Archived: SSG UK Specialist Ambulance Service - Corporate HQ

SSG UK Specialist Ambulance Service Ltd – Corporate Headquarters is operated by SSG UK Specialist Ambulance Service Ltd. The service provides emergency and urgent services and some patient transport service. NHS Ambulance trusts commission 92% of services with the remaining 8% of services being commissioned by the police, prison service and independent healthcare providers. For the purposes of this inspection we focused on urgent and emergency services only as patient transport services made up less than 10% of activity.

We inspected this service using our comprehensive inspection methodology. We made an unannounced visit to the service’s headquarters in Rainham on 8 and 9 May 2019. Another inspection team, from the CQC’s South Central region visited the provider’s location in Fareham, Hampshire on 15 and 16 May 2019. We previously inspected the service in November 2018. At that inspection, we identified significant concerns with the service. Following that inspection, we issued five warning notices requiring the service to take immediate action to address certain concerns. In addition, we told the service that there were other actions they should take to improve the service.

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.

We found the following issues that the service provider needs to improve:

• The service did not have an effective process for sharing the learning from incidents. In addition, staff said they did not routinely receive feedback when reporting an incident.

• Although the service was in the process of updating all staff records, there remained gaps in records, meaning that that there was limited assurance that the relevant safety checks and mandatory training had been completed. As such, the service did not have sufficiently accurate records to provide assurance that there were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.

• It was concerning that staff were not aware that a vehicle had been decommissioned. With the exception of this vehicle, however, all of the vehicles we inspected were clean and clutter free.

• Whilst there had been some improvements in the management of medicines since our last inspection, there were still some issues. For example, some staff kept controlled drugs (Controlled Drugs)s in their home, but there was no clear policy as to which staff were eligible to do so. There was no permanent independent witness to the destruction of Controlled Drugs.

• There was limited evidence of clinical audit activity and the service did not have a planned annual audit programme.

• Staff had variable knowledge of their roles and responsibilities under the Mental Capacity Act. The service’s ‘capacity to consent’ policy was out of date.

• There was a disconnect and a level of distrust between frontline staff and the management team at all levels. Whilst senior leaders told us they continued to work to build trust with frontline staff, there was little evidence of this. Staff continued to describe bullying and unprofessional behaviours from senior staff and there was a perception that promotions were not always made on merit.

• We were not assured of the integrity or validity of information presented to the board. This meant the board did not have a complete corporate understanding of the risks and challenges to service quality and sustainability.

• Risks, issues and performance was not managed effectively. Whilst progress had been made towards addressing the concerns identified by the CQC in November 2018, this progress had been slow and had, in many areas, yet to have demonstrable impact.

However, we found the following areas of good practice:

• The service was now following the Duty of Candour (DoC) and staff were aware of their responsibilities under the DoC.

• There had been some improvements in the management of medicines. For example, the service now routinely monitored drug fridge temperatures.

• The service had suitable premises and equipment.

• The service was meeting the national standards expected under its NHS contracts in respect of response and turnaround times.

• Since our last inspection, all the service’s policies had been updated in line with national guidance and best practice.

• The service had introduced a patient survey.

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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

SSG UK Specialist Ambulance Service Ltd – Corporate Headquarters is operated by SSG UK Specialist Ambulance Service Ltd. The service provides emergency and urgent services and some patient transport service and 92% of services are commissioned by NHS ambulance trusts with the remaining 8% of services being commissioned by the police, prison service and independent healthcare providers. For the purposes of this inspection we focused on urgent and emergency services only as patient transport services made up less than 10% of activity.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced visit to the location on 6 November 2018. We previously inspected the service in September 2016 when it was registered under a different company name.

The service had a combination of emergency response ambulances, patient transport and secure transport vehicles. Secure vehicles were used for the transport of mental health patients and had a secure area or cell.

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.

We found the following issues that the service provider needs to improve:

• Incident reporting and investigation was not effectively managed. There was no evidence of learning from incidents to improve practice. The service did not discharge its Duty of Candour responsibilities.

• Staff training records did not contain accurate information so there was limited assurance that all staff had completed mandatory training and safety checks relevant to their roles. The mandatory training programme did not reflect current good practice.

• The service did not have sufficiently accurate records to provide assurance that there were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.

