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South Central Ambulance Service NHS 111 Good

Inspection Summary


Overall summary & rating

Good

Updated 19 September 2018

This NHS 111 service is rated as good overall. (Previous inspection May 2016 – Good overall with requires improvement in the effective domain)

The key questions are now rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We inspected this NHS 111 service as part of our inspection programme. This was a planned comprehensive inspection which looked at breaches in regulations identified at the inspection in May 2016 and looked at what action the provider had taken in relation to concerns regarding staffing recruitment.

We carried out an inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The NHS 111 service provided a safe, caring, responsive and well-led service to a diverse population spread across central and south England.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • Governance systems and processes were embedded and established.
  • The provider recognised where risks were identified and were proactive in mitigating and reducing these risks. For example, low staff recruitment and retention had triggered the successful implementation of a demand and recovery plan.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines.
  • The provider worked with outside agencies and charities to secure improvements to services.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • Staff had been trained and were monitored to ensure they used NHS pathways safely and effectively. (NHS pathways is a licensed computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call).
  • The provider continued to be used as an approved national testing site for new NHS pathways being introduced.
  • The provider was responsive and acted on patient complaints and feedback. Feedback from patients was welcomed by the provider and used to improve the service.
  • The service were also involved in many projects, joint working and displayed evidence of innovation. For example, being appointed to lead a project for urgent and emergency care and in the provision of new services.
  • The provider was testing a new training programme to help training in the workplace. The equipment allowed non clinical staff to experience a range of medical conditions they would not otherwise see and assist in the telephone triage.
  • There was visible leadership, with an emphasis on continuous improvement and development of the service. For example, expansion of the service and integration with other stakeholders and urgent care providers.
  • The provider was creative and proactive in looking at ways to solve staffing issues. For example, the use of home workers, joint working and change in working patterns to attract more staff. Staffing gaps had been met to provide patient safety. This was maintained through use of external call centre providers and offering overtime shifts.
  • Staff said the NHS 111 service was a good place to work, although acknowledged this had been stressful recently due to issues with staff recruitment.
  • The provider cared about the wellbeing of the staff and had invested in wellbeing officers who provided pastoral and operational support for staff. This had contributed to a reduction in staff sickness levels.

The areas where the provider should make improvements are:

  • Continue with the implementation and monitoring of the recruitment programme.
  • Ensure systems are in place to enable staff to keep abreast of changes, updates and new policies.
  • Continue to review call handling responses to ensure agreed targets are achieved.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 19 September 2018

We rated the service as good for providing safe services

Safety systems and processes

The provider had clear systems to keep people safe and safeguarded from abuse.

  • There was an effective system in place for reporting and recording significant events. The provider used every opportunity to learn from internal and external incidents, to support improvement. Learning was based on thorough analysis and investigation. When things went wrong with care and treatment, patients received appropriate support, truthful information, and a verbal and written apology. We saw 21 open incidents on the providers reporting system. None were overdue for investigation. The provider had a SIRI (Serious Incident Requiring Investigation) review group who were used to review incidents and identify any learning. For example, a death resulting from a medicines overdose resulted in ensuring that all overdoses were reviewed by a clinician.
  • The provider had an embedded system for the management and maintenance of estates. This included fire safety, Control of Substances Hazardous to Health management of legionella, security and staff safety. There were contingency plans in place should events occur. For example, a recent fault with the emergency generator had resulted in a replacement being sourced. The organisation also conducted safety risk assessments, safety checks and had safety policies regarding health and safety issues. Staff received safety information as part of their induction and refresher training. The Health and Safety team performed scheduled ‘walkabouts’ and had established user groups and communicated to staff effectively. Health and safety issues were discussed within each department, the board and with trustees.
  • The organisation had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.
  • The provider worked with other agencies, such as social services, to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out pre- employment (recruitment) checks. We looked at seven staff files which showed that full employment checks were carried out together with Disclosure and Barring Service (DBS) checks (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). Agreements were in place to satisfy the provider that appropriate training and pre- employment checks were completed for external agency call centre staff used.

  • The Trust set a target of 85% compliance for the completion of mandatory training for all modules except safeguarding and information governance where a 95% target was set. We saw data showing that the actual rate of mandatory training completed was 86%. All staff had completed level 1 and 2 Safeguarding training at induction. Some Clinicians had also completed Level 3 Safeguarding training. There was a safeguarding lead in the organisation and five other staff who were trained to a Level 4 in Safeguarding.

  • Staff were able to identify and report safeguarding concerns. We saw staff had a clear awareness of how to identify concerning situations and respond appropriately. For example, we observed staff requesting help from their team leader following a sensitive call. The situation was handled efficiently and the staff member was supported effectively.

  • The provider ensured that equipment was safe and that equipment was maintained according to manufacturers’ instructions.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • The NHS 111 Provider used the Department of Health approved NHS Pathways system (a set of clinical assessment questions to manage telephone calls from patients). This was based on the symptoms the patient reported when they called. The tool enabled a specially designed clinical assessment to be carried out by a trained member of staff who answered the call. Once the clinical assessment was completed, a disposition outcome and a defined timescale were identified to prioritise the patient’s needs. At the end of the assessment if an emergency ambulance was not required, an automatic search was carried out on the integrated Directory of Services (DoS), to locate an appropriate service in the patient's local area.

  • Staff were able to access patient ‘special notes’ via their computer system to alert them to patients with, for example, pre-existing conditions or safety risks where the GP practice had submitted these notes on behalf of their patients.

  • There were arrangements for planning and monitoring the number and mix of staff and these had been monitored closely in recent months.

  • A resourcing team were responsible for organising staff rotas. Outside of the teams working hours it was the responsibility of the call centre managers to manage arrangements for covering sickness or other absence.

There were embedded systems in place for the management of the rota and forecasting staff requirements. Staff explained that they had a clear view of forecast call volumes on an hourly basis using software to identify and schedule staff around expected demand. Staff explained that overtime and shift extensions were used to meet the peak time demands. Staff explained that this had been relied on in recent months whilst recruitment was in process. The organisation used a ‘scheduling’ app to request shift changes and overtime opportunities. We looked at the staff rota for the weekend before the inspection and for the Easter period. Compared to the forecast and actual call numbers we saw that resourcing was matched effectively.

