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South Central Ambulance Service NHS 111 Good

Reports


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.

Inspection carried out on 7 August 2018 to 9 August 2018

During a routine inspection

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 carried out on 3 – 6 May 2016 and unannounced 13 and 16 May 2016

During a routine inspection

South Central Ambulance Service covers the counties of Berkshire, Buckinghamshire, Hampshire and Oxfordshire. There are also NHS 111 services in Luton and Bedfordshire. This area covers approximately 3,554 square miles with a residential population of over four million.

South Central Ambulance Service NHS FoundationTrust (SCAS) is part of the National Health Service (NHS). They were established on the 1 July 2006 following the merger of four ambulance trusts. On 1 March 2012, the trust became a foundation trust.The emergency operations centres handle around 500,000 emergency and urgent calls each year.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and logistics and commercial services. The trust also provides Resilience and Specialist Operations offering medical care in hostile environments such as industrial accidents and natural disasters including a Hazardous Area Response Team (HART) based in Hampshire.

Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There is a PTS contact centre at each EOC. The trust also works with air ambulance partners; Thames Valley and Chiltern Air Ambulance (TVAA) and Hampshire and Isle of Wight Air Ambulance (HIOWAA).

The trust also offers the following services: First Aid Training to organisations and the public, a commercial logistics collection and delivery service for our partners in the NHS, and Community First Responders (volunteers trained by SCAS to provide life-saving treatment).

We inspected this location as part of our planned, comprehensive inspection programme . Our inspection took place on 3 to 6 May 2016 with unannounced visits on13 and 16 May 2016. We looked at three core services: access via emergency operations centres, patient transport services and emergency and urgent care including Resilience and Specialist Operations. The 111 service provided by the trust was inspected separately. The logistical and commercial training services were not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC). During the inspection we visited both ambulance premises as well as hospital locations in order to speak to patients and staff about the ambulance service.

Overall, we rated this location as requires improvement. We rated, emergency operations centre (EOC ) as good and emergency and urgent care and patient transport services as requires improvement.

Overall, we rated the trust as being good for caring and responsive services and requires improvement for safe, effective and well led services.

Our key findings were as follows:

Are services safe?

  • Staff were clear about their responsibilities to report incidents and there was a culture of learning from incidents that was promoted in the trust. However, not all staff received feedback from incidents or had the time to report incidents when they happened, particularly in patient transport services (PTS).
  • Processes to protect people from harm, such as infection control, the cleanliness of vehicles, the safe handling of medicines and equipment and vehicle safety checks were being followed, although this was inconsistent in some areas.
  • Patients were appropriately assessed and appropriate action was taken in response to risk.
  • Patient records were accurately kept and special notes were kept for patients with specific conditions. Records were stored securely.
  • Staff were aware of safeguarding and how to recognise and report abuse or neglect. The trust however, did not have formal systems to ensure safeguarding alerts were sent in a timely way out of hours or at the weekend. If issues were urgent, then the police would be informed.
  • Overall, levels of compliance for statutory and mandatory training did not meet trust targets. This was mainly due to operational pressure, although in some areas time allocated to training had not been broadened to include this essential training. The trust was affected by the national shortage of paramedics and had staffing vacancies across all services, in the operations centres and in patient transport services. Action was being taken on recruitment and bank, agency and independent providers were being used to fill staffing gaps. However, many staff were working long hours, some without breaks and they were working under pressure to meet performance targets. Staffing rotas had been changed to meet peaks in demand, but this was affecting staff work /life balance. The trust was working to introduce new rotas to improve the work life balance of staff, whilst continuing to meet the challenge of rising demand.
  • The ambulance service was classified as a Category 1 responder under the Civil Contingencies Act 2004. Category1 responders are the organizations at the core of an major emergency response. The trust understood their duties under the Civil Contingencies Act 2004 and staff were of their responsibilities. The trust worked with partners to improve the ways in which police, fire and ambulance services worked together at major and complex incidents. Pre-identified high-risk sites in the region were identified so there could be an effective coordinated response in a local area, there were joint training events with other services, such as the police and fire services, and the trust participated in emergency plans and rehearsals to be able to respond to chemical, biological, radiological, nuclear or explosive incident scenarios.

Are services effective?

  • Care and treatment for patients was planned taking account of current evidence based guidance, standards and best practice. Clinical and medical protocols were used to ensure standards met national practice guidelines.
  • The trust monitored national ambulance quality indicators in emergency and urgent care services. There was less evidence of the routine use of clinical audit to monitor standards of care.
  • 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 taking action on this. The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
  • The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
  • The trust was performing above the England average for emergency calls resolved by telephone advice and support only (“hear and treat”).
  • The trust performed above the England average for the number of patients managed without need for transport to hospital, referred to as ‘see and treat’. The re-contact rate for patients, that is, for patients who called the services within 24 hours of their first call, was similar to the England average.
  • Response targets for 999 emergency services for patients with life threatening or urgent conditions were not being met. The trust had an improvement plan in place.
  • Following a cardiac arrest, the Return of Spontaneous Circulation (ROSC) (for example, signs of breathing, coughing, or movement and a palpable pulse or a measurable blood pressure) is a main objective for all out-of-hospital cardiac arrests, and can be achieved through immediate and effective treatment at the scene. Percentage of patients with ROSC at time of arrival at hospital was better than England average. However, using the Utstein Comparator Group (a more comparable and specific measure of the management of cardiac arrest) the percentage of patients with ROSC at time of arrival at hospital was worse than England average.
  • A response targets for the transport of mental health patients in crises who needed a place of safety (section 136) within 30 minutes was being met for 74% of patients. The trust was above the England average of 62% (range 31% to 90%).
  • Most patients who had suffered a stroke received an appropriate care bundles. However, patients who had suffered a heart attack did not always receive an appropriate care bundle. The trust was implementing a recovery action plan to improve this.
  • The trust was above national targets for using care bundles for hypoglycaemia, limb fractures, and febrile convulsion. The trust had not met the target for asthma care.
  • New contracts had extended the operating hours of the patient transport service (PTS), to support the development of a seven-day service. However, key performance indicator data for 2015/16 showed PTS target times had not consistently been met for the arrival and collection of patients following hospital outpatient appointments or discharge. Transport times for renal patients in general met national standard times and had significantly improved from the previous financial year.