• We were not assured all staff had completed relevant safeguarding training. However, most staff were clear about the actions they needed to take if they suspected or witnessed any type of abuse.

• There were insufficient processes to review patient records and the service’s information sharing policy was out of date.

• Medicines were not safely managed. There was a need for more formalised and robust accountability and audit of individual paramedics’ usage, storage and return of Controlled Drugs (CDs). There was no clear and formal policy or process for managing medicine safety alerts and it was not clear how staff competence for safe medicine administration was assessed. Drug fridge temperatures were not routinely recorded.

• There was limited evidence of clinical audit activity and the service did not have a planned annual audit programme. The service did not routinely collect or monitor information on patient outcomes to improve practice.

• There were limited in-house policies and guidance documents based on national guidance and evidence-based practice. The service was required to follow commissioning NHS trust protocols for the treatment and care of patients. The sample of organisational policies we reviewed showed most clinical policies were out of date.

• Self-employed staff did not receive an annual appraisal or participate in supervision. There was no clear process for identifying individual training and development needs, and training processes were applied inconsistently.

• Staff had variable knowledge of their roles and responsibilities under the Mental Capacity Act. The service capacity to consent policy was out of date.

• There were no specific tools available to support patients whose first language was not English or those with communication support needs. Staff sought translation support from the respective commissioning NHS trust.

• The service did not have a robust system for handling, managing and monitoring complaints and concerns. The service did not directly investigate individual complaints so learning was not identified. There was no evidence of information available on vehicles to help patients raise a concern or complaint.

• Local leaders did not all have the necessary range of skills, knowledge, experience or capacity to lead and develop the service. Some directors did not have appropriate training, development or resources to support them in their role.

• There were concerns with the organisational culture within the service, including a perceived disconnect between senior leaders and frontline staff. Senior leaders told us there was still a need to build trust with frontline staff. We received feedback from staff about perceived bullying and unprofessional behaviours by named individuals in the service leadership team and individual crew members.

• We were not assured of the integrity or validity of information presented to the board. This meant the board did not have a complete corporate understanding of the risks and challenges to service quality and sustainability.

• Minutes of governance meetings were insufficiently detailed and did not provide a clear record of discussions or actions. Management information was not routinely shared with staff.

• Risks, issues and performance was not managed effectively. There were limited systems in place to monitor the quality or safety of the service provided. This was because performance and quality data were not routinely collected or formally monitored.

• There was no evidence that the service actively sought patients’ views to improve the service provision.

• A new vision and values statement had been developed in April 2018 and was being communicated to staff through a series of workshops. However, the service’s published vision and values were from the previously registered organisation and had not been updated since it was taken over by SSG.

• The service commissioned an external review in June 2018 which highlighted serious concerns regarding patient safety, quality and organisational sustainability. We found these serious concerns had not been addressed since the review and they continued to impact on the safety of patients using the service.

However, we found the following areas of good practice:

• The service controlled infection risks. Staff used control measures to prevent the spread of infection and keep equipment and vehicles clean.

• The service had suitable premises and equipment. There was appropriate equipment on board ambulance vehicles to provide monitoring and assessment of patients.

• All vehicles we inspected were visibly clean and tidy. Vehicles were well maintained and well stocked. There were suitable processes to ensure vehicles were roadworthy.

• The service had policies and processes for safeguarding children and adults which reflected current national guidelines and good practice.

• Pain scoring and pain relief administration took place routinely and in a timely manner.

• The service responded to calls in a timely way that met national standards. Performance standards were in line with NHS ambulance trusts.

• Crews had good working relationships with staff in commissioning NHS ambulance trusts and in the hospitals they relayed patients to. They felt supported and could contact them for support and advice.

• Crews spoke sensitively about meeting the needs of different patient groups. They made adjustments to better support patients, and demonstrated principles of patient-centred care and respecting individual needs and wishes.

• Vehicles were equipped to meet the needs of differing patient groups. For example, adaptations and specialist equipment.

• Leaders of the service had taken steps to support managers with a new training and development programme.

• Leaders of the service had taken steps to improve engagement with staff working for the service, including surveys, newsletters and workshops with service leaders.

• There was good support for crew members who had experienced difficult clinical situations that impacted on their well-being.

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 issued the provider with a Warning Notice for breaches of regulations. Details are at the end of the report.

The service was rated as inadequate overall. I am placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Nigel Acheson

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