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Trust Headquarters Requires improvement Also known as NHS 111 Service

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 January 2017

The North West Ambulance Service (NWAS) NHS Trust is one of 10 ambulance trusts in England and provides emergency medical services across the North West region, which has a population of around 7 million people. The trust employs 5162 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across the North West.

The trust has 109 ambulance stations distributed across the region, three emergency operations centres, one support centre, three patient transport service control centres, and two Hazardous Area Response Team (HART) buildings (one being shared with Merseyside Fire & Rescue).

The trust also provides, along with Urgent Care and out of hours partners, the NHS 111 Service for the North West Region. Operating from five sites across the North West, in Greater Manchester, Merseyside and Lancashire and Cumbria.

We last inspected this trust between 19 and 22 August 2014 for the announced element of the inspection, and the unannounced inspection visits took place on 26 and 27 September 2014. As the first ambulance trust inspected under the new model, the trust was not rated as part of this inspection. Additionally the 111 service was not inspected at the time of this previous inspection. We told the trust that they must make improvements to:

  • Review the process for pre-alerting hospital accident and emergency departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.
  • Make sure that emergency operations centre staff across all three emergency operation centres (EOCs) are consistently identifying and recording incidents as appropriate.
  • Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.
  • Improve access to clinical supervision for all clinical staff.
  • Review medicines formulary guidance issued to front-line staff to make sure it is current.
  • Ensure that all staff are receiving the mandatory training necessary for their role.
  • Ensure that all staff across all divisions are consistently receiving appraisals.

Before carrying out this inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the Ambulance Service. These included clinical commissioning groups (CCGs); Monitor and the local Healthwatch.

We carried out our announced focused inspection of NWAS between 23 and 26 May 2016, with an unannounced inspection taking place on 6 June 2016. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected three core services:

  • Emergency Operations Centres
  • Urgent and Emergency Care
  • Patient Transport Services

We also inspected the NHS 111 service provision during this inspection.

Our key findings were as follows:

Leadership and Culture

  • There were regional variations in the culture both across the trust as a whole and within regions. Staff in some areas felt very positive about the culture, but in other areas they felt there was a high degree of pressure and that focus was on performance targets rather than care for patients.
  • The Chief Executive Officer had recently commenced in a substantive post on 10 May 2016, following a period of covering the post as an interim, from March 2016.
  • The urgent and emergency care service was moving towards a clinical leadership model, with more focus on clinical quality and a reduction in operational management. This leadership model included a consultant paramedic for the region and advanced paramedics in each sector. An increase in the number of senior paramedics and decrease in assistant operations managers was planned.
  • Staff reported that the new clinical leadership structure with senior paramedics assuming a combined management and clinical leadership role was a positive development. This change had been well received as it provided clearer lines of reporting and less confusion, at the stations where it had already been implemented.
  • Staff felt that leadership from heads of service was strong and visible. Heads of service and sector managers had been supported to develop their leadership skills with attendance at higher education courses.
  • In Liverpool many of the staff said that staff morale was affected by the building which was cramped with teams located in different rooms.


  • There were staff vacancies across all areas of the urgent and emergency care service and the overall vacancy rate was 5.7%.
  • Staff vacancy rates in North Cumbria were the highest in the trust with 35 vacancies, which represented 20%. The paramedic vacancy rate in this area was 16.7%. One of the initiatives to manage this deficit was the employment of paramedics from other countries. Two paramedics from Europe had worked in Cumbria for some time. The trust had employed 35 new European paramedics in Greater Manchester at the time of the inspection. There were plans to recruit a further 36 with 24 of these being appointed to North Cumbria.
  • A high proportion of vacancies related to band five paramedics. A total of 16.2% whole time equivalent (WTE) posts for this role were vacant at the time of our inspection across all areas. This reflected a national shortage of paramedics.
  • The staff turnover rate for the 2015/16 period for the service was 7.2%. The trust was looking at new ways to recruit paramedics to fill these vacancies. This included progression programmes for their EMT staff and also international recruitment. The trust’s human resources department was working with managers on developments to improve the retention in Cumbria where rates were higher at 11%. This included the consideration of relocation packages.


