Archived: Trust Medical Ambulance Services

Updated 22 November 2017

Trust Medical Ambulance Services opened in 2011. It is an independent ambulance service with the head office and two ambulance bases in Morecambe Lancashire. There are also ambulance bases in Burton on Trent, Wakefield and Manchester. The service serves the communities of Lancashire, Manchester, West Yorkshire and the Midlands. The urgent and emergency care vehicles were used in Cheshire and Mersey, Cumbria, Greater Manchester and Central Lancashire.

The service provided emergency and urgent care ambulances to support an NHS ambulance trust. This was provided in specific emergency vehicles with staff who had completed emergency care assistant training. These ambulance crews attended calls which had been triaged by the NHS ambulance service call co-ordinators as low risk and requiring a response within four hours. These patients were assessed at the scene and taken to hospital by the emergency ambulances provided. The number of ambulances required to support the trust varied each week and were booked in advance. At times additional support may be required and if the provider had staff and emergency vehicles available they would provide this.

The patient transport service was provided to support two NHS ambulance trusts as well as NHS acute hospital trusts in Lancashire, Yorkshire, Leicester and Greater Manchester. This included transport for patients from hospital to home, between NHS acute hospital sites and to hospitals for appointments.

The provider is registered with the Care Quality Commission (CQC) to provide treatment for disease, disorder and injury and transport services, triage and medical advice provided remotely.

Specialist ambulance services included the areas of mental health, bariatric transfer, repatriation and end of life support as well as medical support for school pupil transfer. They provide an events support service and if requested by the organiser will convey patients to hospital from the event, using appropriately trained staff.

The registered manager for the service had left this post in July 2017. There was a new manager undergoing the process of registration at the time of the inspection. This person had worked in the organisation since September 2015 and in a senior position since January 2016.

The service had been inspected in 2013 and had been compliant with the regulations at that time.

We completed an announced inspection in the head office on 20 July 2017 and in the Manchester and Wakefield ambulance stations on 21 July 2017. We did an unannounced inspection in the head office on 25 July 2017. On 2 August we carried out an unannounced inspection at the head office and Morecambe and Burton on Trent ambulance stations.

Updated 22 November 2017

Trust Medical Ambulance Services provides emergency and urgent care and a patient transport service.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 20 and 21 July 2017 along with two unannounced visits to the service on 25 July 2017 and 2 August 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.

Urgent and emergency services were a small proportion of activity. The main service was patient transport services therefore we have reported findings in the patient transport section.

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 was no clear procedure for reporting incidents. The information collected about accidents, incidents and near misses was not used to identify trends and themes.
• Not all equipment in use for the bariatric ambulances was up to date with testing under the Lifting Operations and Lifting Equipment Regulations (LOLER, 1998).
• Patient records on the patient transport service were not always completed accurately.
• The systems in place to respond to concerns about patients did not ensure all potential risks of abuse or neglect were identified, acted upon and reported in a timely way. Action was taken by the provider during the inspection and improvements to the systems were made.
• Not all staff had been assessed for their competence to complete specific tasks for patients. This included staff that had completed a recognised health professional qualification, but had no ongoing assessment of their competence.
• Staff that provided care and treatment to children were not up to date with their paediatric life support training.
• Staff were not clear how to obtain or record consent to travel from patients especially those who may lack mental capacity to make their own decisions.
• Staff had not received training regarding their role and responsibilities in the assessment and support of patients who lacked mental capacity. There was no general mental health awareness included in the mandatory training.
• The staff were not all up to date with their annual appraisals.

However we found the following areas of good practice:

• The premises we visited and the ambulances we saw were clean, tidy and stocked with the items deemed necessary dependent on their level of response.
• Medicine management systems ensured the safe storage, administration, recording and disposal of medicines.
• Records were managed so as to protect the confidentiality of patients and meet data protection requirements.
• Most staff were up to date with mandatory training.
• There was a comprehensive induction process in place for new staff.
• Ambulance staff had pocket books which provided comprehensive information about how to assess a patient’s condition and actions to take.
• There were procedures in place to assess and respond to a patient whose condition deteriorated.
• Staff were very complimentary about the leadership of the service, including the visibility of managers at the remote sites. There was an open culture with common shared values.
• The provider and managers were responsive to concerns we raised during the inspection and worked to make improvements in a timely way.

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 five requirement notices that affected both emergency and urgent care and patient transport services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North), on behalf of the Chief Inspector of Hospitals

Updated 22 November 2017

We do not currently have a legal duty to rate independent ambulance services. However, we found the following areas of good practice:

• All vehicles and ambulance stations were visibly clean and tidy.
• All equipment necessary to meet the various needs of patients was available.
• There were robust systems in place to ensure vehicles were well maintained.
• There was comprehensive patient information documentation which was signed by the discharging health professional prior to transfers home from hospital.
• There was a clear medicines management policy which we saw was followed in practice.
• The majority of staff were up to date with mandatory training.
• Emergency care assistants were appropriately trained.
• Systems were in place to identify, assess and manage patients whose condition deteriorated.
• There were good systems for remote staff to obtain clinical advice and support.
• All staff carried a pocket guide with clinical information which was developed from the latest guidance.
• The pocket guides had pictorial communication aids and translations for everyday questions to patients about their comfort.
• There were clear systems for the safe transport of patients who received a mental health service.
• The policies and procedures were based on best practice guidance.
• There was a robust induction procedure.
• Patients gave positive feedback about the service they received.
• Measures were in place to protect the dignity of the patients.
• There were communication aids for patients for whom English was not their first language.
• The leadership structure of the service was clear and staff could discuss any issues openly with the managers.
• There were systems in place for support for remote working staff outside of normal working hours.
• There were clear governance processes in place which included audits, risk management and improvement planning.
• Staff were positive about their engagement with managers.

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

• There was no clear system for reporting and documenting incidents which was separate to accidents and safeguarding issues.
• Not all the bariatric equipment had been checked to ensure it met the Lifting Operations and Lifting Equipment Regulations (LOLER 1998)
• Staff did not always document that consent to travel had been obtained by the patient, despite this being a mandatory part of the patient records.
• Staff did not have a good understanding of the assessment of mental capacity although they were expected to do this as part of their role.
• The safeguarding processes did not ensure patients were protected from harm. Changes were made during the inspection and improvements were seen.
• Not all staff had completed safeguarding training to the required level.
• No staff had completed paediatric life support training.
• Staff who may need to use equipment such as suction had not been assessed as competent. 
• The information required to ensure directors were fit to be in their role was not available.
• In emergency and urgent care there was no assessment of a patient’s infection status prior to them travelling in an emergency ambulance.
• There was no training or competence information documented for the qualified paramedics or nurses who worked for the organisation.