All inspections: Criticare UK Ambulance Service

Criticare UK Ambulance Service is operated by Criticare UK Ambulance Service Limited. The service provides emergency and urgent care and a patient transport service.

We inspected this service using our comprehensive inspection methodology. We gave the service 48 hours’ notice of our inspection to ensure everyone we needed to speak with was available. We carried out the inspection on 29 August 2019.

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 main service provided by this service was patient transport services with some emergency and urgent care transport from events. On this inspection we inspected both core services.

Where our findings on patient transport services – for example, management arrangements – also apply to other services, we do not repeat the information but refer the reader to the patient transport core service.

We rated it as Good overall.

We found the following areas of good practice:

The service managed patient safety incidents well. There was improved incident reporting and sharing of learning through a staff electronic communication application (app) group and staff bulletins.
Staff had mandatory training in key skills, including advanced life support.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Safeguarding concerns were raised correctly and clearly reported to the local authorities.
The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment, vehicles and premises visibly clean.
The design, maintenance and use of facilities, premises, vehicles and equipment kept people safe. Staff were trained to use them. An external company had been employed to service all medical equipment.
Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified patients at risk of deterioration and acted quickly if their condition worsened.
Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care. There had been significant improvements in the forms used to record patient details and transfer information including the development of electronic patient booking and record keeping.
Staff assessed and monitored patients’ pain regularly and gave pain relief when required in a timely way.
The service provided care and treatment based on national guidance and evidence-based practice.
The service monitored, and met, agreed response times so that they could facilitate good outcomes for patients. They used the findings to make improvements.
The service made sure staff were competent for their roles. Managers appraised staff work performance.
Staff supported each other to provide good care and worked with other organisations to benefit patients.
Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
Staff treated patients with compassion and kindness, respected their privacy and dignity and took account of their individual needs. They provided emotional support to patients, families and carers.
People could access the service when they needed it, in line with national standards, and received the right care in a timely way.
It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff, including those in partner organisations.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work. The registered manager was visible and approachable for all staff and staff could raise concerns without fear.
It was clear throughout the inspection that governance systems had much improved since the last inspection in 2018. This included a detailed performance dashboard and a clearer governance overview.
The registered manager and staff were very responsive to requests for information and in completing actions required to maintain compliance with regulations.

However, we found the following issues that the service provider needs to improve:

Staff did not always clearly document mandatory training in staff records.
Documentation of staff appraisals was not clearly recorded.
Records that showed the cleaning vehicles were not completed. There were discrepancies in the recording of time and date the daily vehicle checklist and the vehicles leaving the site to start work and the deep cleaning for one vehicle was not fully documented.
Servicing dates were due to expire for medical equipment on two vehicles and staff had not booked a date for this to be completed.
The child safety harness for use on the ambulance was on another vehicle currently off site for servicing.
Staff used an electronic booking system alongside paper-based patient record systems and these did not always correlate.
The service had systems and processes to administer, store and record medicines but staff did not always document these.
There was no documented assurance of adequate breaks between or during shifts for drivers and technicians.
There was no evidence of annual driving licence checks for staff.
We noted policy documents had a version control but no evidence of review date. This meant staff were not be able to tell if they had read the most recent version.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals (Acute Hospitals South), on behalf of the Chief Inspector of Hospitals

Criticare UK Ambulance Service is an independent ambulance service. The service provides a patient transport service including high dependency transfers and transfer from events.

We carried out an unannounced focussed inspection on 29 August 2018. This inspection was conducted to assess compliance against a warning notice, which was issued to the provider on 12 January 2018. CQC generally follows up on warning notices within days of such notice coming to an end. The warning notice for this organisation expired on 12 March 2018. The warning notice follow up was delayed and we engaged with the provider until the follow up visit.

Our inspection targeted the key concerns identified in the warning notice.