The provider had a demand recovery plan in action to address any staff shortages or gaps within the rota. An external organisation used to provide call centre staffing support was used to ensure patient demand was met.

  • As part of the operating model for delivery of NHS 111 services the provider must comply with the clinician level requirements of the NHS Pathways system at all times. The NHS Pathways End User License Agreement stipulates that there must be at least one accredited clinician physically present for each shift of non-clinical advisors (call handlers). We saw this was in place within both call centres.

  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. Each desk had a folder with quick reference cards for staff to use if needed which covered topics such as sepsis and safeguarding.

  • Staff gave interim advice to patients as the call was ending and told patients when to seek further help should the condition get worse.

Arrangements to deal with emergencies and major incidents

The NHS 111 service had adequate arrangements to respond to emergencies and major incidents.

  • The provider had adequate arrangements in place to respond to emergencies and major incidents. They had engaged with other services and commissioners in the development of its business continuity plan.
  • There was a comprehensive business continuity plan in place for major incidents such as power failure or building damage, as well as those that may impact on staff such as a flu pandemic. The plan included emergency contact numbers for staff.
  • The plan included arrangements for setting up temporary switchboards, moving the calls between the two call centres and back-up systems for power and computer systems. These included using paper based systems if needed. There were details of actions to be taken at various time stages of the disruption. For example, what actions were needed in the first hour, then in the next 24-48 hours and if needed up to five days disruption.
  • In the event of the telephone systems being disrupted then there were procedures in place to re-route NHS 111 calls. Computer systems could be accessed remotely. The two call centres were named as replacement centres should one be unavailable. There were arrangements in place to divert calls to other service providers should this be necessary.

Staff explained that the business continuity processes worked well. For example, the estates manager explained how a faulty generator was identified and replaced with minimal disruption. Staff explained the extreme bouts of poor weather had resulted in volunteers offering to transport staff to work.

Effective

Good

Updated 19 September 2018

We rated the service as good for providing effective services, (at our previous inspection in May 2016, this domain was rated requires improvement).

Effective needs assessment, care and treatment

Telephone assessments were carried out using a nationally recognised operating model.

  • The NHS 111 provider used the Department of Health approved NHS Pathways system (a set of clinical assessment questions to manage telephone calls from patients). The tool enabled a specially designed clinical assessment to be carried out by a trained member of staff who recorded the patients’ symptoms during the call. When a clinical assessment had been completed, a disposition outcome was reached and agreed with the patient. For example, what the patient needed next for the care of their condition and a defined timescale was identified to prioritise the patients’ needs.

  • We saw evidence that all call advisors had completed a mandatory training programme to become licensed users of the NHS Pathways programme. Once training was completed, call advisors became subject to call quality monitoring against a set of criteria such as active listening, effective communication and skilled use of the NHS Pathways functionality.

  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

  • The NHS 111 provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • There was a system in place to identify frequent callers and patients with particular needs, for example, patients with mental illness and palliative care patients. Care plans and guidance for staff to follow were in place to provide the appropriate support for these patients. We saw no evidence of discrimination when making care and treatment decisions.

  • When staff were not able to make a direct appointment on behalf of the patient clear referral processes and safety netting information (information given should the condition worsen) were in place. These were agreed with senior staff and clear explanation was given to the patient or person calling on their behalf.

It is a condition of the NHS Pathways user licence and a National Quality Requirement for NHS 111 providers that the organisation must regularly audit and review a random sample of patient contacts. The sample must include enough data to review the performance of all staff that provided care. The NHS 111 provider had an embedded system in place and team of auditing staff to ensure the applicable standards were maintained.

Calls were randomly selected and the auditors listened and scored how the call handler managed the call. The system for audits was set out so that staff in their probationary period were subject to a minimum of 5 audits per month for a period of six months and then a minimum of three per month after six months. Should staff require any support or a cause for concern was identified, the frequency would be adjusted. An achievement target of 86% was needed for a call audit to be compliant. The audit covered headings including control of the call, communication, use of the pathways tool, provision of advice and delivery of safe outcome for the patient. Results of audits were emailed to staff.

When targets were not achieved, the shift manager was informed and the rate of audits increased. A call review plan was implemented to offer support and guidance to the member of staff. Feedback was provided face to face and via email, rather than via email only. Any learning or development needs were identified and additional support provided to enable staff to meet the expected targets.

  • Any complaints or significant events triggered an automatic audit of the call.

  • The audit team were able to target themes for audits to identify any additional training need or look for any issues. For example, calls relating to prescriptions were targeted and resulted in a change to the information provided in the directory of services.

  • The clinicians’ call handling was also audited. For example, one clinician said 50% of their calls were audited as they were making specific clinical revalidation calls. Learning from themes raised in audits was shared with staff when relevant.

We saw records and data to show that between March 2017 and July 2018 the organisation had achieved between 71% and 126% of the completed audit targets each month. Of these between 77% and 93% of audits had achieved full compliance with the average being over 90%. We saw that 41% of audits had been completed so far for the month of August 2018 (one week).

Staff feedback regarding audits was mixed. The majority of staff saw the process as positive and proof they were ‘doing their job properly’. However, some staff saw the process as more punitive.

Monitoring care and treatment

Clinical shift managers and team leaders managed the call centre daily and were responsible for monitoring call performance. Call advisors and clinicians’ performance was also monitored through appraisals, review of significant events and meeting requirements for ongoing training.

Clinicians could listen into calls if needed and provide advice during the call. When required the call was transferred to a clinician for further triage, as a ‘warm transfer’, when this was not possible the call was placed into a call back queue which was monitored. This queue was assessed and some calls were prioritised to receive an urgent clinician call back. Staff told us that the availability of clinicians for support and call backs varied depending on the time of day but was generally effective in meeting their needs. During the calls we observed there were five examples where there were no clinicians immediately available for advice and seven examples where clinicians were available.

