Transcare Secure Services - Birmingham

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed learning culture, safe systems, pathways and transitions; safeguarding; involving people to manage risks; safe environments; safe and effective staffing; infection prevention and control and medicines optimisations for the safe key question. The rating for the safe key question has improved to good. The service had enough staff to care for patients and keep them safe. Staff mostly had training in key skills, understood how to protect patients from abuse, and managed safety well. The environment was safe and appeared clean and tidy. Staff assessed risks to patients, acted on them and kept good care records. However, the service did not have systems in place to ensure medicines were managed well. Policies in relation to infection prevention and control and medicines were not tailored to the specific needs of the service, often referring to irrelevant information. Some staff were working with vulnerable patients when not all essential background checks had taken place. Although incidents were reported and staff were debriefed on the incidents they had raised, we did not see evidence of how this learning was shared across all staff who worked at the service.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were unable to observe care and treatment during our onsite assessment due to there being no transfer during this time. This meant we were unable to gather the views and feedback from patients who used the service ourselves. However, we reviewed the feedback which the service had gathered themselves and found feedback was largely positive with words such as “amazing”, “caring” and “well supported” used to describe the service patients had received. The service had also started to gather feedback from stakeholders who used the service to provide care and treatment for their patients. They were equally as positive about the service with feedback observing how respectful and kind they were with patients.

Staff received and kept up to date with their mandatory training. Staff told us they felt the training met their needs and was appropriate for their roles. The mandatory training was comprehensive and met the needs of patients. Staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism, and Equality, Diversity, and Inclusion. The service target of 85% training completion had been met in 34 out of 38 of the training modules. However, 4 of the modules including Crisis Prevention Institute (CPI) training, body searching, use of handcuffs and Intermediate Life Support (ILS) training were still to be completed by some staff. The service documented incidents well; these were logged on the incident audit tool, reviewed, analysed and staff de-briefs were completed. Staff told us that lessons learned from incidents were shared with the team, for example to be aware that young people leaving their parents may need extra support and/or risk assessing. Following a transfer the service completed a post transfer form. Any accidents or incidents were recorded on the post transfer form and if a search of the patient had been completed during the transfer. Staff told us they received feedback in relation to incidents.

We spoke to 2 partners who used the service, they gave feedback that the booking system was efficient, reliable and the service responded to requests in a timely manner. They told us the service completed patient journeys at the expected time and handovers were good.

The service completed approximately 7 transfers each month at the time of our assessment. It was therefore difficult to gather information about the experience of those who they had transferred. However, the information the service had gathered from patients indicated a positive service.

Staff we spoke with were able to explain the risk assessment process and the actions taken to ensure a safe transfer journey for patients. Staff reviewed the patient information provided at the booking stage and completed their own risk assessment. Staff told us they planned transfers using the least restrictive holding practices if needed. Staff were able to explain the handover procedure at the beginning and end of journeys and the escalation process to be used if they had any concerns when collecting a patient for example, staff explained to us that, on occasions, some of the patient's additional needs had not been identified on the booking assessment.

We spoke to 2 partners who used the service, they gave feedback that the booking system was efficient, reliable and the service responded to requests in a timely manner. They told us the service completed patient journeys at the expected time and handovers were good.

The service had processes in place to engage regularly with stakeholders and partners to ensure the service provided met the needs of them, as well as the patients they transported. The service regularly engaged with local hospital trusts in the region to discuss current needs and the improvements they had made to ensure their service met the needs of patients.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had a safeguarding lead. Within the post transfer summary, the service had a section which identified if a safeguarding form had been completed. This was then cross referenced with the initial transfer form for the patient which held all the information. The service had no reported safeguarding concerns in the last 6 months. The service had a safeguarding application on their mobile devices, this application provided easily accessible, up-to-date information at any given time, ensuring that the service always had the most current contact details available. All patients were transferred separately, so there was never a time when children and adults were within the vehicle at the same time. Staff told us they documented on their post transfer documentation if interventions were used, what type of intervention and if there were any safeguarding concerns raised. Staff also documented on a body map screening tool and gave a description of the transfer, this also identified the staff that were involved in the intervention. Between the months of January and April 2024 there were 4 interventions which had been reported, these were documented on the transfer reports, and documented in the transfer restraint governance summary report for April 2024. This report identified the number of interventions there were for the month, what type of intervention was used, and how long the intervention lasted.

When speaking with partners they spoke positively about the service and how they interacted with patients. They did not have any concerns in relation to safeguarding.

There were processes in place for staff to follow to ensure patients were safeguarded from the risk of harm and abuse. The service had a process in place to identify where patients were at risk due to safeguarding concerns. The policies were in date, however the safeguarding policy did not contain the most recent national guidance and legislation. During the previous inspection, the service was in breach of Regulation 13, there was a risk that restraint could be required for children and there was not a policy and procedure in place. During this assessment we found the service had a policy in relation to children’s restraint, which clearly identified what interventions could be used. This was last reviewed and updated in April 2024. The service also had the appropriate child restraints within the vehicles. The service had a process in place to monitor staff training to ensure staff remained compliant with training requirements. The information provided after the assessment showed 87.3% of staff had completed safeguarding children and young people training, 94.6% of staff had completed safeguarding and protection of adults training and 82% of staff completed safeguarding in class training.

