HTG (UK) Limited

Thames Ambulance Service is operated by Thames Ambulance Service Limited. The service provides a patient transport service from 16 sites nationwide.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 23 October 2018.

We previously carried out an announced comprehensive inspection of the service on 22 November 2016 and an unannounced inspection on 8 December 2016, both were at the service’s Canvey Island base, which was one of only two sites operated by the service at the time. We also carried out unannounced inspections of the service at two local hospitals and at the Milton Keynes base on 9 December 2016. At this inspection there were a number of safety and quality concerns identified. Following this inspection, the service voluntarily ceased their urgent and emergency work and became a solely patient transport service. During 2017 the provider expanded their patient transport significantly, taking on a number of patient transport contracts nationwide.

We carried out another comprehensive inspection of the service on 22 September and 9 October 2017 at the service’s Canvey Island, Grimsby and Scunthorpe sites. Following this inspection, we issued a warning notice for breach of Regulation 17: Good governance. We followed this up in February and March 2018 and extended the compliance date due to extenuating circumstances, because there had been significant changes in the management and governance structures.

We had also issued requirement notices in relation to Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment; Regulation 16 HSCA (RA) Regulations 2014 Receiving and acting on complaints; Regulation 18 HSCA (RA) Regulations 2014 Staffing.

The service was last inspected on 15 May 2018 where we carried out a focused inspection to follow up a warning notice we had issued to the provider in October 2017 under Regulation 17: Good governance.

In April 2018 we issued and published details of two fixed penalty notices for breaches of Care Quality Commission (Registration) Regulations 2009: Regulation 12 Statement of Purpose and Regulation 15: Notice of changes. These were paid in full by the service in May 2018.

Over 2018, Thames Ambulance Service Limited has been attending regular risk review meetings with CQC, NHS England and clinical commissioning groups, due to the level of concern. Given our level of concern at this service we contacted NHSE and they commenced risk review meetings to oversee the actions the provider was taking.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005 (MCA).

The main service provided by this service was non-emergency patient transport services (PTS).

• Some staff we spoke with during our inspection of the ambulance stations said they had not completed safeguarding or mandatory training and station managers told us they had no access to training data. At the time of our inspection, the provider was unable to tell us staff compliance rates with safeguarding or mandatory training.

• Some ambulance staff we spoke with during our inspection said they had no training on the MCA or meeting the needs of bariatric patients. Staff said they had not received handling and moving training and felt unsafe transferring bariatric (morbidly obese) patients. However, we could not corroborate this

• All staff files were held centrally at the Lincoln head office. However, at the Grimsby ambulance station, managers told us they had no access to staff contact information and didn’t know how to contact staff if they needed them to cover shifts or inform them of any changes.

• We found infection control issues at the ambulance stations we visited, this included staff not having access to running water at the Spalding location and staff were unable to clean vehicles, and records of deep cleaning were unavailable. At the time of our inspection, the Grimsby ambulance station had ongoing issues with cleanliness and bird control. Following our inspection, the provider took action to install pest control equipment to eliminate this. We found visibly unclean vehicles at the Spalding and Lincoln ambulance stations.

• Some ambulance staff and managers we spoke with during our inspection did not understand risk at the stations we visited, we found out of date policies in use and some of the ambulance staff had no personal digital assistants (PDA) to support their day to day activities limiting their access to information. This was particularly evident at Grimsby, where nine PDA were out of use.

• Ambulance staff we spoke with during our inspection told us they had no access to equipment for transporting children, despite the provider offering this service and we found limited equipment for this purpose during our inspection.

• Medical gasses at Spalding site were not being stored safely, there were environmental issues with the base being on a second level and staff access to equipment provided.

• Some ambulance staff told us they had not received appraisals or supervision, and data supplied by the provider showed appraisal rates below the providers compliance target.

• Generally, ambulance staff we spoke with during our inspection told us of their concerns regarding the safe transport of patients with mental health needs or dementia and questioned how the provider was assessing patient needs and if staff were competent to transfer these patients.

• Some ambulance staff told us they did not receive feedback from complaints or incidents, unless they were directly involved. Information sharing was not routine and we found staff lacking in information about the new organisational structure and proposals for the business going forward.

• Some managers and ambulance staff were not using key performance data at ambulance station level, generally staff we spoke with were unaware of how this was used or how it impacted on the business or quality of the service.

• The provider monitored call centre handling times and at the time of our inspection we saw compliance against call handling targets was not being achieved. Some ambulance staff we spoke with questioned how work was allocated to the ambulance teams as they often felt patients were not assessed correctly.

• Generally, staff we spoke with at the ambulance stations didn’t know the providers vision or strategy, staff did say they wanted to provide good care, but they were not aware of the providers vision or strategy.