The NHS 111 provider monitored its performance through the use of the National Quality Requirements and the national Minimum Data Set, as well as compliance with the NHS Commissioning Standards. In addition, the NHS 111 service established its performance monitoring arrangements and reviewed its performance each day; weekly and monthly, as well as reviewing real time calls. The NHS 111 service had a real-time wallboard in each call centre hub which showed call volumes and alerts of incoming calls.

NHS Providers of 111 services are required to submit call data every month to NHS England by way of the Minimum Data Set (MDS). The MDS is used to show the efficiency and effectiveness of NHS 111 providers. We saw this data was routinely provided.

A situation report was sent to NHS England and the clinical commissioning group, on a weekly basis which recorded details of how many calls were received; dispositions made; length of call time and whether call backs had been made within 10 minutes when needed.

Data from this report showed that between June 2017 and June 2018 calls closed following clinical advice ranged between 37.7% and 57.4%, which was above the target of 50%. An improvement was visible in April 2018 when performance which had previously been consistently around 39-40% increased to above 55% for three consecutive months as a result of changes made to reporting. This change in reporting was signed off by NHS Digital and the CCG and was an accurate reflection of clinical involvement. This was an indicator of how clinicians were now being used within the NHS 111 service and the potential impact on other services such as accident and emergency.

At the last inspection we saw that the provider had consistently missed the targets for clinician call backs within 10 minutes. At that time, 27% of calls were made within the 10 minutes, which missed the national target rate of 95%.

Since the last inspection as part of the agreed prioritisation of national targets in March 2018 the CCG had asked the organisation to consciously deprioritise some nationally reported targets (warm transfers and clinician call backs) to focus on revalidation of ambulance disposition codes and concentrate resources on other patient outcome measures such as safe revalidation of ambulance dispositions and emergency department dispositions. The agreement was that the service make a note of the types of disposition made and measure against these rather than stock approach of ten minutes for all. We saw minutes from a recent contract meeting to show that the CCGs who held the contracts were comfortable with the performance of the organisation and the improvements being made.

  • Revalidation rates had increased to 94% (June 2018) with approximately 60% downgraded safely.
  • Overall 999 dispositions had reduced from 12,000 in December to less than 9,000 in June (with steady monthly reduction)

At this inspection the agreed prioritisation of call backs was in process. Calls were being placed in a clinical queue which included allocated clinical navigators assigned to the queue providing a clinical line of sight and triage at all times. Calls were re-prioritised into either 10 minute, 60 minute or 120 minute call backs dependent on the disposition code and clinical need. Performance against these measures showed that:

  • Over 85% of call backs took place within the 60 minute period.
  • 99% of call backs took place within the two-hour period.
  • 100% of calls were achieved within 10 minutes were made for requests to speak with a clinician where the patient was receiving palliative care or required emergency contraception
  • 95% of calls were achieved within 10 minutes for specific requests for reassessment of patients.
  • 99% of calls were achieved within 60 minutes where patients had refused an ambulance disposition.

50% of these calls were audited to ensure the decision to de-escalate was appropriate. We saw the results for two clinicians who had achieved well over 85% of the target pass rate for this type of call.

Patient feedback about response times was positive. For example, in the November 2017 survey areas of good practice identified included the speed and efficiency of the service.

At the last inspection we found that between January and March 2016 performance calls answered within 60 seconds had dropped to 56%. At the time, the provider said this was due to longer winter, higher numbers of colds and flu and an outbreak of Scarlett fever. At this inspection, safe targets had been agreed and were being monitored. The provider also shared the monitoring of these targets with commissioners.

At this inspection the average percentage of calls answered within 60 seconds of the number of calls answered, data showed for the period from June 2017 to June 2018 the percentage of calls answered within 60 seconds ranged between 66.4% and 96%. As a comparison, NHS 111 MDS statistical data showed that of calls answered by all national NHS 111 services in March 2018, an average of 70.0% of calls were answered within 60 seconds. Although the national target of 95% was not achieved during this period there was consistent performance of over 87% with five of the nine months achieving over 90%.

  • The lowest performing month (67% March 2018) was due to two bouts of extreme weather conditions. The average over the year was 87%. We discussed performance with the operational management team and they had clear plans in place to improve performance; these linked in with the recruitment and performance recovery plan.

  • The percentage of calls abandoned (after waiting 30 seconds) had improved since the last inspection. Abandoned calls were at 8% in March 2016 reducing to 2% in April 2016. At this inspection they ranged between 0.4% and 6.9%; the target of less than 5% was achieved in 13 out of the 14 month period. The average for the year was 1.7%.

Real-time data seen during the inspection on 7 and 8 August 2018 showed:

8 August 2018 at 18:33 1328 calls had been answered, 39 calls were abandoned (2.9% abandonment rate below 5% target); the longest wait time was 2 minutes and 11 seconds. 16 calls were waiting with 37 agents online. A total of 85.5% of calls were answered within 60 seconds.

The organisation had a clear line of sight into their performance and had robust plans in place to show how they have begun to improve performance in these areas. They had actions for continuing this improvement.

Effective staffing

Prior to the inspection we received information from the provider that they were experiencing a high turnover of staff and low recruitment. At this inspection the provider had introduced an established programme of recruitment to rectify this and were following a demand and recovery plan. This included a focus on Summer recruitment to ensure appropriate staffing was introduced in time for Winter pressures.

The provider continued to be aware of their need to recruit clinical and non- clinical staff to address the vacancy rate which had been higher than the 5% target but was now reducing.

The provider had introduced different approaches to work alongside the recruitment programme to help with retention and recruitment. These included introducing:

  • Remote home working for 10 clinicians, including staff who work out of area.
  • Health and wellbeing welfare officers in both call centres which, as a consequence, had seen a reduction in sickness rates. For example, since the introduction of the welfare officers in March 2018 sickness rates had reduced from 13% to 5%.
  • Joint working with the 999 and patient transport provider within the organisation to introduce a multiskilled workforce.
  • A specified recruitment lead.
  • A review of shift patterns and introduction of a new service advisor role to reduce the number of weekends worked by staff and make the role more attractive to new employees

The provider was using external NHS 111 call centre providers and call centre agencies. The agency was currently taking approximately 20% of calls working under the providers licence. There had been no significant events during the three years of working with the call centre agency. Staff from the operations team told us they had a clear overview of governance/complaints/incidents with the agency.