  • Information relating to patients’ care and treatment was recorded on patient record forms (PRFs) which were paper based forms in a duplicate book. This meant the ambulance service could maintain their own record and also supply one copy to the hospital or patient, depending on whether the patient was conveyed to hospital. They also had one copy without patient identifiable information to use for audit purposes.
  • We reviewed 236 PRFs within urgent and emergency care. We saw that, in 218 of these cases, the records were completed in legible handwriting, were signed and dated and the history of the patient incident, treatment provided, medicines administered, assessments of pain and observations were completed.
  • There was a limited amount of free text space available to record a full history and clinical assessment. If there was not enough space to complete all details, a second PRF would be completed. Some staff felt a continuation sheet would be beneficial but others told us there was enough space to document all necessary detail. Paramedics on the Manchester urgent care desk completed patient review forms for each patient seen. These records were posted into a locked cabinet in the office and were collected once a month to be stored securely elsewhere in the trust. The urgent care desk team did not have access to the cabinet and, as such, we were unable to review any of these records. This meant there was a risk these records could not be accessed urgently if required.

Governance and Risk Management

  • The quality committee met every two months and discussed areas, such as risk and mitigation, safeguarding, response times, complaints, incidents, medicine management, infection prevention, quality improvement and National Ambulance Clinical Quality Indicators. This meant that the executive team only got oversight on these quality areas every two months.
  • The board did not have an overview of the reporting and monitoring of serious incidents. This meant there was no monitoring of how quickly serious incidents were reported, timescales for investigations and how quickly actions were implemented following the outcome of the investigation. Serious incidents regularly took longer than the 60 day timeframe (set by NHS England in the serious incident framework) to investigate and conclude.
  • There was a trust-wide risk register in place which recorded all operational risks with a score of 12 and above. There was evidence that the register was reviewed and updated regularly. However, there were some improvements required. In particular, some risk descriptions did not clearly describe the risk; some of the information recorded under controls and assurance were not actually controls or sources of assurance; there was no target rating for risks, meaning it was unclear what level of risk the trust was aiming for, and there were a number of risks without actions identified to mitigate the identified risk. Additionally a significant number of risks had been on the risk register for a number of years with little evidence of progress or impact being reported. In addition local risk registers were not totally aligned to the trust wide risk register.

We saw several areas of outstanding practice including:

  • The Hazardous Area Response Team (HART) teams in both Manchester and Merseyside were delivering an excellent service to patients. They were proactive in their approach to gaining new skills and forging relationships with other emergency services, to ensure the smooth running of rescues in difficult areas. Their co location with the fire service training headquarters in Merseyside afforded them and all NWAS staff excellent and unique training opportunities. This ensured that they were equipped to deal with and manage a wide range of hazardous emergencies and undertaken formalised de briefs in a multidisciplinary manner.
  • The service had community care pathway designed to share information across services and ensure ambulance clinicians were aware of pre-existing care plans for patients being managed by community services. This included when it was most appropriate for patients to be treated at home, involving other professionals or conveyed to an alternative care setting than an emergency department. This was also supported in some areas by the long term conditions teams based at local hospital trusts.
  • The community engagement manager was in the process of implementing an electronic application initiative called ‘Good SAM’. This application could be downloaded onto mobile devices and alerts users who have been vetted and checked to a nearby cardiac arrest. Through this initiate the manager had also mapped all defibrillators in the North West area and from August 2016, this information would be available to call centre staff so that they could direct members of the public attending cardiac arrests to these devices.
  • All staff we observed were exceptionally caring in their approach and went above and beyond their duty to provide compassionate, supportive care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In Urgent and Emergency Care:

