8 June 2018
The Colin Sully Centre is operated by Devon Ambulance and First Aid Services CIC. The service opened in 2015. It is an independent ambulance service in Buckfastleigh, Devon. The service primarily serves the communities of the south west peninsular.
A registered manager has been in post since 2015. At the time of our last inspection in November 2017, a new manager Richard Stanton had recently been appointed and registered with the CQC on 31 August 2017.
The service is registered to provide the following regulated activities:
- Transport services, triage and medical advice provided remotely.
During this inspection, we visited The Colin Sully Centre location. We spoke with two staff including: the planned patient transport driver and the registered manager.
There were no special reviews or investigations of the service ongoing by the CQC at any time during the 12 months before this inspection. The service has been inspected once, in November 2017. At that inspection, we found the service was not meeting all the standards of quality and safety it was inspected against.
Activity November 2017 to 17 April 2018
- There were no planned or unplanned patient transport journeys undertaken. The registered manager told us this was due to them wanting to make the changes to their service to meet the regulations. They planned to start attending events which may need unplanned transport following this inspection. Planned patient transport was not taking place as the main driver had been off sick since December 2017.
The nine staff working for the service included two ambulance technicians, one emergency care assistant and five ambulance care practitioners who all volunteered at the service.
Track record on safety
- No Never events
- No Clinical incidents
- No serious injuries
- No complaints
8 June 2018
The Colin Sully Centre is operated by Devon Ambulance and First Aid Services CIC and provides a patient transport service. Devon Ambulance and First Aid Services is a Community Interest Company owned by Devon Essential Medical Services, a Registered Charity. They provide an event ambulance service, specifically where there is an actual or identified need to provide off-site transportation to a local hospital. In addition, Devon Ambulance and First Aid Services CIC provide a limited planned patient transport service either using a two-man ambulance crew or single person wheelchair accessible vehicle. All staff who worked for the organisation are volunteers who do this in their spare time.
We initially inspected Devon Ambulance and First Aid Services CIC on the 14 November 2017. During that inspection we had concerns about the safety of service users. Following the inspection, we took enforcement action and issued two warning notices. These included concerns about safe recruitment procedures for new staff and governance arrangements to monitor service provision. We also issued four requirement notices. These included; the lack of comprehensive assessment of patients’ needs for the planned transport service, no incident reporting system, no maintenance and servicing of equipment, infection control procedures and no on-going appraisal system for staff.
On 21 February 2018, the registered manager sent us an action plan outlining the actions they had taken, and planned to take, to improve the areas of concern we identified. On the basis of this, we carried out a focused inspection on 17 April 2018. This inspection was only focused on the areas of concern reported in the warning notices and requirement notices.
Services we do not rate
We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.
We found the following areas of good practice:
- Staff who required safeguarding training at level two for adults and children had or were due to attend courses provided by the local county council.
- Processes to identify and demonstrate the service was assessing the risk of infection, taking action to prevent, detect and control the spread of infections had been implemented.
- The maintenance and use of equipment kept patients safe. All equipment was up to date with their servicing and maintenance.
- A new comprehensive risk assessment document had been developed for people who were going to use the planned transport service. Risk management plans would then be developed to make sure their needs could be met during the journey (no planned patient transport had been undertaken since our last inspection).
- A new recruitment and selection policy had been introduced to make sure new staff were suitable for their role.
- Arrangements for reviewing and investigating incidents when things went wrong had been implemented.
- Structures, processes and systems of accountability to support the delivery of the strategy, good quality care and sustainable services had been developed.
However, we also found the following issues that the service provider needs to improve:
- The new recruitment application form did not have enough room for proposed staff to fill in details about previous employment history.
- The updated recruitment policy needed to be amended to make sure the references they obtained with information about new staff is kept.
- Risks to the service provision were not documented and therefore could not be kept under review.
Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected patient transport. Details are at the end of the report.
Deputy Chief Inspector of Hospitals (South), on behalf of the Chief Inspector of Hospitals
8 June 2018
The main service provided by Devon Ambulance and First Aid Services CIC was patient transport. This included both planned and unplanned transport.
During the inspection, we saw a significant number of improvements which had been made in response to the breaches identified in the two warning notices and four requirement notices issued to the service. The registered manager demonstrated a lot of work had been undertaken to making sure the service was compliant against the Health and Social Care Act 2008 (Regulated Activities) 2014 and was providing a safe service to patients.
New systems and procedures had been introduced to ensure the safety of patients using the service and to enable the registered manager to monitor the safety, quality and performance.