The provider had looked at the recruitment process as an end to end process to identify why the dropout rate for new applicants was higher than expected and had introduced ways to address this. For example:

  • Recruitment open days had been organised for potential employees to come into the call centre to see what the role involved prior to making a decision to apply for the post.
  • Initial telephone interviews were offered to reduce the non-attendance at interview.

Ongoing recruitment continued.

  • Social media platforms were being used to attract new staff to the organisation.

  • Existing staff were kept informed of staff recruitment. For example, the monthly staff newsletter had a recruitment section. For August, the newsletter contained details of induction and training dates to reassure staff of the ongoing efforts to recruit new staff.

  • A weekly recruitment conference call was held to keep managers informed of the recruitment progress, dates of interviews, number of applicants, number of job offers made and number of staff undertaking the induction programme.

  • We saw data to show the recruitment numbers for the first four months of the 2018/19. These showed the provider had recruited 40 full time equivalent staff against the planned 34 full time equivalent staff.

  • In 2017, 53 recruitment events had been attended by SCAS staff.

Once employed, staff had access to an established training programme. All call advisors had completed a mandatory training programme to become licensed users of the NHS Pathways programme. Once training was completed, call advisors became subject to call quality monitoring (audits) against a set of criteria such as active listening, effective communication and skilled use of the NHS Pathways functionality to maintain their license.

  • The provider had an induction programme for all newly appointed staff and ongoing mandatory and role specific training. The induction training covered topics such as use of display screen equipment; fire safety; information governance; and safeguarding adults and children. Staff received mandatory training that included: use of the clinical pathway tools, the Mental Capacity Act 2005, safeguarding and fire procedures. Staff had access to and made use of e-learning training modules and in-house training. We saw evidence of a detailed induction process. The induction and training period for call advisors in the 111 service was six weeks in length. Quality assurance coaches spent time on a one to one basis listening to, and helping new call handlers with “live calls”. They were then assessed using a competency framework and if further training was required this was followed up on a weekly basis or more frequently if required.

Ongoing learning needs of staff were usually identified through a system of appraisals, meetings and reviews of NHS 111 service development needs. At the time of inspection 87% of appraisals for all staff who worked in the call centres had been completed. However, at the time of writing the report this figure was reported at 91% after a data cleanse. The data cleanse removed staff who were on maternity leave or career-break from the analysis.

  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

  • We saw evidence of exit interviews for staff along with health and wellbeing surveys and staff engagement surveys all being used to improve the staff morale

Coordinating care and treatment

Staff worked together, and worked with other organisations to deliver effective care and treatment.

  • The NHS 111 provider used a system called Adastra, a clinical patient management system designed to manage episodes of care quickly and safely. The entire patients’ journey could be measured and analysed from the initial telephone call, through to internal and external referral to another service. The system, with the patient's consent, automatically sent details of patient contact with the NHS 111 service to the GP practice they were registered with.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • The NHS 111 provider was not able to book appointments directly with a patient’s GP, but electronically contacted the practice to alert them of the patient’s contact and their follow up needs. We saw that patients were clearly signposted to their own GP practice and informed of follow up advice and what to do if their condition worsened (safety netting). Where patients needed to be assessed by the out of hours GP service, the NHS 111 service would send information to a specific queue within those services for follow up. Staff knew how to access and use patient records for information and when directives may impact on another service for example, advanced care directives or do not attempt resuscitation orders.
  • Protocols were in place between the ambulance service, hospital consultants and doctors in A & E departments, to assist the NHS 111 provider to arrange the most suitable disposition.
  • The NHS 111 provider ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances. There were arrangements in place to work with social care services including information sharing arrangements. A range of health professionals were able to access patient notes and record information in them. These included the palliative care team, dental staff, pharmacists, midwives and Mental Health Practitioners within the NHS 111 Service. The organisation also worked with the Samaritans charity and were able to transfer calls to them.
  • There were clear and effective arrangements for transfers to other services, and dispatch of ambulances for people that required them.
  • Issues with the Directory of Services (DoS) were resolved in a timely manner and call handlers were able to fully explain what actions they take when the DoS provided a nil, or incorrect response. Particular attention was given to safety netting in this area.

Consent to care and treatment

Staff sought patients’ consent in line with legislation and guidance.

  • The message greeting callers for the NHS 111 provider alerted them that continuing with the call showed that they gave consent. When needed, consent was also recorded on the computer system, for example, when passing the call to a clinician or the caller was not the patient.
  • Access to patient medical information was in line with the patient’s consent.
  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Caring

Good

Updated 19 September 2018

We rated the service as good for providing caring services; previous rating in March 2017 was also good.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We observed members of staff were courteous and very helpful to people calling the NHS 111 service and treated them with dignity and respect.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients. Staff were provided with training in how to respond to a range of callers, including those who may be abusive. Our observations were that staff handled calls professionally, sensitively and with compassion.

  • The NHS 111 provider gave patients timely support and information. Call handlers gave people who phoned into the NHS 111 service clear information. There were arrangements in place to respond to those with specific health care needs such as end of life care and those who had mental health needs.

Patient feedback demonstrated a consistent achievement of positive patient feedback regarding attitude of staff and treatment outcomes. For example, friends and family test results from November 2017 showed that 94% of 134 patients would be extremely likely or likely to recommend the service. Findings from the November 2017 patient survey showed high levels of patient satisfaction across all responses including feedback about staff listening to callers, being kind, caring, reassuring, helpful, compassionate, polite and professional. For example,

  • 93.5% of respondents were satisfied with the way the service had handled their call.
  • 97% of respondents found the service to be helpful and
  • 94.5% said they were extremely likely or likely to recommend the service to friends and family with a similar problem

Involvement in decisions about care and treatment

  • Call handlers and clinical advisors were confident in navigating through the NHS Pathways programme and the patient was involved and supported to answer questions thoroughly. The final disposition (outcome) of the clinical assessment was explained to the patient and agreement sought that this was appropriate. In all cases patients were given advice about what to do should their condition change or deteriorate.
  • Care plans, were in place and informed the NHS 111 provider’s response to people’s needs, though staff also understood that people might have needs not anticipated by the care plan.
  • We saw that staff took time to ensure people understood the advice they had been given, and the referral process to other services where this was needed.
  • Staff were trained to respond to callers who may be distressed, anxious or confused. Staff were able to describe to us how they would respond and we saw evidence of this during our visit. Staff would adapt questions to enable patients to understand what information they were being asked for. Staff handled calls sensitively and with empathy and compassion. There were arrangements in place to respond to those with specific health care needs such as end of life care and those who had mental health needs. This included care plans and special notes.
  • There were established pathways for staff to follow to ensure callers were referred to other services for support as required.
  • There was a system in place to identify frequent callers and care plans/guidance/protocols were in place to provide the appropriate support. There were also systems in place to respond to calls from children and young people.