At our inspection we found there were many areas where the provider had still not made any progress. For example, we found the following:

There were no systems to make sure the vehicle was safely cleaned between patient journeys and reduce the risk of cross-infection.
There were no established systems for quality assurance including overarching document which clarified expected targets and how these measured the service performance.
The provider had limited processes to minimise risks and the impact of risks on patients, staff and others.
There were no systems or processes for staff to follow to maintain a secure and accurate record for each patient about the care and treatment provided to and of decisions taken.
Patient records were consistently not held securely and controls were not used to ensure only authorised personnel accessed them.
There were no records to confirm that equipment on had been checked and properly maintained. We found the registered manager, who was not qualified to service equipment, undertook such tasks.
Following this inspection, we told the provider that it must take some actions to comply with the regulations. We issued the provider with one warning notice and three requirement notices, which affected patient transport service. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South) on behalf of the Chief Inspectors of Hospitals

Criticare UK Ambulance Service is an independent ambulance service. The service provides a patient transport service including high dependency transfers, medical cover at events and training.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 13 December 2017, along with an unannounced visit to the service on 21 December 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.

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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 issues that the service provider needs to improve:

There were no formal governance arrangements . Whilst senior staff were able to describe systems and processes there was no formal record or evidence of these. This had a significant impact on many aspects of the service.
There were no systems to monitor the safety or quality of the service. Audits were not undertaken and therefore learning did not take place from review of practices and procedures.
The service did not have recruitment procedures to ensure all staff were subject to a robust check of their suitability and experience for the role. There was no evidence that the service consistently carried out pre-employment checks on staff.
Staff did not consistently report incidents and the service did not have a clear system for identifying trends to implement learning from incidents.
Staff did not consistently complete and record essential daily checks such as vehicle maintenance and equipment checks. The patient stretcher was not included on the essential checks prior to staff attending a patient transport request.
The service did not have an effective robust understanding and governance processes for the use of restraint. Staff did not recognise that physically holding a patient to prevent them from harming themselves or others was restraint and staff did not receive training. The policy for the use of handcuffs did not outline a clear criteria where handcuffs could legally be used. The service had not followed its own governance procedures for the reporting of use of handcuffs.
We found there was inconsistency over the documentation used for patient records and booking patient transport journeys. There was no clear process and staff could choose to use either paper or electronic patient records. Patients’ medical records were not securely and there was a risk of unauthorised access.
There was no formal process to triage or assess patients at the time of booking. This included assessment of patients’ mental capacity. Staff did not always undertake risk assessment to monitor the individual risks to patients.
Arrangements for safeguarding children were not adequate. Staff did not always have training appropriate to their role and the policy for safeguarding children did not reflect national guidelines or specify training requirements.
There were no formal systems to ensure staff received regular appraisals on their performance and development. There was no competency framework to assure the service that staff were competent to undertake their duties work in line with best practice guidelines. The service did not formally record the induction for new staff members.
Not all staff had completed mandatory training appropriate to their role. Some training such as practical manual handling was not provided at all by the service.
There were limited clinical policies and guidelines to support staff and provide evidence based care and treatment. Staff did not have access to the most up to date Joint Royal Colleges Ambulance Liaison Committee clinical guidelines.
There was no provision on ambulance vehicles to support people who were unable to communicate verbally or for whom English was not their first language.
Information for patients on how to make a complaint was not readily available in the vehicles or on the company website. The service did collect patient feedback.

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

Vehicles were visibly clean and there was evidence staff had carried out deep cleans on the vehicles at regular intervals. There was access to personal protective equipment for staff and clinical waste facilities.
Equipment on vehicles was well maintained and the service kept an asset register to ensure clear documentation of when equipment needed to be serviced.
Staff were aware of how to report a safeguarding concern and there were examples of when they had done so. Senior staff could also demonstrate they had investigated and learnt lessons from safeguarding referrals made to the company.
Staff demonstrated a good knowledge of their responsibilities in regard to the Mental Health Act (2005). There were several examples where staff gave examples of working in the best interests of patients.
The service provided opportunities for staff to undertake additional training which was not mandatory to their role.
There was evidence the service had investigated and learnt from complaints.
Staff spoke highly of the senior leadership team and felt they were supportive and visible. Staff felt they could contact senior staff and any time for support and advice and concerns would be taken seriously.
Staff enjoyed working for the service and were passionate about providing high quality care to patients. Staff told us there was a sense of teamwork amongst the 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 one requirement notice and took enforcement action against the provider. Details are at the end of the report.

Amanda Stanford

on behalf of the Chief Inspector of Hospitals

Criticare UK Ambulance Service

All Inspections

29 August 2019

During a routine inspection