  • The service must ensure staff are given adequate opportunities to report incidents and safeguarding issues.
  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy.
  • The service must ensure all staff receive the required level of mandatory training.
  • The service must ensure that all staff receive the required level of mandatory safeguarding training and ensure that there is a mechanism to check that staff have completed this training.
  • The service must ensure all community first responders have the required level of training to undertake their role including how to recognise and act on safeguarding issues.
  • The service must ensure that vehicle log books are completed fully and that checks undertaken by managers reflect the true content of the log books.
  • The service must ensure that all equipment used in the delivery of patient care is subject to the appropriate and required checks, including that held by the community first responders.
  • The service must ensure that vehicles receive deep cleaning when required.
  • The service must ensure that controlled drugs are stored, managed and checked in line with trust policy and national legislation.
  • The service must ensure that all staff involved in the administration of medical gases, for example Entonox, have received the required level of training to ensure they are competent to undertake this duty.
  • The service must ensure there are adequate numbers of suitably qualified staff deployed in all areas.
  • The service must ensure that all guidelines and policies used in the delivery of patient care are reviewed and updated at the frequency required.
  • The service must ensure that patients have timely access to care and treatment in line with national targets.
  • The service must ensure all staff received their annual appraisal.
  • The service must ensure all staff have received the required level of training to ensure they are able to exercise their duties in line with the Mental Capacity Act (2005).
  • The service must ensure that the consent policy and guidance on mental capacity assessments issued to staff is in line with the Mental Capacity Act (2005) code of practice. The service must ensure there is specialist equipment and training for staff to safely manage the care of bariatric patients.
  • The service must ensure that staff received back up when requested in a timely way.
  • The service must ensure that risks are appropriately documented, reviewed and updated.
  • The service must ensure that any allegations of bullying are taken seriously and managed appropriately with support provided to the staff involved.
  • Ensure that departmental risk registers are kept up to date and reviewed appropriately.
  • Ensure that processes are robust and effective in relation to safeguarding processes and procedures.
  • Ensure compliance with the fit and proper person regulation.

In Emergency Operations Centres:

  • The service must ensure that staff are reporting all adverse incidents in line with NWAS policy and ensure all staff have received appropriate training on the incident reporting system.
  • The service must ensure there are robust processes for sharing lessons learned from incidents and complaints with staff across the three sites.
  • The service must ensure that all safeguarding concerns are reported in line with the NWAS policy and must improve staff awareness of the safeguarding policy.
  • The service must ensure all staff receive their annual appraisal.
  • Ensure that risk registers clearly document short and long term risks local to each emergency operations centres (EOC) site as well as to the EOC service as a whole, including control measures that have been identified and implemented, and planned review dates.

In Patient Transport Services:

  • The trust must ensure that investigation reports fully reflect the actions taken during an investigation and provide a summary of the root cause of the incident and the lessons learned, in line with trust policy.
  • The trust must ensure patient information is kept confidential. The management of patient information provided to volunteer drivers did not promote confidentiality.
  • The service must finalise its existing PTS structure and quality reporting framework to ensure that there is a clear oversight of escalation and monitoring of governance, risks and performance of the service.

In addition, the trust should:

In Urgent and Emergency Care:

  • The service should consider implementing systems to ensure that feedback from incidents and investigations is consistent and accessible to all staff including community first responders.
  • The service should ensure that communication aids for patients with visual or mental capacity impairments are available.
  • The service should consider providing training to all frontline staff on the duty of candour and their responsibilities in relation to this.

  • The service should consider ensuring that staff with level three safeguarding training are available for staff to access for advice and guidance.

  • The service should consider providing training on key safeguarding subjects which crews may come across such as female genital mutilation, radicalisation recognition and human trafficking.

  • The service should consider implementing a system to ensure the key codes to access keys in the ambulance stations are changed regularly.

  • The service should ensure that all records are completed fully and legibly.

  • The service should consider implementing a system by which all staff members involved in the care of the patient can sign for the care they have delivered.

  • The service should consider ways to improve staff compliance with the use of patient pathways and care bundles.

  • The service should ensure that patients can be provided if necessary with information on how to feedback about the service.

  • The service should ensure that complaints are dealt with consistently and in line with trust policy.

  • The service should ensure that staff are aware of the trust vision and values.

  • The service should consider implementing a more consistent way of monitoring of performance and quality across the regions.

  • The service should improve staff engagement and address areas of low morale.