Privacy and dignity

The NHS 111 provider respected and promoted patients’ privacy and dignity.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions.
  • The NHS 111 provider monitored the process for seeking consent appropriately.

Responsive

Good

Updated 19 September 2018

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The NHS 111 provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its population and tailored services in response to those needs. The NHS 111 provider had a system in place that alerted staff to any specific safety or clinical needs of a person using the NHS 111 service. For example, those with mental illness and those receiving palliative care.

  • The provider had also been active in improving the care of patients and had been leading innovation in the provision of new services including mental health, pharmacy, dentistry, paediatrics and end of life care. These had been achieved through working with system partners. The provider considered that risk sharing arrangements demonstrated the ability to deliver effective patient outcomes.

  • The provider had introduced differing models of care within each call centre to meet the needs and demands of the local populations. There were plans to introduce additional services but the provider had already introduced midwifery, dental, pharmacy and mental health advisors within the call centres to enable patients to receive evidence based advice from a specialist. Plans were in place to increase these services and included recruitment of children’s nurses.
  • The provider was near completion of the implementation of a national integrated urgent care workforce blueprint training staff to manage specific calls under a ‘Pathways light’ system. This enables patients to select what they require during the telephone call. Should this be a repeat prescription or a call from a healthcare professional, these calls were transferred to designated staff who could remove these from the GP call back queue. These calls could be selected by the caller pressing keys on the telephone handset.

The organisation worked effectively with other providers and were currently booking patients into two urgent treatment centres and planned to go live with another in the next few months. The provider had also been working on computer software with external healthcare providers to be able to book patients with some in hours GP practices.

  • The provider engaged with commissioners to secure improvements to services where these were identified. The service provided reported to the clinical commissioning group, these reports covered operational and clinical performance activity, serious incidents, complaints, outcomes of investigations and patient feedback. We also viewed minutes of public board meetings where the wider community could gain an understanding of how the provider was responding to patients’ needs.
  • The provider made reasonable adjustments when people found it hard to access the service. There were translation and large print document services available.
  • An NHS 111 British Sign Language service was open seven days a week, 8am – midnight.

Timely access to the service

  • Patients were able to access care and treatment at a time to suit them. The provider operated 24 hours a day, 365 days a year and took account of differing levels in demand when planning services. Nationally recognised times of increased activity to the service included weekday mornings between 7am and 8am; weekday evening between 6pm and 9.30pm and the 24hour period on weekends and bank holidays. Patients were able to access care and treatment within an appropriate timescale for their needs.
  • Referrals and transfers to other services were undertaken in a timely way. Details of patients who had contacted the NHS 111 service were sent to their GP by 8am the following morning and referrals to other services such as social services were made via secure information systems.

Listening and learning from concerns and complaints

  • Information about how to make a complaint or raise concerns was available and it was easy to do. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The organisation received 1.2 million calls per year. Thirtyfour complaints were recorded on the complaints spreadsheet and 24 on the DATIX system (web based incident reporting scheme). We reviewed four complaints and found that they were satisfactorily handled in a timely way.
  • The provider had completed a review of timescales for investigations of complaints. This had resulted in the introduction of more detailed investigation training and increased resources to further improve how complaints were handled.
  • Complaints were discussed fortnightly to ensure appropriate duty of candour and action was being taken within policy timescales.
  • Any learning from complaints was shared with the complainant, external stakeholders, national pathways, board members and staff.
  • The provider learned lessons from individual concerns and complaints and analysis of trends. It acted as a result to improve the quality of care. For example, concerns were raised about the awareness of transgender issues. Learning resulted in local guidance being changed and feedback to the national pathways organisation.

Well-led

Good

Updated 19 September 2018

We rated the service as good for well led.

Leadership capacity and capability

The chief executive stated that they were ‘incredibly proud to lead an organisation where staff and volunteers continue to deliver high standards of patient care and help ensure we deliver safe, effective and responsive services in sometimes challenging circumstances.’

There were clear lines of responsibility and accountability within the organisation. These were listed within the organisations management structure chart. Operational leaders responsible for the service had the capacity and skills to deliver the service strategy and address risks to it.

  • Operational leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them within the scope of their roles and responsibilities. For example, the leadership team had identified where staff numbers were beginning to fall and took prompt and creative actions to address the recruitment and retention issues.
  • Staff reported that line managers ‘walked the floor’ and were approachable.

Vision and strategy

  • The values of the organisation included ‘team working, innovation, professionalism and caring’. This ethos was continued through all levels within the organisation. From senior managers to frontline call centre staff. Whilst staff could not relay the exact values and vision, they were able to explain the overall theme and understood they existed. Staff said they thought their peers and managers displayed these values.
  • The provider had a strategy and supporting business plans that reflected the vision and values.

  • The provider had developed its vision, values and strategy jointly with patients, staff and external partners.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The provider planned the service to meet the needs of the local population and monitored progress against delivery of the strategy.
  • Staff referred to a culture that was supportive, encouraging and patient centred. Eighty one percent of staff survey respondents agreed with this and agreed that the care of patients was the organisation's top priority

Culture

The provider aimed for a culture of high-quality sustainable care.