  • There was effective coordination of services with other providers and good multidisciplinary working to support seamless care, admission avoidance and alternative care pathways. For example, hospital ambulance liaison officers and hospital liaison officers were viewed by positively by hospital staff to coordinate emergency ambulance services and patient transport services respectively.
  • Staff had good induction procedures and access to training. The trust was supporting staff to enhance their roles, for example, specialist paramedics. However, many paramedic staff identified difficulties with accessing training and qualification opportunities.
  • Many staff did not receive regular supervision although, most staff had an appropriate annual appraisal. Some staff in PTS services had not received a recent appraisal
  • Staff followed consent procedures. Many staff did not have a clear understanding of the Mental Health Act, although this had improved for staff working in emergency 999 services and there was support for staff from mental health practitioners.

Are services caring?

  • Staff across all services were caring, compassionate and treated patients with dignity and respect. Patients were positive about the service they received and the way they were treated.
  • Staff supported patients to cope emotionally with their care and treatment. They were also supportive and reassuring when dealing with patients who were distressed.

  • Call handlers took time to ensure callers understood the advice and to explain treatment or expectations to callers in a way the callers could understand.
  • Ambulance crews explained treatment and care options in a way that patients understood and involved them and their relatives in decisions about whether it was appropriate to take them to hospital or not.
  • Care was outstanding in patient transport services were patients reported well developed supportive and caring and trusted relationships particularly regular users, such as renal or mental health patients. Patients appreciated this personal approach and the respect shown by staff for their social and emotional needs.

  • Patients could receive advice from clinicians to manage their own health. Clinicians would also provide information to patients about managing conditions if symptoms worsened and would signpost patients to alternative services non-emergency services such as their GP or local urgent care centres.
  • There were only a few examples where patients had highlighted being treated inappropriately and without care.

Are services responsive?

  • The trust had developed services in order to meet the needs of the local population and respond to the increasing demand for emergency and patient transport services. Many services were being introduced to manage demands on the service, avoid hospital admissions and refer patient to alternative non-urgent pathways of care.

  • The emergency operations centres had clinical specialists, for example, in mental health, and support staff. More community first responders (CFR) and co-responders were being used to respond to emergency calls.

  • Prolonged delays at some acute hospital’s emergency departments had reduced the capacity of front line staff to respond to patient’s needs. The number of long waits for an ambulance had steadily increased.
  • Action was being taken to address the increasing demand for emergency ambulance services. There were demand practitioners in post to manage frequent calls and provide patients with individual care plans. Services were being developed to ensure waiting times for an ambulance arrival met national targets, for example, more resources were being identified to support GPs calling for an ambulance calls. More specialist paramedics had been employed who could treat patients at the scene or at home in order to avoid hospital admission.
  • 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.
  • Patient transport services (PTS) had been extended to operate over seven days. The service was accessible to all eligible patients irrespective of any additional needs. Staff could identify patients who needed prompt transport, for example, if they had significant pain, a chronic illness or were to receive a home care package from the detailed notes. However, the electronic systems did not flag patients as a priority for collection to ensure this happened in a systematic way.
  • Patients and staff experienced delays when calling the contact centres to identify when transport would be available. Call response times were not met. A new on line PTS booking system had been introduced to try to reduce delays. The online ‘book ready’ system was also introduced to prevent vehicles being sent when a patient was not ready for collection. The system also allowed hospital staff to see the estimated time of arrival. Patients could access this information through the ‘my booking’ section of the trust website.
  • 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.
  • There was provision to provide ambulance transport for bariatric patients.
  • Staff had access to translation and interpreter services for people whose First language was not English. Callers also had access to services that supported patients with hearing and speech impairments
  • There was a clear process for the management of complaints, staff were aware of their responsibilities, and complaints were investigated at local level. However, information and learning from complaints was not always shared effectively in PTS services. The trust was not routinely responding to complaints in a timely manner.

Are services well-led?

  • Services had a clear vision and strategies were being developed or revised to take account of increasing numbers of emergency admissions and changes to patient transport services.
  • Staff were engaged with the trusts vison and strategy and displayed the trusts values in their own work.
  • Many staff were positive about their local leadership and felt supported within their teams. Team leaders were given support and training to do their roles
  • Staff were proud to work for the organisation, although staffing pressures were affecting staff moral and wellbeing. Staff in all areas were working long hours and under pressure with late or missed meal breaks. Many staffing cited disruptions to their work/ life balance. The trust was recruiting to all roles including overseas recruitment for paramedics. They were also supporting staff development and training some emergency medical technicians to paramedic level.
  • Governance arrangements to monitor the quality and safety of services were in place. The level of staff involvement and understanding, the feedback and sharing of information and the monitoring of services through audit varied. Staff in frontline emergency 999 services had an awareness of risk but sometimes lacked knowledge on the progress being made and the action being taken to manage locally identified risks.
  • The trust could demonstrate some improvements to the service following the last inspection in September 2014.
  • Not all staff groups were given the opportunity to attend team meetings and some did not have time to attend team meetings. This did limit opportunities for some staff to raise concerns, share in learning or contribute to service development.
  • There was a focus on improving the health and wellbeing of staff and the trust had recognition and reward schemes for staff.
  • Services could demonstrate innovative practices.