Due to the limited number of patient journeys, it was difficult to gain the patients experience within the service. However, staff told us they ensured individual patients coping strategies and communication needs were used to plan transfers to reduce the risk of the patient becoming distressed.

Staff used information provided by the organisation booking a patient journey to manage and mitigate risks, for example the individual patients coping strategies and communication needs were used to plan the transfer to reduce the risk of a patient becoming distressed. Staff told us that when a patient was moving to a service in a different part of the country this may cause anxiety for the patient, and they highlighted this as part of the risk assessment. Staff we spoke to told us they understood the actions to be taken if a patient was deteriorating. Staff said they would review the patients care where there had been a deterioration and inform key partners and other organisations where necessary. The service completed Basic Life Support (BLS) training of which 89% of staff were trained, 97% of staff were trained in first aid. However, only 70% of staff were trained in Intermediate Life Support (ILS). This did not meet the service's target of 85%. Staff had completed induction mental health training; the compliance was 100%. Staff had completed mental capacity act and Deprivation of Liberty Safeguards training, the compliance was 97%. Some staff were trained mental health nurses and had a good understanding of supporting patients who presented with mental health concerns. Staff had completed training on eating disorders training, all staff except 1 had completed this training and the 1 staff member had this training booked.

There was a process in place which for management and escalation of a deteriorating patient. This provided staff with the information they required to ensure the situation was managed well regardless of where the emergency occurred. There were processes in place to manage patients who required restraining. The policy was reviewed on annual basis or sooner if significant updates were made to national policies or guidance. The policy identified the assessment at the booking stage was essential to enable staff to prepare for any potential restraint requirements. The service had a risk management policy which had been last amended in March 2024, this had reference to the Health and Safety policy, the escalation procedure, major incidents, the risk register, this also identified any learning and clinical governance.

We could not collect evidence due to no patients being transferred during our assessment and therefore unable to directly ask questions related to this. Where evidence included people’s experience, we have used this in areas to support the quality statement that it related to.

Staff told us patients could bring a chaperone or support worker on their transfer journey if requested as long as the risk assessment allowed for an extra person on board the vehicle. The staffing mix for each journey was reviewed to ensure there was always at least one staff member of the same sex as the patient on each journey. Staff told us that the seating on the vehicles was arranged so that the staff sat to the patient's side and not immediately facing them as this can been intimidating or stressful for some patients. Staff told us they completed a vehicle post transfer checklist to check the following for the next journey: was there appropriate road safety equipment, appropriate fire safety equipment, was there a first aid kit in the vehicle and had this been checked, was the AED (defibrillator) present and checked on the vehicle, had seatbelts been checked, were there any warning lights showing in the vehicle, were tyres fully inflated, and were lights and indicators on the vehicle fully functioning.

Whilst on site we inspected the vehicles, these were all in working order, clean, tidy, well maintained and had the correct equipment. The service had the following insurances: vehicle insurance, employer liability, public liability, and medical malpractice insurance, which all were due to expire in September 2024. Both vehicles had MOTs (Ministry of Transport), health checks and had been serviced, these were all in date. The vehicles harnesses and chairs were available and were also suitable for transferring children and young people.

There were processes in place to ensure the vehicles used were maintained in accordance with vehicle requirements. During the onsite assessment, records were reviewed which showed the vehicles were in a road worthy state and were in date with their MOT and servicing requirements. There were also processes in place to ensure equipment used within the vehicles had also serviced and safety tested to ensure they were safe to be used with patients when transporting them.

We could not collect evidence due to no patients being transferred during our assessment and therefore unable to directly ask questions related to this. Where evidence included people’s experience, we have used this in areas to support the quality statement that it related to.

Staff told us there were 4 full time staff and 32 bank staff at the service with a registered manager in place. The service employed registered mental health nurses (RMN’s) and health care assistants. A monthly staff monitoring governance summary report identified how many staff were employed, staff sickness levels, how many journeys had been completed for the month and how many hours that this covered. For the month of April 2024, there were no vacancies and no staff sickness. Staff we spoke to told us they felt the staffing levels were safe, there would be a minimum of 4 staff for each patient transfer. They told us in some instances following the risk assessment review for a patient a 5th member of the team would also attend the transfer. Staff told us the service had a staff ratio policy which had been renewed in June 2024, this stated “For patients under any section of the Mental Health Act, the minimum staffing requirement is four staff members, which must include one RMN and a driver”. This had been evidenced within the patients transfer request and transfer reports which were viewed during the assessment. Staff told us the service made sure staff were competent for their roles. Where necessary and where staff had identified areas for further training, staff underwent further competency assessments. Staff completed clinical supervision to enable them to continue to provide safe and effective treatment. There was a process in place where this was monitored to ensure staff completed the required amount of supervision.