  • Openness, honesty and transparency in the service were demonstrated when responding to incidents and complaints.
  • Staff were able to access occupational health services and a confidential telephone counselling service. Staff said they received appropriate support after they had dealt with difficult calls.
  • There was a culture of recognising positive staff behaviours and work. The organisation had a high five ‘Onesie of the month’ award where staff could be nominated by a colleague. The August nomination was for a member of staff who had demonstrated an empathetic, warm and caring approach during a traumatic call. This was highlighted when the call audit of the member of staff was carried out. The wellbeing staff had also commenced a ‘job well done’ card which was sent to staff who went above and beyond their job role.

We engaged with 45 staff and received surveys from both call centres. Feedback received directly from staff was positive but were mixed within the staff surveys. Positive feedback included compliments about fellow colleagues, the care provided and professionalism of service as well as the recent efforts to make the call centres a better place to work. Negative feedback was focussed on the staff numbers, lack of time to read emails and complete mandatory training.

Staff said they felt respected, supported and valued by their immediate line managers. Feedback regarding senior managers was mostly positive, although nine of the 42 surveys we received considered the senior management team did not respond to emails and did not focus on the important issues. We saw evidence of formal action plans and communication regarding improvement strategies which focussed on concerns. For example, from staff survey results, staffing shortages and call centre targets. The management team gave assurances that these concerns would continue to be addressed.

Governance arrangements

The organisation had an overarching governance framework to support the delivery of the strategy and service. This outlined the processes and procedures and there were reporting structures in place, from operational front line reports on performance, through senior management meetings, business meetings to board level and external working with out of hours GPs, urgent care services and CCGs.

  • Communication was effective, ensuring the Board received a comprehensive understanding of performance.
  • Managers who were responsible for day to day management were aware of their responsibilities and what changes they were able to influence and deliver.
  • NHS 111 service specific policies were implemented and were available to all staff. Staff were able to access Standard Operational Procedures on their computers and we found these were regularly reviewed and updated.

  • Systems were in place for identifying, recording and managing risks. Processes were in place to implement mitigating actions. The provider had a risk register which was used to capture this information, monitor actions taken and report to the CCG and board.
  • Monthly clinical governance and performance reports were produced and included statistical data related to call activities, audits and trends. Actions to address any performance issues were highlighted and monitored through contract meetings with commissioners of the service.
  • Board meetings were held every other month. The meetings ensured that the performance of the NHS 111 service was continually monitored against contracts and staffing issues. These meetings also routinely covered updates on quality and patient safety reports including Care Quality Commission updates and operational performance reports.
  • Learning from complaints and significant events were shared throughout the service and externally with other stakeholders. For example, the provider held monthly routine end to end meetings with the local integrated urgent care partners, quality leads and clinical governance leads from the commissioners. Representatives from the organisation included staff from operations, audit and training departments and the clinical governance leads for the 111 service. Meetings were planned to look at themes and trends from complaints, concerns, incidents and health care professional feedback. On some occasions extraordinary meetings were held to look at specific significant events or major cases. The aim was to follow the patient care pathway to identify what good practice had occurred, what service improvements could be made and how the services could work more effectively together.
  • There were systems in place to ensure data was accurate and timely. These included daily, weekly and monthly performance reports which were shared internally with the Trust Board and externally with the clinical commissioning group and NHS England.

  • Operational staff knew who to go to in the organisation for guidance and support. They were clear about their line management arrangements as well as the clinical governance arrangements in place. There were a range of mechanisms to cascade information, which included email and a monthly newsletter.

Managing risks, issues and performance

Systems were in place for managing risks, issues and performance.

  • There were processes in place to identify, understand, monitor and address current and future risks including risks to patient safety. These were embedded into the overall governance structure.
  • Issues and concerns were reported through the appropriate channels to the senior leadership team and Trust board.
  • Operational leaders also had a clear understanding of NHS 111 service performance against the national and local key performance indicators. This performance was discussed at senior management and board level.
  • There were embedded and established management and monitoring systems in place for the facilities and premises.

Engagement with patients, the public, staff and external partners

There was a section on the providers website which allowed patients to give feedback specifically on the NHS 111 Service and NHS 111 patient surveys were sent out every six months. Findings were communicated to staff within the monthly newsletter (Onesie) and to the board. Findings from the November 2017 patient survey showed high levels of patient satisfaction across all responses.

Areas of good practice were identified and included:

  • Speed and efficiency of the service
  • Staff listening to callers, being kind, caring, reassuring, helpful, compassionate, polite and professional.
  • Providing advice which is followed wholly or in part by up to 97% of patients
  • Providing effective links to other services, including GP out of hours and 999.

Areas of dissatisfaction included:

  • The time taken to complete the pathways assessment
  • Repetitive and/or irrelevant questioning by NHS 111 staff
  • Robotic questioning by staff
  • Long waits for contact or an appointment or home visit from the out of hours GP.

Findings from the survey were discussed and shared with the CCGs, staff within the organisation, out of hours providers and agency call centre service.

We saw evidence of staff survey results from November 2017. 283 surveys were completed. Higher scores within the NHS 111 part of the organisation included staff feeling trusted to do their job, ability to do their job and doing the job to a standard they were pleased with. Lower scores included, not feeling fully involved in deciding changes that affect work, lack of sufficient opportunities to meet to discuss the team's effectiveness and not enough staff to do the job properly. We spoke with members of the management team about these findings. They said that due to not being enough staff, opportunities to hold meetings had reduced.

The organisation had staff representatives which enabled staff to discuss their concerns or issues they may have in a safe manner. Themes and trends had included concerns regarding staffing levels and rotas. Staff said they had been informed of the work being done regarding these and noticed opportunities for overtime were less frequent.

The organisation were scoping a ‘tap happy’ app to gauge the wellbeing of staff. Staff were also encouraged to share ‘lightbulb moments’ where good ideas are shared and implemented. A recent example of action taken following staff feedback had included improvements to the staff room.

The website contained information about the services South Central Ambulance NHS Trust provide and included specific information regarding the NHS 111 service. Additional healthcare advice and signposting was provided including when to call the NHS 111 service and where to find the nearest defibrillator.