In Emergency Operations Centres:

  • Improve EOC staff’s skills in managing calls from children or from people who may have mental health problems, those who may be in crisis, and those living with dementia or learning disabilities.
  • Improve communication across all EOC teams, including those working night shift patterns, of changes to procedures or announcements.
  • Improve accessibility, and readability, of information transferred by the system to the EOC from NHS111, including the reduction of duplication of information.
  • Raise awareness among all EOC staff on the trust’s vision and strategy and how they can contribute to it.
  • Consider how the environment at the Liverpool site can be improved, including what reasonable adaptations may be needed for staff who have reduced mobility.
  • Review the policy for deploying the HART team and how it reflects the way in which the triage and dispatch system operates in practice.
  • All patient records made by the paramedics on the Manchester urgent care desk should be made accessible to relevant staff, as required.
  • Review the use of the MPDS system in terms of the tools not being available when a second follow-up call is made.
  • Review the Mental Capacity Act (2005) training for all staff.

In Patient Transport Services:

  • The trust should ensure all staff have timely access to a computer in order to submit electronic incidents or safeguarding referrals.
  • The trust should consider facilitating ambulance crews to meet regularly to ensure new developments and lessons learned from local, trust wide and national incidents can be shared and discussed.
  • The trust should explore that all recorded safeguarding incidents have been appropriately referred and that PTS staff are aware of what constitutes abuse or neglect and that they are all clear about the referral process.
  • The trust should review the staff training requirements for the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) guidelines to provide a common understanding of how patients are cared for in accordance with their best interests.
  • The trust should review its process for maintaining all vehicles in good visual repair and that rusty items are replaced as quickly as possible.
  • The trust should review its process for reviewing and updating policies and procedures as appropriate.
  • The trust should consider implementing regular refresher driving courses or skills checks for PTS drivers.
  • The trust should review the process for ensuring that DNACPR documentation travelling with the patient is in the appropriate format.
  • The trust should review the process for responding to and investigating complaints to improve the timeliness of this procedure.
  • The trust should review its process for including operational issues within a strategic overview or central risk register related to internal risks.
  • The trust should review its PTS operating model to produce a formal vision and strategy for PTS linked to the overarching organisation vision and strategy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 19 January 2017



Updated 19 January 2017



Updated 19 January 2017



Updated 19 January 2017


Requires improvement

Updated 19 January 2017

Checks on specific services

Access to the service

Updated 10 December 2014

Cumbria and Lancashire

Staff in the trust’s Emergency Operations Centre in Broughton were proud to work for an ambulance service. The systems that call handlers and dispatchers used made sure that patient safety was a priority and that they maintained accurate and detailed records. Staff had received appropriate training and most staff felt confident they had been supported to gain the competencies for the role.

However, many call handling staff did not feel listened to or engaged by managers, and minutes of meetings showed that staff suggestions were not responded to or acted upon in a timely manner.

Systems and processes supported the responsive deployment of emergency vehicles and coordination with other emergency services.

Call handlers were compassionate, reassuring and gave people appropriate support and information.

While call handlers at one of the trust’s other operations centres had regular input from clinicians, call handlers at Broughton did not. Non-clinical staff re-triaged calls with competing priorities.

Individual audit data for call handling staff was not available to support the effective performance management and development of staff.

Greater Manchester

The emergency operations centre was well-led, effective, responsive, and provided a caring and safe service to people accessing the service. The practices and environment at Parkway, Manchester enabled staff to provide access to the service. 

Systems, processes and practices were used to keep people safe and safe from abuse. Staff learned when things went wrong and took steps to improve. Staff assessed and monitored safety in real time, reacting to changes in risk levels for individuals. Staff anticipated potential risks and planned for them in advance, working with a range of other providers to keep people safe.

The service was effective in ensuring people with healthcare needs could access the service. Staff used a internationally approved call triage system called the ‘advanced medical priority dispatch system’ (known as AMPDS) to triage the high volume of people attempting to access the service. Staff worked well with other emergency services and health and social care providers to ensure people’s health and social care needs were met.