We saw several areas of outstanding practice including:

  • A smartphone triage app had been produced in conjunction with the Wessex Trauma Network. This meant clinicians could use the triage tool to identify if their patient needed to bypass a local hospital and be conveyed directly to a major trauma centre, and which one was the closest.
  • The trust had introduced demand practitioners and emergency care practitioners (specialist paramedics) to support patients to manage their own health conditions at home and to treat patients without the need for hospital admission.
  • The trust uses a mobile simulation vehicle which offers an innovative approach to training for staff.
  • Mental Health practitioners are in control contact centres at weekend peak times. They are piloting direct referrals to Samaritans and local mental health teams. This has improved timely patient access to mental health services.
  • The Berkshire Hub connects services together as a single point of access location. The Hub includes out of hours, community, minor injury and illnesses and mental health services. There are shared records and special patient notes for patients. The Hub has increased access to NHS, GP, dental, pharmacy, mental health and labour line services.

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

Importantly, the trust must ensure:

  • Staff in urgent and emergency care are supported with their development through supervision
  • Response times for emergency and urgent care services are met.
  • Governance arrangements in emergency and urgent care services must ensure that staff are aware of risks and safe practices are consistently applied.

In addition the trust should ensure:

  • Staffing levels across all services meets planned levels identified by the trust.
  • Review compliance with appraisals and mandatory and statutory training, including safeguarding training, to ensure that staff are supported to complete the required training in a timely.
  • Ambulance response bags are appropriate for use and are replaced when necessary.
  • Noise levels in Northern House are reviewed to minimise the risk of missing, miss-hearing or delays in recording patient information.
  • Escalation procedures for the immediate handover of emergency patients are developed and agreed with all hospital trusts.
  • The process for making safeguarding referrals to local authorities is reviewed and referrals happen in a timely manner to ensure safety of vulnerable patients outside of normal working hours.
  • All medicines must be safely managed at all times, particular attention must be given to the safe management of controlled drugs.
  • All staff should have adequate training in mental health and dementia awareness, which is updated at regular intervals to ensure that mental health knowledge is current.
  • All complaints should be investigated and responded to in a timely manner in line with the trust policy.
  • The structure of team meetings should be in place for all staff groups to ensure staff are given the opportunity to attend, share information and raise issues or concerns.
  • The processes for sharing the learning from incidents, safeguarding and complaints with staff is reviewed to ensure staff are using this information to improve the quality of care provided to patients.
  • Health and safety risk assessments are completed at resource centres.
  • Rest breaks for all ambulance staff should be planned into their schedule, compliance monitored and action taken to ensure staff well-being.
  • Staff comply with hand hygiene and infection control polices with regular infection control audits to check compliance across the PTS.
  • The risks associated with lack of connectivity for PTS staff working in rural areas is reviewed and ensure staff, particularly lone workers, are able to summon help through their PDAs in an emergency, and the reliability of this system is monitored.
  • There is clarity in the standard operating procedure and policy for the administration of oxygen to patients by frontline PTS and this process is clearly understood by staff.
  • Current systems for PTS are reviewed so patients with the greatest need are more easily identified as priorities for patient transport.
  • There is a standard approach to record minutes for meetings across the PTS. These should be in sufficient depth and recognised as being a formal document, with the content written in a style to reflect this.
  • Improve the recording of the authority to administer or supply a medicines under a PGD
  • Medicine modules are managed correctly, and tamper evident tags are consistently recorded.
  • All patient records are kept securely and disposed of in line with trust policy.
  • Staff are given the time and opportunity to report incidents in emergency and urgent care services and they have appropriate feedback.
  • The time allocated for staff to complete vehicle checks at the start of each shift is reviewed and actioned appropriately so that staff have sufficient time to complete the task.
  • The current recruitment drive continues, while monitoring and taking action on the health and wellbeing of the current work force, including the impact of shift rostering and any changes implemented.
  • Continues to work with commissioners and other providers to improve response times and their ability to meet their key performance indicators and national targets..
  • The reasons for staff turnover and low morale across all services is continually addressed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3 and 4 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of the NHS 111 service provided by South Central Ambulance Service NHS Foundation Trust on 3 and 4 May 2016. We visited both sites which are located in Bicester, Oxfordshire and Otterbourne in Hampshire.

A responsive inspection of this NHS 111 service was undertaken in November 2015. The service was not rated at this time and not all of the domains were inspected. We found the provider reacted positively to the issues raised during that inspection and had implemented an action plan and made the necessary improvements by May 2016.

Our key findings were as follows:

The NHS 111 service provided a safe, caring, responsive and well-led service to a diverse population spread across central and south England. However, improvements were required to provide a fully effective service. Overall the provider was rated as good.

  • At the time of inspection, we noted times between January-March 2016 where there was insufficient access to clinical staff, particularly during periods of high demand. However, more recent data showed this had improved in April 2016, with minimum standard clinician ratios being met  91% of the time.

  • Regular specialist training was provided to staff and there were a number of different courses for staff to access flexibly. However, some staff indicated that sometimes it proved difficult to find the time to access role specific training due to their busy roles.