The service had processes in place to ensure there was enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. All transportation jobs were staffed safely with individuals with the right skills to meet the needs of the patient they were transporting. Each month, the service produced reports on the staffing position which included the number of staff they employed and any sickness. The report also identified how many bank staff the service employed. At the time of our assessment, the service were staffed to establishment with 4 permanent staff (2 registered mental health nurses (RMN), 1 healthcare assistant (HCA) and 1 administration staff member). There were no vacancies within the permanent staff establishment. There were 32 bank staff within the service which was made up of 8 RMNs and 24 HCAs. There was a policy in place which identified the staffing for each transportation job was provided following a thorough risk assessment of the patients needs. The policy identified when transporting patients to a psychiatric intensive care unit (PICU), there would always be a staff to patient ratio of 5 staff for 1 patient. In addition to this, the policy identified a member of the same gender as the patient will also be present. During the assessment we reviewed staff files, there was evidence that safe recruitment processes in relation to Disclosure and Barring Service (DBS) checks for staff were not always completed. Four staff files out of 16 did not have a DBS check on record, leading to 2 staff completing a new request for a DBS check, post assessment the service provided this information, However, the service did not identify this themselves. The service was also not monitoring right to work restrictions, these would identify when staff can work and how many hours they can work. The service had a right to work policy which was last reviewed September.

We could not collect evidence due to no patients being transferred during our assessment and therefore unable to directly ask questions related to this. Where evidence included people’s experience, we have used this in areas to support the quality statement that it related to.

Staff told us they completed infection prevention and control (IPC) training and that service leaders gave them information on the outcome of IPC audits. Staff were able to explain the process for cleaning up bodily fluids on vehicles and had access to spill kits. Staff completed infection control training, where all staff except 1 had completed this, however the staff member had a date to complete this training. Staff completed control of substances hazardous to health (COSHH) training, all had completed this except for 1 staff member who had a date to complete this training. The service completed vehicle cleaning logs which had all been completed.

During the assessment we found both vehicles and office space were clean and tidy, and clutter free.

The service had an infection prevention and control (IPC) policy in place which was last reviewed in August 2023. The policy referenced key national guidance and policies in relation to IPC. However, there were references made to practices within the policy which was not relevant to the service, an example of this being in relation to exposure prone procedures. We were therefore not assured the service had a policy in place which was specifically tailored to their IPC practices. In addition to this, we were not assured the service had a full understanding of IPC practices due to incorrect information being displayed. The service had a process in place to audit IPC practices and standards, however there was no evidence provided to demonstrate the frequency of the audits. The IPC audit provided after the onsite assessment was completed in May 2023. There was no overall compliance provided for the audit and no associated action plan to address the issues identified. We were therefore not assured there was an effective audit process to ensure action was taken to improve IPC standards and practice.

We could not collect evidence due to no patients being transferred during our assessment and therefore unable to directly ask questions related to this. Where evidence included people’s experience, we have used this in areas to support the quality statement that it related to.

Staff showed us how medication was stored for patients when transferring with medication. There were no medicines stored onsite at the ambulance station. There were no medical gasses on the vehicles or stored within the ambulance station. Staff we spoke to told us medicines were only administered to patients in an emergency and this would be the patient’s own medication for conditions such as diabetes but that this would be risk assessed by the team on the vehicle. Staff said they would be given medication for patients to handover on arrival at the service. However, there was no evidence of training for staff on administering medication, medication transfer forms not been completed as per the service policy. There were no records of medication being handed over before and after transfer to another service, this included controlled drugs. The service policy stated staff must only administer medication when they had been trained and assessed as competent. The service policy was generic, and the leaders could not provide assurance that the policy was being followed or that staff fully understood the policy.

We could not collect evidence due to there being no opportunities for staff to administer medications.

At the time of the onsite assessment, the service had a medicines policy in place, however, the policy was not adapted to ensure it fully met the service's requirements and the staff's needs. The policy provided details which were not relevant to the care and treatment staff provided. Within the policy, there was reference to rescue medicines, however there were medicines which staff would require a patient group directive for (PGD) if they were required to administer these. The policy provided no details around any PGDs being in place for staff to work in line with. There was also information relating to stock rotation, however during the onsite assessment, we found medicines were not stored on site. Staff were required, as part of their policy to complete medication transfer report, which was identified by the service as a legally binding document which was retained by them and provided evidence of safe transfer and handover of patient medicines. During our onsite assessment, we found these were not completed by staff. This was a concern which was previously raised during the inspection in August 2022. We were therefore not assured the service had taken the appropriate action to ensure there was a safe process in place for the management of medicines when transferring a patient. There were specific training requirements which staff were required to complete to enable them to administer medicines. The policy stated staff who were identified as being able to administer medications, would require competencies signing off prior to them commencing. We did not observe any records for staff who had completed this during our onsite assessment. We requested further information from the service who informed us the medicines policy was now under review and a new draft policy was being completed. The medication policy that was in place at the time of the assessment was no longer in use.