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Archived: NSL South West Region

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Inspection report

Date of Inspection: 9, 12 February 2015
Date of Publication: 18 April 2015
Inspection Report published 18 April 2015 PDF | 88.94 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 9 February 2015 and 12 February 2015, talked with people who use the service and talked with staff. We reviewed information given to us by the provider and reviewed information sent to us by commissioners of services.

Our judgement

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

At our inspections in November 2013 and June 2014 we issued a compliance action because we evidenced that whilst the provider monitored the quality of the service delivered, they did not take into account action to reduce identified risks to people. We received an action plan from the provider detailing how they intended to address this issue.

During this inspection, concerns had been raised with us about the planning of patient transport given the geographical locations within Cornwall. An example of this was one patient who was due to be collected by ambulance at 2pm. The staff that were due to pick the patient up were allocated another job whilst they were waiting. Whilst on a map, the new journey looked relatively easy; it resulted in nearly a two hour delay for the patient waiting to be picked up. In another example, another patient had to wait an additional two hours in hospital because the crew had been dispatched to another job in between dropping the patient off at their appointment and picking them to take them home. This lack of insight into the planning of patient transport particularly in and around Cornwall could put additional pressure on staff and impact on the safety of patients. The provider had implemented new initiatives to improve the timeliness of transport and reduce waiting times for patients. However, there remained evidence of poor and adhoc planning of journeys which meant delays for patients were not kept to the minimum.

Before staff start their shift, they were required to completed basic checklists to show they had checked the vehicle for any defects and that the necessary equipment was on board. Additional checks were also completed for cleaning of the vehicles at the end of each shift. These checks were not always completed and therefore any defects of omissions were not always noted or acted upon. There was a lack of a robust system in place to monitor the checks were being carried out. This could have led to injury or harm to patients or staff.

The provider did not have a robust system in place to monitor the maintenance of its vehicles across Somerset, Devon and Cornwall. We saw a recent provider fleet audit that had identified that the system for reporting defects was not fully completed and that a record of defects that had been remedied was not evidenced.

The system involved a daily check by staff and a report of any defect or concern would be recorded and made available for the team leader to action. A secondary record was made on a white board. Within the Exeter station, this was more robust than the system operated at the Redruth branch in Cornwall. Staff told us that sometimes concerns were raised about vehicle safety and no action was taken. These included concerns over brakes making unusual noises, faulty ramps and ambulances not being able to be locked. One record noted an ambulance brakes making a grinding noise. Staff told us they had written this on the white board and that the next day the white board was cleared without staff being given feedback or reasons why remedial action was not taken.

The team leaders within the Exeter branch were aware of the conditions and status of the vehicles based at Exeter. However, there was no co-ordinated approach across the three counties and different ambulance bases to ensure provision of assurance that all vehicles identified with a defect were repaired in a timely way to protect patients and staff from risk of harm or injury. Whilst the provider had an up to date training matrix, the system in place to make sure each member of staff had the necessary probationary review or appraisals was not sufficiently robust to provide a timely overview for monitoring and assurance.