  • The NHS 111 service had systems in place to mitigate safety risks. Incidents and significant events were identified, investigated and reported. The provider was responsive when things went wrong and was also proactive in the prevention of these incidents. The provider was monitored against the Minimum Data Set for NHS 111 services and adapted National Quality Requirements. These sets of data provided intelligence about the service and showed SCAS performed in line or better than other NHS 111 providers. These were shared with commissioners and action plans were implemented where a variation in performance had been identified. For example, the low performance of clinical call backs.
  • The provider also worked with outside agencies and charities to secure improvements to services.
  • 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).
  • Eighty-one percent of nurses and paramedics had undertaken level 2 safeguarding training.

  • The trust had also been identified and approved as an appropriate national testing site for new NHS pathways being introduced.
  • Staff were supported to report issues and concerns and considered the organisation a supportive, no blame culture to work in.
  • Patients using the service were encouraged and supported to respond to the telephone clinical triage and their consent and decisions were respected.
  • The provider was responsive and acted on patient complaints and feedback. However, the trust recognised improvements were required and action had been taken since November 2015 to reduce the length of delays and long response times to complaints. Further work to deliver improvements were still in progress.
  • Feedback from patients was welcomed by the provider and used to improve the service.
  • There was visible leadership, with an emphasis on continuous improvement and development of the service.
  • The vision to develop and expand the service in accordance with the trust five-year business plan was being implemented.

The areas where the provider must make improvements are:

  • Ensure the provision of clinical advice is managed in line with national targets and callers receive call backs and timely advice to care and treatment.
  • Review processes to ensure staff have sufficient time to access the training provided for them required to perform their roles.Ensure all staff receive appraisals within appropriate time periods.
  • Ensure all clinical and non-clinical staff are trained to the appropriate level for safeguarding adults and children.

There were areas of practice where the provider should make improvements:

  • Raise staff awareness of who the professional leads are within the organisation.
  • Review telephone answering messages to ensure patients have the correct advice in an emergency.
  • Continue to implement effective changes to ensure complaints are received, recorded, handled and responded to appropriately and in a timely way.
  • Review and implement updated business continuity plans for each of the NHS 111 call centre locations. Specifically, updating the key contact details.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 11 and 12 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a focused inspection of the NHS 111 service provided by South Central Ambulance Service NHS Foundation Trust on 11 and 12 November 2015. We visited both sites located in Bicester, Oxfordshire and Otterbourne, Hampshire. This was a focussed inspection to focus on the specific areas of the media coverage. Please note that the full key lines of enquiries and domains were not reviewed.

The Care Quality Commission (CQC) carried out this focused inspection as a result of an undercover reporter’s media article on 1 July 2015 which raised concerns about the way the NHS 111 service was operated by South Central Ambulance Service NHS Foundation Trust. The concerns included alleged inappropriate use of systems and processes, for example, inappropriate referrals to the 999 service. The article also raised concerns relating to recruitment processes, inadequate staffing levels, lack of staff training and support, and the way complaints and significant events were managed. There were also concerns raised about how governance was managed, general leadership of the organisation and the processes in place for staff feedback.

The trust had notified CQC of the media interest prior to its publication and has subsequently kept CQC informed of the progress of the investigation. We inspected after the Trust had put into place a number of actions following their investigation.

The NHS 111 service provided by South Central Ambulance Service NHS Foundation Trust was a telephone based service where patients were assessed, given advice or were directed to a local service that most appropriately met their needs. For example, this could be an out-of-hours GP service, a NHS walk-in centre or urgent care centre, a community nurse, the emergency department at their local hospital, an emergency dentist, emergency ambulance or late opening chemist.

Our key findings were:

The South Central Ambulance Service NHS Foundation Trust provided safe, effective, responsive and well-led services.

  • The provider had suitable systems in place to monitor safety over time, which included learning from incidents and complaints. For example, the investigation performed by the provider showed that of the specific issues raised by the newspaper, none had been substantiated to give significant cause for concern over the safety of the service that the Trust provided. These judgements had been externally reviewed by the Commissioning Clinical Governance GP leads. However, the Trust acknowledged that other issues had been identified during the course of the investigation which did give cause for concern and had resulted in changes and improvements being made.

  • Staff understood, were provided with sufficient time and fulfilled their responsibilities to raise concerns and report incidents.

  • The service was monitored against the Minimum Data Set (MDS) for NHS 111 services and adapted National Quality Requirements (NQRs). These data collection tools provided intelligence to the provider and commissioners about the level of service being provided. Action plans were implemented where variation in performance was identified. National data collection and monitoring showed the 111 service was being managed effectively.

  • The provider had responded promptly to concerns received and had proactively used the information to review systems and processes and further improve service provision.

  • Patients were assessed and treated in line with best practice and current national guidance using the latest version of NHS Pathways and NICE guidelines. (NHS Pathways is a software system of clinical assessment for triaging telephone calls from the public based on the symptoms they report when they call).

  • There were effective day to day working arrangements within the service, with staff having clear roles and responsibilities. Staffing levels and skill mix were well managed. Systems were in place to manage peaks in demand.

  • There was a robust recruitment process in place. Staff had access to an improved training and induction programme. Systems were in place for ongoing support and coaching.

  • Communication through the organisation had continued to improve following the investigation. Staff felt supported and well informed following the investigation and felt able to freely offer feedback.

  • Staff were trained and monitored to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a licenced 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). Systems were in place to mentor new staff members until they were competent in its use. Staff were then continually monitored. Regular updates of the clinical NHS Pathways were undertaken.