We saw several examples of call handlers and paramedics based at the emergency operations centre talking with people compassionately. They listened carefully to the patients details and asked clear questions to gather more information to ensure the right action was taken, whether that was an ambulance or a telephone conversation with another healthcare professional.

There were clear escalation protocols in place for increasing levels of demand. All staff were well equipped to provide care for people in consideration of their needs. Screens were visible to staff to make them aware of the demands on the service and the flow.

Staff  were proud of their roles and felt supported and well-led. Their health and well-being was considered and there was a ‘no blame’ culture within the team. 

​Cheshire and Merseyside

The concept of safety was embedded into clinical practice throughout the service. There were systems, processes and practices in place to keep people safe from abuse.

Patient transport services


Updated 19 January 2017

Procedures to ensure the safety of services were good, with systems in place for reporting incidents and equipment checks performed to a good standard. Ambulances were clean, and the service was well staffed. Ambulance crews were trained in using dynamic risk assessments and we saw evidence of this occurring. Effective systems were in place to facilitate the timely maintenance and replenishment of vehicles. Ambulance staff had good access to information about patients and journeys through the use of mobile data terminals which were regularly updated by the control centre teams.

Staff knew what steps to take when a patient became unwell while being transported and were clear on their roles should a major incident occur. Arrangements were in place to respond to emergencies and the service took account of seasonal fluctuations in demand, the impact of adverse weather or disruption to staffing. All areas had sufficient staff numbers to meet the needs of the service. PTS staff in all areas were seen as caring, compassionate and dedicated to improving the service. All staff took their duty to report safeguarding concerns seriously. Local culture was good in most areas and we found that the morale had improved in the control room in Chester immediately after the last inspection. The performance of call centre staff was effectively audited to make sure they followed scripts and algorithms provided. Between 1 May 2015 and 30 April 2016 core service targets were met in Lancashire for nearly all months, for all KPIs related to journey and appointment times

However, we found no evidence that incidents were being managed at an overarching organisational level or that themes were being identified and addressed to prevent the same issues recurring. This meant that some issues were not dealt with effectively, for example ongoing problems with DNACPR forms not being in the correct format. Volunteers used by the service were not given enough supervision as they carried out their roles, and policies needed to be updated in light of the Savile enquiry. Safeguarding concerns were dealt with at a local level, but were not always reported to the safeguarding team in Carlisle.

Enhanced priority service (EPS) patients spent longer on the transport than they needed to because journey times were longer than acceptable limits. Cumbria, Mersey and Cheshire failed to meet the 95% target for the KPI related to appointment times for all 12 months in the period May 2016 to April 2016. At our last inspection we found an apparent disconnect between managers and senior staff across PTS; senior managers acknowledged the challenges of working across such a large geographical area and the need to increase the visibility of the senior management team. At this inspection we found there was still no vision or formal strategy for PTS although we were provided with the service contract and operating model. We did not see any evidence of a project plan or timelines for the delivery and implementation of a PTS strategy. There was no clear governance framework for the service in terms of quality structures, lessons learned or risk registers.

Emergency and urgent care

Requires improvement

Updated 19 January 2017

Staff were not always given time to report incidents and told us that this discouraged them from doing so. Feedback from incidents was not consistent across the service. The uptake levels for mandatory training in some areas were lower than the trust’s target. Data relating to safeguarding training uptake levels provided by the trust did not give a true reflection of the number of staff who had undertaken this and there was no mechanism for checking that staff had completed the training.

Log books used to record vehicle checks including infection control and prevention checks were not completed consistently and some vehicles were overdue for their deep cleaning. Essential checks of controlled drugs were not completed consistently and key codes to access keys to these drugs had not been changed for a number of months in some bases and years in other bases.

Some policies and protocols were past their date for review and appraisal rates were below the trust target in some areas. Response times to 5% of life threatening calls were worse than other ambulance trusts. Consent was not always appropriately sought from the patients themselves. There were insufficient processes to ensure mental capacity was assessed and considered, where appropriate.

Response times to emergency calls did not always meet national targets. Communication aids for patients with visual or mental capacity impairments were not available on most vehicles and there was a lack of specialist equipment and training for staff to safely manage the care of bariatric patients. Information for patients about how to complain was not readily available on the vehicles and there was a lack of consistency between areas in how well staff learned from complaints.

