the electronic incident reporting system that had been introduced. The registered manager did not have clear oversight of all policies and procedures in place.

Some policies, for example, the Health and Safety Policy referenced the non regulated work of the provider but did not clearly reference the regulated mental health transfer work. Therefore, it was not clear that all policies had been written with full consideration of the mental health transfer regulated activity work.

The Governance Policy identified that policies would be approved by the Board of Directors. We reviewed a ‘documents review’ sheet that included policy issue, review dates and the author.

The registered manager told us that team meetings happened when needed or the team would communicate on text messages or on the phone. The registered manager was not clear about whether team meeting minutes were recorded or not. We asked for all team meeting minutes. We were provided with monthly board meeting minutes and saw these had set agenda items. These were attended by appropriate board members. However, the minutes were brief with no actions or reviews and limited content.

We asked the registered manager for the record keeping policy. The registered manager was unable to find a record keeping policy and sought help from the operations manager. The operations manager confirmed that there was not a record keeping policy and that record keeping was referred to in a number of other policies. We reviewed the Governance policy. This stated that record keeping guidance would be referenced in the Risk Management Policy. We asked for the risk management policy and were not provided with a copy of this. There was a Mental Health Policy in place. This identified that when any form of restraint was used ’this must be recorded in the patients clinical record and journey log’. We saw a transport paperwork audit that had been completed. We asked for guidance regarding completion of this audit. We were not provided with any guidance. The audit did not directly link to any guidance or policy regarding documentation. The provider did not have appropriate systems and processes to ensure they were maintaining accurate, complete and contemporaneous records in respect of each service user, including decisions taken in relation to the care and treatment provided. For example, we reviewed two patient records where restraint had been used. There was no documented rationale for the use of restraint in either set of records. We reviewed a further set of records that identified a secure minibus had been requested, however a car had been taken on the job instead. There was no documented rationale for the change of vehicle. We were told that ’dynamic risk assessments’ would be carried out at the point of picking up a patient. The registered manager was not clear how these would be recorded.

The registered manager told us that there was a risk register in place and the top risks were ‘finances and risk to patients’. We asked for a copy of the risk register. We were provided with a document that was referred to as the policy within the text although this was entitled ‘risk register’. There was a matrix within the document but no scoring and no control measures. We were not provided with a copy of a risk register detailing current risks to the service. There was no evidence of review process. The registered manager told us that there was no formal review in place for

the risk register. There was no evidence of a clear process for ensuring the service was able to assess, monitor and improve the quality and safety of services provided in the carrying on of the regulated activity.

We were provided with a health and safety risk assessment document that was entitled ‘medical risk assessment’. This covered three areas including medical gases, general work within the public domain and administering first aid (non-regulated work). Reference was made to the third point being for non-regulated work only, however, the overall risk assessment did not differentiate between aspects that related to the providers regulated mental health transfer work and that which related to the non-regulated work also carried out.

There was a business continuity plan. This did not align directly to the services critical functions and risks.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. Staff did not share information and learning with partners or collaborate for improvement.

The service sought feedback from the referring organisation following transportation of patients. We did not see any evidence of detailed feedback. We did not see any evidence of collaborative joined up working with other partners. For example, we did not see evidence of collaborative working detailed in patient notes where restraint had been used.

We were told that there were frequent issues with risk assessments provided by commissioners, for example disagreement regarding the level of risk identified for a patient. There was no joined up working demonstrated to address these issues.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. Staff did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff did not actively contribute to safe, effective practice and research.

There was a member of staff working in the providers non-regulated activity service with mental health expertise. We heard this person had input into the development of policies and procedures for mental health transportation. This person was identified as a mental health lead. This staff member was available to support learning or advise on mental health but did not work directly with patients in the mental health transport service. We did not see documented evidence that this person was included in any board meetings or policy reviews.

We did not see evidence of processes to ensure continuous learning and improvement within the service.

We heard that there were no identified opportunities for joined up learning with other partners or organisations, for example, with other peer providers.