• We found limited records of team meetings at the stations we visited, staff told us they have had very few meetings, if any, in the last six to 12 months.

• Leadership was not embedded throughout the service, staff described a culture of significant change, consistent changes in management and a lack of senior management presence throughout the organisation.

• Some ambulance staff we spoke with told us that relationships with the transport booking and call handling teams was fractious and there were difficult relationships between front line and office staff. Ambulance staff said that workloads often led to them not getting breaks or correct information about patients.

• Generally, staff told us that staff morale was low at the ambulance stations we visited. Staff said they had no contact with the senior team and that managerial posts had changed so much they were unsure who was in managerial roles.

However, we also found:

• The provider had recruited a fleet manager, we noted an improvement from our last inspection in terms of fleet management and the provider had detailed records of vehicle maintenance and scheduling.

• Staff we spoke with across the providers teams, demonstrated caring attitudes towards patients and a will to provide them with the right level of care and support.

• The complaints team had increased in size and the provider now had a system to log and respond to complaints formally.

• The provider had implemented a corporate risk register, strategic plan, vision and business plan.

• The provider had introduced a quality team and was beginning to review some areas of performance data.

• The provider had increased the number of staff trained to safeguarding level 3 and 4.

Following this inspection, we told the provider that it must make other improvements, to help the service improve.

Amanda Stanford

Deputy Chief Inspector of Hospitals, on behalf of the Chief Inspector of Hospitals

Thames Ambulance Service is operated by Thames Ambulance Service Limited. The service provides a patient transport service from 16 sites nationwide.

This inspection was an unannounced focused follow up inspection to assess the service’s compliance with the warning notice we had issued in October 2017, details of which are included in the background section, below.

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 improvement in relation to the warning notice we had issued in October 2017:

• Locality risk registers had been introduced and named individuals knew of their responsibilities to maintain these. These fed into a centralised system, overseen by the associate director of corporate services.
• Audits had been implemented to monitor quality and safety aspects of the service and results of these were being collated into monthly reports by a dedicated compliance member of staff.
• There was a quality and governance dedicated team whose responsibilities included assessing safeguarding concerns and escalating incidents for review, and carrying out ad hoc quality visits at sites.
• There were clear separate logs to record incidents and safeguarding concerns and these were overseen and updated by the quality and governance team.
• Investigations into incidents were more robust, clear and comprehensive than at our previous inspection.
• There was improved clarity of job roles, particularly at team leader/area manager levels, towards improving accountability for specific tasks.
• Safeguarding procedures had been strengthened and leads identified to support staff with safeguarding concerns.
• There had been improvements in accessibility of policies via the staff portal app which flagged up clearly when there was a new or updated policy.
• There had been some improvement in measures to ensure regular communication and engagement with operational staff including newsletter updates and information via the mobile app.

However, we also found the following issues in relation to the warning notice where the service provider still needs to improve:

• Processes such as risk management, quality and governance meetings and feedback from incidents were not yet embedded within the organisation.
• Whilst we saw that standardised agendas had been developed for the ‘three tier’ meetings mentioned in the CQC action plan, there was no evidence that these meetings had taken place. We spoke with two members of staff at Scunthorpe base who advised us that they had held one meeting and were awaiting the minutes from that meeting.
• Staff who were not new recruits were still out of date with refresher training, including in safeguarding. Although governance leads and senior managers were able to explain there was a plan in place to address this, evidence from staff indicated there had been a lack of communication and updates to staff as to when this would be fully effective.
• Not all policies were up to date and relevant for the scope of the service, and shared effectively with staff.
• The service needed to ensure they were identifying specific themes and trends in incidents. Although quality and governance leads verbally recognised this as the next part of the plan, it was not formally documented and there was no set timescale for this.
• There was a lack of clear systems or measures to ensure specific learning, feedback and actions from incidents were shared with all staff across the organisation to reduce the risk of similar incidents reoccurring and to improve staff knowledge and awareness.
• The service needed to ensure they were identifying specific themes and trends from audit results. Quality and governance leads verbally recognised this needed to be implemented and embedded, but there was no clear plan or timescale for this at the time of inspection
• It was not clear whether actions were being taken in response to concerns highlighted from specific audits, where these actions were documented, and how audit results were shared with the wider staff group.
• There was discrepancy between individual sites in relation to communication and information sharing with operational staff. For example while some sites were having weekly meetings or using a ‘speak out’ system for escalating concerns, other sites had not yet implemented regular meetings.
• There was also evidence that suggests Grimsby remains a particular point of concern. We discussed this with the quality and governance team at the time of inspection. This included concerns that staff continued to feel disengaged; low morale; lack of effective and consistent communication with staff.