The majority of staff we spoke with did not know about the trust vision or values and had no awareness of the five year business plan. Risks were not always appropriately escalated to the locality risk register and monitoring of performance and quality was not consistent across the regions. The culture of the service was varied across the region, with some areas experiencing low morale or bullying and feeling separated from the rest of the trust. Staff did not feel they had the opportunity or time to read bulletins or emails and staff meetings were infrequent, if held at all.

Emergency operations centre (EOC)


Updated 19 January 2017

Overall we have rated the Emergency Operations Centre (the EOC) as good.

Safety required improvement as we identified regulation breaches in relation to the reporting of incidents and safeguarding concerns. Staff were not always clear on what should be recorded as an incident. Incidents were not always recognised or reported by staff and staff told us they were not always given time to report incidents. Feedback and learning from incidents was inconsistent. However, incidents that were reported were robustly investigated, explanations were provided to those involved and, where appropriate, apologies were provided in line with the duty of candour. The trust’s safeguarding policy was not well embedded and not all staff reported safeguarding concerns in line with the policy. There was no routine system in place to establish if ambulance crews had considered or acted on any safeguarding information passed to them from the EOC. However, mandatory training levels were above the trust’s targets, and staffing levels were adequate with a good skills mix and few vacancies. Escalation and risk assessment tools ensured patients received the right level of response and clinical support was available. Clinical escalation plans and major incident plans were in place.

Staff had limited or no knowledge of the Mental Capacity Act and making a judgement on whether or not a patient lacked mental capacity. There was no specific training on dealing with patients living with dementia or learning disabilities. However, the service worked with, and supported, frequent callers to manage their own health and reduce the number of calls they made to the service.

Effective was good as staff were well trained in using the triage and dispatch system and had access to clinical support and advice when needed. The number of calls abandoned was better than the England average, with 95% of calls answered between three and four seconds. There was an effective system for communicating warnings or medical information to ambulance crews. There was good co-ordination and liaison with hospitals to manage handover times. The urgent care desk carried out telephone triage assessments to assess patients’ need, which meant more patients were treated safely in their own home.

Caring was good. Communication with callers who contacted 999 was effective and reassuring. Staff were compassionate, reassuring and treated callers with dignity and respect. Staff showed kindness and empathy for those experiencing mental health crises and we saw numerous examples of letters from patients and carers thanking EOC staff for the care they provided.

Responsive was good because the EOC planned its services to meet the needs of the local population and different levels of demand. There were good escalation and risk assessment tools in place to ensure patients received the right level of response and clinical support was available, where required.

Call performance was continuously monitored with action taken to reduce pressures on the service. Complaints were thoroughly investigated, and learning was shared with staff involved. However, staff told us they would benefit from training in dealing with patients or carers living with mental health issues or dementia.

Well-led was good because there was a clear governance structure with good communication between the EOC site managers in the regions, and the local leaders were visible and staff told us they were supportive. Detailed plans were in place to develop the urgent care desk service further, and a telehealth scheme had been introduced to support suitable patients at home.

The EOC sites in conjunction with the urgent and emergency care service engaged with the public, including frequent callers, to reduce the number of unnecessary calls.

The EOC sites engaged with the public, including frequent callers, to reduce the number of unnecessary calls. The service developed public information campaigns, ‘Make the right call’ and ‘#Team999’ to educate people about the services. However, we identified a regulation breach as the EOC was not adequately managing risk'.

Risks were recorded in different documents but did not give a complete picture of the risks to each individual site or to the EOC service as a whole. We could not be assured that all appropriate risks for the sites had been identified or mitigated.

There was no separate vision and strategy for the EOC, and staff were not clear on how they could contribute to the trust’s vision and strategy. One of the sites was in a cramped, dated building, which was not suitable for staff with reduced mobility; staff told us the environment was affecting morale.

Other CQC inspections of services

Community & mental health inspection reports for Trust Headquarters can be found at North West Ambulance Service NHS Trust.