Continuous improvement and innovation

There were systems and processes for learning and continuous improvement. The service were also involved in many projects, joint working and displayed evidence of innovation. For example:

  • The organisation had been appointed as the lead partner in a co-design project for urgent and emergency care.
  • The organisation were leading innovation in the provision of new services such as mental health, pharmacy, dentistry, paediatrics, and end of life care.
  • The provider was testing a ‘HoloPatient’ training programme in which staff used augmented reality headsets which provide holograms to help training in the workplace. The equipment allowed non clinical staff to experience a range of medical conditions they would not otherwise see and assist in the telephone triage.

The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

The provider had recognised retention of staff as a challenge and had used innovative ways to address this. This included use of social media, telephone interviews and additional communication and support. Work-life balance was identified from survey results and employment exit interviews as the reason for leaving the service or sickness. As a result, the provider had employed wellbeing officers within each call centre. Since their employment in March 2018 the provider had seen a reduction in sickness rates from 13% to 5%. The wellbeing officers had:

  • Introduced a point of contact for new staff to reduce feelings of isolation within the workplace
  • Completed telephone calls to staff off sick to ensure their wellbeing needs were being met
  • Completed wellness action plans to support the mental health needs of the staff
  • Devised and started sending ‘a job well done’ acknowledgment card to staff
  • Written a guidebook of practical strategies for shift workers to help staff with sleep hygiene, coping with night shifts and healthcare tips.
  • Written a ‘Welcome to NHS 111 integrated urgent care service staff information booklet.

Checks on specific services

Access to the service

Updated 14 January 2015

Emergency 999 calls were triaged through NHS Pathways (which is a software system of clinical assessment for triaging telephone calls from the public based on the symptoms they report when they call).  There was good compliance to prioritise and categorise calls for ambulance dispatch according to the clinical needs of patients. However, staff knowledge of appropriate dispatch times for mental health patients in crises under a Mental Health Act Section 136 and needing a place of safety needed to improve. There were dedicated triage lines for GPs and healthcare professionals, and for patients who were critically unwell and needed the air ambulance or other specialist services. Some safety processes needed to improve, such as incident reporting and raising safeguarding concerns, and some staff needed a better understanding of the Mental Capacity Act 2005. Staffing levels were a concern and staff worked long hours, sometimes without breaks. Action was being taken to manage peaks in demand but staff were not meeting target times to answer emergency calls. Long-term planning against the rising increase in demand for services was ongoing. Staff had identified the need for more effective communication with the NHS 111 service to better manage demand. The trust however, did have some of the lowest referral rates from NHS 111 to 999 services and was continuing plans to reduce these further.

The staff were supportive to patients who called in distress. They listened carefully, explained their actions and involved patients in their decisions. Clinical advisors were available to help staff and to support patients to manage their own health when appropriate. They also undertook welfare checks over the phone to ensure a patient’s condition was not deteriorating while they were waiting for an ambulance. A new 24-hour labour line run by midwives had proved successful in supporting women in labour. However, the trust was below the national average for ‘hear and treat’, which is the proportion of calls that are dealt with based on provision of telephone advice only. The re contact rate within 24 hours of ‘hear and treat’ was higher than the national average in 2013-14 but had decreased this year and was below the national average in (April to July 2014). Staff had access to training but dedicated time to complete this had only recently been introduced and the uptake of some training, such as mandatory and statutory training, was low. The trust had a clear strategy for this service to provide clinical coordination of care across a range of health and social care settings, but most staff were not aware of this strategy. Governance arrangements needed to improve to support staff to share learning, raise concerns, manage risk and act on performance information. Staff worked well in their teams but some wanted better support from managers, particularly in the northern EOC. Public engagement activity was being developed further.

Patient transport services

Good

Updated 20 September 2016

We rated patient transport services (PTS) as good overall . We found the service to be outstanding for caring, good for effective, responsive and well-led and requires improvement for safe

All feedback from patients and hospital staff was positive about the care patient transport services (PTS) staff provided to patients. Patients told us staff treated them with kindness, were caring and went above and beyond to meet their needs. Staff treated patients with dignity and respect, encouraging patients to be involved with their care. Staff understood the importance of supporting patients’ emotional needs and patients valued the personal approach of staff.

The service was able to meet the individual needs of patients and was accessible to all patients who met the eligibility criteria by commissioners and national criteria for renal dialysis patients. There was good use of risk assessments to keep patients and staff safe, with information stored electronically so it was easily accessible. Staff though did not always feel confident to meet the needs of patients with mental health problems.

Services were planned to meet the needs of local people. New contracts had extended the operating hours of the service. Staff felt involved with PTS and able to make suggestions on how the service could be improved and developed. PTS had introduced a number of innovative changes, to improve the quality of the service but also to consider the future sustainability.

Staff working for PTS told us they enjoyed working for the trust, as they provided a good standard of care to patients. They felt well supported by the team they worked with and their manager. We observed good multidisciplinary working and co-ordination with other providers to deliver good quality care to patients.

Senior managers understood the importance of the commercial aspect of the service and the current competitive market for PTS. Key performance indicators (KPIs) were used effectively to monitor compliance with contracts but patient care remained the overall focus.

However:

We found that staff did not always report incidents as sometimes they did not receive feedback or learning was not shared at team meetings. Senior staff took appropriate action to respond to and investigate complaints. However, the learning from the investigations were not always shared with staff at a local team level.

Practices to keep staff and patients safe were not always identified or concerns acted upon. This included lack of clarity for staff around the administration of oxygen to patients, concerns around requesting emergency assistance when working in rural areas due to variable connectivity, Some vehicles were also not appropriately maintained and staff did not follow best practice guidance for infection prevention and control.

In PTS, some staff groups were below the trust target for compliance with mandatory training and appraisals.

The service struggled to meet some of the performance indicators set in the commissioner contracts as part of the quality monitoring of the service. In particular telephone calls were not being answered quickly enough and there were delays in patients being collected before and after their appointment.

The introduction of new contracts had been a challenging time for staff and had extended working hours. In some areas there remained issues with recruitment of staff, particularly frontline staff, in the Thames Valley area. Private providers were being used to cover vacant shifts.

Emergency and urgent care

Requires improvement

Updated 20 September 2016

Overall we rated emergency and urgent care services as requires improvement. We found the service requires improvement for effective and well led and was good for safe, caring, responsive services.