  • Patients were involved in care and treatment decisions and consent. Staff knew the action to take if a person’s capacity to make decisions was in question.

  • The provider worked with the lead Clinical Commissioning Group and NHS England to respond to and meet patients’ needs and had involved them following the investigation.

  • Staff had access to best practice guidance and a Directory of Services. These documents were well maintained and kept up to date by a designated member of staff.

  • The vision and values of the service had been communicated well to all staff members. Staff were positive about the continued improvement of quality of care they provided for patients and told us they were proud to work for the trust. Staff said morale had improved in the last three months and had welcomed the additional support offered.

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

Importantly the provider should:

  • Introduce a robust system to ensure all staff records are updated when they have read updates to current guidance and policies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 8 – 12, 30 September and 1 October 2014

During a routine inspection

South Central Ambulance Service NHS Foundation Trust (SCAS) was formed on 1 July 2006, after the merger of the Royal Berkshire Ambulance Service NHS Trust, the Hampshire Ambulance Service NHS Trust, the Oxfordshire Ambulance Service NHS Trust and part of the Two Shires Ambulance Service NHS Trust. It provides NHS ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire in the South Central region. This area covers approximately 3,554 square miles with a residential population of over 4 million. On 1 March 2012, the trust achieved foundation trust status.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and logistics and commercial services. There is also a Hazardous Area Response Team (HART) based in Hampshire. Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There was a PTS contact centre at each EOC.

Our inspection took place on 10 and 11 September 2014 with unannounced visits on 30 September and 1 October. We inspected the trust as part of our first wave of comprehensive ambulance inspections. We looked at three core services: access via emergency operations centres, patient transport services and emergency and urgent care. The 111 service provided by the trust was not inspected on this occasion. The logistical and commercial training services were also not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC).

The team of 48 included CQC inspectors and inspection managers, an analyst and inspection planners and a variety of specialists: The team of specialist was comprised of a consultant physician in intensive care, two nurses working in accident and emergency departments, four paramedic staff, one emergency care practitioner, a paramedic clinical supervisor and development manager , three managers with an operations role, a head of governance, a director of service delivery, two chief executives, a pharmacist, a safe guarding lead, two people with a role in an operations centres and three experts by experience

We did not provide ratings for this trust because this inspection was part of our first wave of ambulance inspections to apply our methodology and develop our understanding of inspecting in this sector.

Key findings

Across the core services:

  • Staff were caring and compassionate, and treated patients with dignity and respect.
  • Staff were positive about the quality of care they provided for patients and were proud to work for the trust. There was low morale in places and the pressures faced by the trust were recognised. Staff however “lived” the values of the organisation: “Towards excellence – Saving lives and enabling you to get the care you need”.
  • Patients told us their experiences of care and treatment was good. They were positive about emergency ambulance response times but there were concerns about the punctuality of patient transport services.
  • Incident reporting was increasing on the newly introduced electronic reporting system. The trust was taking action following incidents, but there needed to be earlier and quicker investigation for some incidents. Learning was shared via clinical bulletins, the trust intranet, noticeboards and email. The trust had introduced SCAScade to improve organisational learning from when things go wrong. This included anonymous cases and reflective tools for staff to use on the trust intranet. However, staff in the EOC and PTS needed to be encouraged to use and take responsibility for reporting incidents and also required feedback and shared learning in their areas.
  • Staff in the emergency and urgent care service had good knowledge of the Mental Capacity Act 2005, but staff in EOC and PTS needed to have better knowledge to ensure the best interest of patients.
  • Safeguarded procedures were being used but needed to improve and the safeguarding lead had a limited capacity to deliver the safeguarding agenda across the organisation. Safeguarding champions in geographical areas were to be developed but this needed to be prioritised.
  • Staff had good training opportunities and specialist training on dementia care, learning disabilities and mental health was being improved. Staff were supported with funding for further qualifications and professional development, However, some staff did not always have access to computer facilities to undertake training or the dedicated time to complete it, and attendance at mandatory and statutory training was low.
  • Most complaints were responded to within the trust’s target time of 25 days and action was being taken to improve services as a result. Complaints were analysed to identify themes and the trust aimed to share learning, for example, through teams and noticeboards. There was evidence of actions taken as a result of complaints in all services. However, staff told us they did not always get feedback on complaints or concerns raised.
  • The trust understood its duties under the Civil Contingencies Act 2004 and all staff were aware of what to do in the event of a major incident. Staff had appropriate training, there was joint working with partner organisations (such as the fire service, police and military), and rehearsals were undertaken as part of preparation and planning exercises.
  • The trust had worked with partner organisations including fire and rescue, police, and the environmental agency during the floods in the Thames Valley area in early 2013. The Hazardous Area Response Team (HART) had worked throughout the region and specifically in Wraysbury, Berkshire, 24 hours a day over 4 days, to assist with the rescue and support operation.

Emergency Operation centres (EOC)

  • 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 (the Helicopter Emergency Medical Services, [HEMS]) or other specialist services, such as the Hazardous Area Response Team (HART).
  • 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.
  • Overall, the trust had referral rates of 8% from NHS 111 to 999 services, and these were better than the service level agreement performance of 10% and one of the lowest in the country. Staff identified the need for further action on managing the demand created by the NHS 111 service, and the trust’s long-term planning against the rising increase in demand for services was ongoing.
  • 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. The clinical adviser also undertook welfare checks over the phone to ensure a patient’s condition was not deteriorating while they were waiting for an ambulance. 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).
  • Engagement between the trust and the public and patients was being developed further.
  • The trust had a clear strategy for the EOC to provide clinical coordination of care across a range of health and social care settings. However, most staff were not aware of this strategy in relation to their service. 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.