Following this inspection, we told the provider that it must continue to implement and embed measures to comply with the regulations. We also issued the provider with one requirement notice that affected patient transport services. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals, on behalf of the Chief Inspector of Hospitals

Thames Ambulance Service is operated by Thames Ambulance Service Limited. The service provides patient transport services from 16 sites nationwide.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 19 September 2017 along with an unannounced visit to the service on 4 October 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The service had experienced fast-paced expansion in its PTS work over the past 12 months. However, we were concerned it did not have the systems and processes in place to carry this out safely and reliably, due to our findings for example around lack of monitoring service activity, lack of audit, poor support and management for operational staff and patient complaints.

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 where the service needs to improve:

• There was a poor culture around incident reporting, investigating and learning. The service’s incident management process was not embedded across all sites. Not all staff were aware of the service’s incident management policy.

• We were told about a patient death that had occurred, which was not notified to the Care Quality Commission as a statutory notification.A service lead could not locate the incident report or explain where they were in terms of the investigation of this.

• The service did not have a clinical quality dashboard or similar to provide an overall picture of safety and quality at any given time by collating information, for example around incidents, infections, safeguarding referrals, and complaints among other indicators.

• The process and responsibility for deep cleaning vehicles at the Grimsby and Scunthorpe sites was unclear and inconsistent with the service policy on deep cleaning and infection prevention and control (IPC)

• There were no audits for deep cleaning or IPC being carried out at the Grimsby and Scunthorpe sites.

• It was not clear who had oversight of vehicle and equipment safety at the Grimsby and Scunthorpe sites as there was no documentation around this.

• The service did not have clear records to show that all vehicles had received an MOT.

• The documentation of safeguarding referrals and investigations was unclear and inconsistent.

• Service leads were not able to demonstrate effective oversight of training compliance to ensure staff were up to date with mandatory training.

• It was not clear what the service policy and procedure was relating to transporting children and the risks this could present.

• There was a lack of consistency in how to access policies and procedures across sites. There was no evidence that updates to policy and guidance, was being shared between sites to ensure staff were working to the same standards. Many of the policies at the Grimsby site were out of date.

• There was no audit activity taking place at Grimsby and Scunthorpe for the service to monitor its own performance in terms of quality and safety aspects.

• There was no formal induction procedure for staff at the Grimsby and Scunthorpe sites. Team leaders, who were responsible for the day to day operations at site level, had received no additional training or induction to ensure they were competent in this role.

• Staff at Grimsby and Scunthorpe raised concerns they had not been trained to use equipment such as wheelchairs, ramps and stretchers. The service did not provide evidence of staff competencies in this.

• There was no system to ensure appraisals were carried out annually. Staff at Grimsby and Scunthorpe confirmed they had not had appraisals. This was not compliant with the service’s guidance on staff appraisals.

• Staff said they did not always receive the information they needed from a discharging hospital, such as whether a patient had MRSA, was living with mental health difficulties, or any particular mobility needs. This meant they often arrived and realised they would not be able to carry out the transfer.

• Managers at each site could not explain how the service was monitoring any key performance indicators to ensure services were planned and delivered to meet patients’ needs, or show us any systems for this.

• There was no clear process for managing and learning from complaints across all sites.

• There was no vision or strategy for the service.

• Governance, risk management and quality measurement processes were not embedded at all sites. Service leads could not explain their local risks and were not aware of any systems for monitoring and mitigating risk.

• No meetings for staff or service leads were taking place in the northern region.

• There was evidence of a poor culture and morale at the Grimsby and Scunthorpe sites, in relation to staff feeling unsupported.

• There were no systems for public or staff engagement at the service.

However, we also found the following areas of good practice:

• Vehicles at the Canvey Island base had ‘deep cleaning passports’ to document deep cleans, and were deep cleaned every six weeks at this site in accordance with service policy.

• Equipment on vehicles at the Canvey Island base was checked and in accordance with the equipment and vehicle checklist. This was also audited by an external company, with actions highlighted for improvement.

• At the Canvey Island site, there had been initiatives to improve safeguarding awareness, reporting and learning since our previous inspection. For example, the service had employed a safeguarding lead since our last inspection, trained to level four in safeguarding, and staff at this site confirmed they could access them for advice and support.

• The service had a deteriorating patient policy, which was an improvement from the previous inspection.

• Operational staff displayed a patient-focused approach and ensured patients’ privacy and dignity were maintained. This was reflected in positive feedback from patients about the care from frontline staff.

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 three requirement notice(s) that affected patient transport services (PTS). Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals, on behalf of the Chief Inspector of Hospitals