Front-line 999 services provided an emergency response to people with life threatening emergency or urgent conditions. The service had met its emergency response times for calls to be responded to within eight minutes up until May 2015. Since then there had been a decline in performance, and the target times had not been met. The national target time for patients to have ambulance transport to hospital within 19 minutes was also not met. The number of patients discharged, after treatment at the scene or who had onward referral to an alternative care pathway rather than a hospital “see and treat” was above the England average.

The trust used a Resource Escalation Action Plan (REAP) in order to plan for additional resources in the event of operational pressure being experienced . There was moderate pressure on the service during our inspection and the trust was communicating effectively with hospitals to align conveyancing decisions against waiting times and the capacity to receive patients. There was effective coordination of services with other providers and good multidisciplinary working to support seamless care, admission avoidance and alternative care pathways

The service followed safety procedures overall, but needed to improve the consistency of mandatory training, incident reporting, infection control, medicines management, and vehicle checks. The service was affected by a national shortage of paramedics within the NHS and in some areas there were a high number of vacancies. Active recruitment had been undertaken in Australia and Poland during the previous year and this had improved the situation, as well the use of bank and agency staff and independent providers to fill gaps. However, some staff we spoke with reported that they sometimes finished late, or missed meal breaks. Many staff reported being frustrated and tired.

National evidence-based guidelines were used to assess and treat patients. National ambulance quality indicators were being used. However, clinical audit needed to be further developed to monitor standards of care. Patients experiencing a stroke received an appropriate care in line with the England average. However, patients who had a heart attack were transported quickly to centres for treatment but did not always receive an appropriate care by ambulance staff. The trust was implementing an action plan which was being monitored by commissioners. Patients were a mental health condition th.at required a place of safety were being transported within 30 minutes to a designated location.

Staff reported that they felt extremely well supported by their local management teams and they had access to clinical advice although this was sometimes difficult to obtain in a timely way. However, the trust was not reaching its targets for the completion of mandatory training and staff reported that face to face training was cancelled when there was insufficient emergency cover. Staff were positive about the appraisals but many had not received appropriate trainee mentorship, supervision or a current appraisal. New staff had received appropriate induction and support.

Staff were caring and compassionate to patients and people that were important to them. They gained consent for assessment and treatment and explained treatment options in a way that the patient could understand. Patients and their relatives and carers received good emotional support.

The trust was dealing with an increasing number of emergency calls and was developing alternative pathways to transport to hospital. Long waiting times for an ambulance was steadily increasing and the trust was developing services to reduce these and increase its use of community first responders, identifying further resources for GP ambulance calls, and employing specialist paramedics to who could treat patients at home in order to avoid hospital admission. The trust was above the national average for treating people without the need for further transport. Demand practitioners were working to reduce the number of inappropriate calls and frequent callers to the service. The air ambulance services could respond to calls within their region within 15 minutes. In addition, night flying had commenced (until 2am) to meet the demand of the service.

There was support for vulnerable patients, for example, people with a mental health condition, a learning disability and those living with dementia. Staff told us they had more awareness of meeting the needs of vulnerable patients. Complaints to the service were mainly about delays and these were handled appropriately but were not being responded to within the trusts’ own target of 25 days.

The trust was revising its strategy for the service to take account of operational demands. There was still an emphasis on providing mobile healthcare and to coordinate care in hospital, the community and people’s homes. Staff were supportive of the strategy and told us they worked well together in teams and with their managers. Governance arrangements were in place to monitor performance and quality and to manage risks. Although these needed to further improve to ensure consistency across the service. Staff reported low morale. However, staff engagement was improving and work had started to address staff concerns, particularly around shift patterns and rotas. Staff received support in terms of their health and wellbeing. Patient and public engagement was developed through a variety of channels, such as social media and community liaison work. There were many examples of innovation and improvement.

    

    

     

Emergency operations centre (EOC)

Good

Updated 20 September 2016

Overall, we rated the emergency operations centre (EOC) as ‘’good’’. We found the service to be good for safe, effective, caring, responsive and well led.

Staff used evidence-based systems to provide care, advice and treatment to patients. Clinicians worked to national guidance and standards when providing advice over the phone. Calls were monitored for consistency and to ensure advice was in line with clinical protocols.

Emergency operations centre services were delivered by caring and compassionate staff. We observed good examples of staff treating patients and callers with dignity and respect.

Staff had good awareness of how to ensure vulnerable patients including children were safeguarded and there was a dedicated team who ensured safeguarding referrals were appropriately made. However, there was not a direct referral route to local authority safeguarding teams outside of normal working hours, although when urgent the police would be informed.

The service had an escalation plan for when calls exceeded capacity and action was taken to shorten calls if safe to do so. There was organisational and individual learning from incidents and complaints, staff told us they received learning through feedback from managers.

Staffing levels were a concern and staff worked long hours, often without breaks. There were a number of staff vacancies and staff were working under pressure.

The average time to respond to emergency calls was worse than the England average and the trust had some of the longest call waiting times. The trust was performing better than the England average for the proportion of emergency calls resolved by telephone advice and support (hear and treat). The proportion of the calls abandoned before being answered had decreased and was now better than the England average. The trust participated in the ambulance quality indicators, which enabled it to monitor performance.

There had been delays in sending emergency response vehicles to emergencies. This frequently happened due to excessive hospital handover times when ambulances were being held because hospital emergency departments did not have sufficient capacity.

The trust were not routinely responding to complaints in a timely manner. They were not always meeting their own target of investigating and responding to complaints within 25 days.

There were clear governance processes in place, risk registers were regularly reviewed, and managers were able to describe the current risks to the emergency operations centre. The service managed risk appropriately and performance was measured through monthly staff audits, management meetings, and reports to the board. There was a long-term strategy for the EOC and staff were aware of the trust’s vision and strategy.

We saw that staff received appropriate induction and training. Staff were trained in the NHS pathways, (the process for assessing the calls received into the call centres) so that patients could be triaged appropriately. Staff were supported to identify good and poor practice and learn about how to handle emotional calls in a sensitive and caring manner.

Other CQC inspections of services

Community & mental health inspection reports for South Central Ambulance Service NHS 111 can be found at South Central Ambulance Service NHS Foundation Trust.