The Care Quality Commission
  • Ambulance service

Ponders End Ambulance Station

Overall: Requires improvement read more about inspection ratings

9 Morson Road, Enfield, EN3 4NQ (01692) 598911

Provided and run by:
Emergency Medical Services (GB) Ltd

All Inspections

08/06/2022

During an inspection looking at part of the service

The overall rating for this service stayed the same. We rated this service as requires improvement:

  • Mandatory training was completed by staff and there were systems in place to monitor and ensure its completion.
  • The service had sought to improve the leadership and governance of the service through support and coaching from an external consultancy.
  • The named safeguarding lead was appropriately trained and had a good understanding of their role.
  • The service had introduced a new system of incident reporting. The manager and staff had been trained on the new approach and were encouraged to report incidents with a view to learning.
  • There was a process in place for reviewing and updating policies. All the key policies had been reviewed. There was a system for writing and approving policies.
  • The service was developing an effective governance process. There were regular governance meetings which had a standing agenda and were recorded.

However:

  • There was no process to monitor or improve response times. Following the inspection the provider informed CQC that they had set up a process to start monitoring response times when they restarted the service.
  • Not all risks, such as a potential vehicle break down were recorded in the risk register.
  • It was not clear how patients can make a formal complaint if they wish to.

1 and 9 February 2022

During a routine inspection

Ponders End Ambulance Station is operated by Emergency Medical Services (GB) Ltd. The regulated activity provided is patient transport services. It provides non-emergency transport for patients who were unable to use public or other transport due to their medical condition. This includes those attending hospital, outpatient clinics, and patients being discharged from hospital wards.

The service had one vehicle which covered shifts between 7am and 8pm Monday to Friday. During the inspection period, the usual ambulance was in a garage for essential maintenance and repairs. We inspected the hired ambulance that the service was using in place of the main one, but all equipment belonged to the provider.

There was no registered manager in place at the time of inspection. The service was run by the owner and manager of the company, who acquired the company from the previous provider in May 2021.

At the time of inspection, there was one full-time self-employed member of staff plus two other self-employed staff who worked for the service on an ad hoc basis. There were also two self-employed administrative staff who worked part time.

This service was previously inspected, in 2018, but it was not rated as the CQC did not have legal duty to rate independent ambulance providers. There were no requirement notices at the last inspection.

30 July 2018

During a routine inspection

Ponders End Ambulance Station was operated by Emergency Medical Services (GB) Ltd. The service was based in Enfield, London. The main service provided was a patient transport service.

We inspected this service using our comprehensive inspection methodology. We carried out an announced inspection on 30 July 2018.

Services we do not rate

We regulate independent ambulance services and we currently have a legal duty to rate them. This inspection was carried out under our old methodology and the service has not been rated. 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:

  • The management team worked well with the organisations it sub-contracted to and provided services, which met the needs of local people.
  • The service had enough skilled staff to safely carry out patient transfers and ensured a minimum of two staff were allocated to each patient transfer. The staffing levels and skill mix of the staff met the patients’ needs.
  • The ambulance and the ambulance station were visibly clean and systems were in place to ensure vehicles were well maintained.
  • All equipment necessary to meet the various needs of patients was available.
  • There were effective recruitment and systems such as providing to mandatory training to support staff.
  • The service employed competent staff and ensured all staff were trained appropriately to undertake their roles. Staff had a clear understanding of the Mental Health Act (1983) and Mental Capacity Act 2005 (MCA) and were aware of their role and responsibilities.
  • Staff demonstrated pride in their role and we observed where they had shown care and compassion when transporting patients. The provider sought to gain feedback from patients using a patient feedback form.
  • The leadership of the service was open, approachable and inclusive and staff confirmed this.

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

  • The service did not carry out infection control and hand hygiene audits to measure the quality and effectiveness of the service delivered.
  • The service did not ensure all patient report forms were fully completed and stored securely.
  • The service did not carry out a risk assessment for hazardous substances including cleaning products following Control of Substances Hazardous to Health (COSHH) guidance.
  • The service was not meeting the Accessible Information Standard (AIS) to ensure people who have a disability, impairment or sensory loss get information that they can access and understand.

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

Amanda Stanford

Deputy Chief Inspector of Hospitals (London)