Emergency and Urgent Care

  • Front-line 999 services provided an emergency response to people with life threatening emergency or urgent conditions. Overall, during 2013/14, the trust was meeting national emergency response targets for 75% of calls to be responded to within 8 minutes. The national categories are for Red 1 calls (for patients who have suffered cardiac arrest or stopped breathing) and for Red 2 calls ( for all other life threatening emergencies). Red 1 and Red 2 calls added together and are referred to as Category A calls. The category A target is to have a vehicle that could convey a patients to hospital arrive at the scene within 19 minutes for 95% of cases. This target was also met.
  • The trust had the highest percentage of ‘see and treat’ in the country (that is, managing patients at the scene without the need for ambulance transfer to hospital). The re-contact rate within 24 hours of this treatment was higher than the national average in 2013-14 but was  decreasing.
  • The trust used a Resource Escalation Action Plan (REAP) as a way of forecasting performance and service delivery. There was moderate to high 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. This included having hospital ambulance liaison officers (HALOs) to support the timely handover and safety of patients in A&E departments and to monitor and respond to situations, particularly at times of increased demand for services. There was effective planning and preparation for major incidents and the trust had worked effectively with partner organisations.
  • The trust was monitoring long waiting times and had introduced measures to ensure that people were monitored while waiting and that high-priority calls took precedence. There was an impact however on people who may be in a healthcare setting but awaiting transfer to another hospital for acute care and for people at a distance from an ambulance station. The trust was taking action to reduce these waiting times.
  • The service followed safety procedures overall, but needed to improve infection control practice and the management of medicines. Staff had a good understanding of the Mental Capacity Act 2005 and of safeguarding procedures although the timeliness of reporting concerns and referrals needed to improve. The performance of the external contractor to ‘make ready’ ambulances (that is, to prepare ambulances, for example,  in terms of cleanliness and appropriate equipment) was monitored but the quality of their work required better supervision and monitoring. Ambulance crews had allocated time to check vehicles but told us they spent more time rechecking vehicles to ensure they were ready for use.
  • The trust was affected by the national shortage of paramedics and there were a high number of vacancies. The allocation and skill mix of staff were appropriate but staff worked long hours and some reported stress and fatigue. There was a rising demand for services that was above predicted levels. The trust had introduced shift changes to help manage resources to meet demand in emergency services and new rotas were being introduced to further improve the work life balance of staff. The trust used private providers to ensure service cover and these providers were appropriately monitored. Staff spoke positively about the level of communication on issues and they understood the need to match resources and demand, and requested further ongoing dialogue around these issues.
  • National evidence-based guidelines were used to assess and treat patients. Patients experiencing a heart attack did receive pain relief although this was not always the pain relief that was nationally recommended. Patients experiencing a heart attack were transported quickly to hospital. Patients that had had a stroke had appropriate care but there could be delays in their transport to hospital. Some hospital staff identified the need for better pain relief for children in certain circumstances.
  • The coordination of emergency care with hospitals and GPs was good overall, but needed to improve for heart and stroke care in Buckinghamshire and for mental health patients in crisis across the four counties. The trust was working with its partners and had action plans to improve care in these areas.
  • The trust was ranked the best in the country for patients who had had a cardiac arrest and stopped breathing, who then after resuscitation, had a pulse/ heartbeat on arrival to hospital. This is called return of spontaneous circulation (ROSC). The trust had improved its effectiveness of action taken when staff witnessed a cardiac arrest and was fourth best in the country this year (April to August 2014) a change from eighth best in 2013-14.
  • The trust was ranked the best in the country for patients who had had a cardiac arrest and survived to be discharged from hospital.
  • Staff explained treatment options to patients in a way that they, or their relatives, could understand. Patients, and relatives or carers, received good emotional support if they were in distress. There was support for vulnerable patients, such as those with a learning disability, bariatric patients and people whose first language was not English.
  • Engagement between the trust and the public and patients was well developed through a variety of channels, such as social media, surveys, newsletters and liaison work.
  • The trust had a clear vision and strategy for the service to provide mobile healthcare and to coordinate care in hospital, the community and people’s homes. Staff were supportive of the strategy and worked well together in teams and with their managers. There were good governance arrangements to monitor performance and quality and to manage risks although more action was needed on ongoing risks.

Patient Transport Services

  • Patient transport services (PTS) provided non-emergency transport for patients who attend, for example, outpatient clinics or day hospitals, or were discharged from hospital. Commissioners had identified eligibility criteria for the service and the trust was working with 12 clinical commissioning groups to monitor performance and compliance.
  • Staff followed the eligibility criteria designed by commissioners and were also working to improve the signposting of people to other services if they did not meet the criteria.
  • Procedures to ensure the safety of services needed to improve, specifically around incident reporting, equipment checks and safeguarding procedures. Most vehicles were visibly clean. ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) orders were understood and used appropriately, but staff had limited awareness of the Mental Capacity Act 2005.
  • There were staffing vacancies and staff felt stretched, particularly in the dispatch team where this had an impact on the planning and scheduling of transport. The trust was using volunteers and private providers to cover driving shifts. There needed to be better governance arrangements for private providers and for driving and employment checks for volunteers.
  • The trust had made significant changes to the IT system in the PTS on the day of our inspection. Anticipated resource and capacity risks needed to be better managed, for example, problems with the new IT system had caused a serious disruption to transport arrangements for many patients during our inspection
  • Dispatch staff did not always have appropriate assessment information, from hospitals or patients or from their own records. Patients sometimes did not have an appropriate vehicle or equipment, and transport sometimes had to be reorganised. The system to plan journeys was manual and often reactive based on a lack of timely and coordinated information and this had caused delays to patient transport.
  • The trust was not meeting performance targets and this was having an impact on patients’ care and treatment. Patients were experiencing delayed and missed appointments for outpatient consultations and diagnostic scans, and renal dialysis, and some were choosing to curtail their treatment in order not to risk missing their transport home for fears of excessive delay. Some hospitals had reorganised clinics, for example, to finish early to accommodate the vagaries of the PTS. There were good examples of multi-disciplinary working with GPs and health professionals in hospitals.  The trust had been working with other providers to improve the coordination of care and some progress had been made.
  • Patient surveys were regularly undertaken; these were positive about the service but identified delays. Patients we spoke with were positive about the care and compassion of staff. However, they were concerned that the service was not effective and that they were not given enough information about delays, missed appointments and the eligibility criteria.
  • Many patients told us they had been distressed and anxious waiting for transport, but did not know whom to contact within the service. Call handlers were overwhelmed with calls about service delays and only half of all calls were answered.
  • There was good support for vulnerable patients (for example, those with dementia or a learning disability), and carers and escorts could travel in the ambulances too. A policy for the transport of children needed to be developed.
  • The trust had a clear strategy for the development of PTS to support safe non-emergency travel between people’s homes and healthcare settings, but most staff were unaware of this strategy. Governance arrangements needed to improve in order to assess and manage risks. Although staff worked effectively in teams, many wanted the management and leadership of the service to improve and for the trust to prioritise PTS services alongside the emergency 999 service.

We saw several areas of outstanding practice:

  • We observed many examples where staff demonstrated outstanding care and compassion to patients despite sometimes working in very difficult and pressured environments. Staff “lived” the values of the trust “Towards excellence – Saving lives and enabling you to get the care you need”.
  • Representatives of the trust attended local youth organisation meetings, village fetes and school assemblies. The trust had developed a child-friendly first-aid book printed specially for schools and the wider local community.
  • The trust provided an innovative learning resource to their frontline staff using the educational resource centre and film centre at Bracknell. The staff were involved in making films which supported learning around new guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).
  • The trust had introduced a lifesaving automatic external defibrillator (AED) locator mobile phone application. By using GPS, this app locates the nearest AED in the event of a cardiac arrest. In total, the app identified over 800 AEDs across four counties.
  • A new initiative was the introduction of a ‘Simbulance’: a large command vehicle fully equipped with simulation learning activities. It was an innovative virtual classroom facility in that it gave ambulance staff the opportunity to experience realistic medical situations inside an ambulance saloon.
  • Operation centres had direct access to electronic information held by community services, including GPs. This meant that the staff could access up-to-date information about patients (for example, details of their current medication).
  • Trauma risk management (TRiM) was in place to provide confidential support to staff who may have been affected by traumatic incidents or conditions. Staff were assessed 3 days after a traumatic event and again after 28 days. Thirty-two TRiM practitioners gave peer support and advice, and there was also an external counselling service. The early intervention had both reduced sickness absence and improved the welfare of staff.
  • The Helicopter Emergency Medical Services (HEMS) showed innovative practices and learning taken from combat zones. The team now had the equipment and skills to give blood transfusions and perform ultrasound and blood gas tests. In some circumstances, this bypassed or reduced the time a patient had to spend in the accident and emergency (A&E) department, and meant they could receive treatment immediately on arrival at the hospital. HEMS was also planning to introduce a night service, so it would operate 24 hours every day.
  • The introduction of a midwife to the clinical support desk (CSD) in the Southern House emergency operation centre had improved the outcomes for expectant mothers and their new babies. The 24-hour labour line started as a pilot in May 2014. It gave women in labour access to advice and support, whereas the ‘professional’s line’ enabled medical professionals to speak to a midwife 24/7 during a woman’s labour and birth. The service had over 1,600 calls in the first eight weeks.
  • The trust provided a service on Friday and Saturday nights in the city centres of Portsmouth (Safe Place) and Southampton (ICE Bus) to provide support, first aid and transfer to hospital if required for the public enjoying a night out. This had been set up in partnership with other organisations such as the Hampshire Police, the local council, volunteers and the local street pastors
  • The trust had a clinical lead in mental health and learning disability. This role was unique among ambulance trusts. The lead had established a national mental health group for ambulance trusts, and worked with partner agencies such as the Royal College of Psychiatrists and the College of Policing. The introduction of mental health practitioners into the EOC was supporting operational practice and care to mental health patients.
  • The trust had worked in partnership with Oxford Brookes University to provide staff with extra opportunities to develop their careers by becoming a paramedic, and to counter the national shortage of paramedics. A foundation degree course was to start in January 2015. The training covered an 18-month period and included in-hours training. The trust’s investment had been significant in terms of the time taken to negotiate the resources and facilities for the programme and the release of staff from work duties.

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

Importantly, the trust must ensure that:

  • Staff uptake of statutory and mandatory training meets trust targets
  • Staff in EOC and PTS understand the Mental Capacity Act 2005
  • All EOC and PTS staff receive safeguarding training to the required level so that they are able to recognise signs of abuse and ensure there are robust arrangement in place for staff to report concerns within the agreed timescale.
  • Emergency call takers answer calls, and the emergency medical dispatchers dispatch an ambulance within target times

In addition the trust should ensure that:

  • Procedures for incident reporting continue to improve and staff in EOC and PTS have appropriate training and are able to report incidents directly. There must be timely investigation of incidents, staff must receive feedback and learning must be shared.
  • The risks around IT vulnerability in the EOC and PTS are appropriately managed.
  • Infection control practices are followed and ambulance stations (resource centres) and vehicles are effectively cleaned and deep cleaned.
  • There are suitable arrangements to ensure that equipment regularly checked and fit for purpose.
  • Staff are aware of the appropriate steps to take to reduce the risks to patients left unattended in PTS ambulances because of staff working alone.
  • Appropriate equipment is available in all areas for the transport of children in PTS and this continues to be rolled out for emergency transport.
  • Volunteer drivers in PTS have the appropriate safety and employment checks before working within the service.
  • The trust to continue to work with partners and ensure the planning and scheduling of PTS improve to prevent delays and missed appointments, and to reduce the impact on the clinical care, treatment and welfare of patients.
  • The governance and security arrangements for the management of controlled drugs need to be improved in Hampshire.
  • Recruitment of staff in all areas continues and there are specific staff retention plans in response to identified reasons as to why staff leave.
  • Staff in PTS receive appropriate training on dementia care, learning disabilities and all staff continue to received training in mental health conditions.
  • Anticipated resource and capacity risks in PTS continue to be appropriately identified, assessed and managed.
  • Pain relief continues to be appropriately administered for patients with ST segment elevation myocardial infarction (STEMI) and pain relief for children is effectively monitored.
  • Continue to work with acute trusts to review protocols for the non- critical transfer of hospital patients.
  • There is better coordination of care between providers, in particular for cardiac and stroke services in Buckinghamshire and mental health services.
  • Complaints are responded to within the trust’s target of 25 days. All staff in EOC and PTS receive feedback from complaints and learning is shared.
  • Operations staff in PTS are appropriately resourced to be able to answer telephone calls.
  • Patients (or people acting on their behalf) using the PTS  are made of aware of how to complain or send compliments about the service.
  • Staff in PTS have regular supervision and the trust should raise awareness amongst staff about the professional and career development opportunities within the trust.
  • The formal structure of team meetings is in place for all staff groups and staff are given the opportunity to attend, share information and raise issues or concerns.
  • Staff have a better understanding of the trust’s vision and strategy as it applies to their service in EOC and PTS and staff communication continues around service changes and development.
  • Leadership in the northern EOC and PTS supports staff and action is taken to improve staff morale where this is low.
  • Staff in PTS receive feedback from the completed patient satisfaction surveys.
  • There are better governance arrangements within EOC and PTS to share information with staff, so that staff can raise concerns and risks are appropriately identified, assessed and managed.
  • There are better governance arrangements for private providers of PTS and make ready services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 7, 8, 15 August 2013

During a routine inspection

As part of this review we made unannounced visits to four ambulance bases and to the South Central Ambulance Service (SCAS) head quarters where the emergency control centre was based. We spoke with people who had experience of using the emergency or patient transport service. We spoke with staff at all levels of the organisation, including trust board members. We received information from NHS hospital trusts, care homes and primary care trusts about their experience of SCAS services.

People who used the trust's emergency service were mostly very positive about the standard of care they received. People's experience of the patient transport service was also positive in terms of the staff. There were some concerns raised with us about delays experienced collecting people for transport to hospital clinics and collecting them after treatment.

We found there was a thorough system of monitoring of quality and performance of all areas of SCAS's operation. We found any of the concerns raised with us had already been identified and action either had or was being taken to address them as far as possible.

We found people who used the service were protected from risks of infection by procedures in place. We found previous areas of non-compliance in respect of cleanliness and tidiness at ambulance stations had been addressed.

The standard of record keeping was satisfactory and meant people were provided with appropriate treatment which took account of their individual circumstances and requirements.

Inspection carried out on 8, 9 November 2012

During a routine inspection

People's comments about South Central Ambulance Service (SCAS) staff were overwhelmingly positive. We spoke with four care home managers in Buckinghamshire and Oxfordshire who were in general positive, especially in respect of the quality and expertise of ambulance service staff. One person said "Very efficient, considerate and polite." Their assessments in respect of written communication was more varied.

The SCAS patient satisfaction survey of May 2012 showed 91% of respondents rated the service they received as excellent or very good with no safeguarding concerns. We saw analysis of safeguarding referrals made by SCAS. This showed that there had been an increase compared with the same period in the previous year of 23% for children and 65% for adults. This increase could have reflected an increased awareness of all staff following safeguarding training. People were cared for in a clean, hygienic environment. All of the patient transport service (PTS) vehicles, emergency ambulance and response vehicles seen were clean. We found SCAS vehicles were well-equipped and appeared to be in good condition. At both of the ambulance stations we visited there were significant pressures on storage and the standard of cleanliness was variable.

We found that SCAS carried out regular patient surveys to monitor the satisfaction and experience of patients using their services. These were analysed and reported at board level, with action plans drawn up and progress monitored.

Inspection carried out on 25 October 2011

During an inspection in response to concerns

We did not speak with people as part of this review.

Inspection carried out on 4 May 2011

During an inspection to make sure that the improvements required had been made

We did not, on this occasion, speak to people who used the service, so cannot report what they said.

Inspection carried out on 8 October 2010

During an inspection in response to concerns

Patients and service users were not interviewed for this particular review, due to the nature of the ambulance operation. However, a review of patient views, undertaken in February 2010, showed that overall quality of service was viewed as excellent. In the majority of cases, vehicles were seen as being comfortable and suitable to needs, in all cases there was total confidence in the ambulance staff and in the majority of cases patients reported that pain was controlled.