• Ambulance service

Trust HQ

Overall: Good read more about inspection ratings

Abbey Court, Eagle Way, Sowton Industrial Estate, Exeter, Devon, EX2 7HY (01392) 261500

Provided and run by:
South Western Ambulance Service NHS Foundation Trust

All Inspections

Other CQC inspections of services

Community & mental health inspection reports for Trust HQ can be found at South Western Ambulance Service NHS Foundation Trust. Each report covers findings for one service across multiple locations

23 July 2019 to 24 July 2019

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection May 2018 – Good)

The key questions are rated as:

Are services effective? – Requires Improvement

Are services well-led? – Good

We carried out an announced focused inspection of Trust HQ- South Western Ambulance Service NHS Foundation Trust (SWASFT) NHS 111 service on 23 and 24 July 2019 in response to concerns regarding performance and staffing. We looked at whether the service was providing effective and well led services.

At this inspection we found:

  • Performance of the service and outcomes for patients was mixed. The provider has been open with commissioners, staff and regulators about the difficulties the service has faced, future plans and current measures to attempt to keep the service safe.

  • The provider worked effectively and had systems of ongoing monitoring of the services. Efforts had been made to address gaps in services (including: ongoing staff recruitment, use of national contingency resources/plans, staff incentives, call audit performance).

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

  • Staff involved and treated people with compassion, kindness, dignity and respect.

  • The service had 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.

  • There were embedded systems in place in relation to learning from adverse incidents and significant events and joint working and sharing with external stakeholders, other providers and patient representatives (Duty of Candour).

  • Continued positive feedback from patients about the care received.

  • During our inspection we found sections of staff, notably advisors and first line managers to be highly dedicated and proud of the important work they were undertaking. However, they were also open and honest about the challenges they were facing on a daily basis. Staff were positive about the support received from direct line managers. Support from the senior management team was less embedded and needed improvement to improve working relationships.

  • There was a continued and focused programme of recruitment.

  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure care and treatment, including call answering, call abandonment and clinical advisor call back rates, are delivered in a safe way for service users.

The areas where the provider should make improvements are:

  • Continue with the planned programmes to improve staff engagement and disconnect between staff and leadership teams.

  • Continue with the ongoing recruitment of staff.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

2 May 2018

During an inspection looking at part of the service

This service is rated as Good overall. The previous inspection of this service was completed in December 2016 and was rated Requires Improvement overall. (Safe- Good, Effective- Requires Improvement, Caring- Good, Responsive- Good and Well led- Requires Improvement)

At this inspection the key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced focused inspection at South Western Ambulance Service NHS Foundation Trust (SWASFT) 111 on Wednesday 2 May 2018 to follow up on breaches of regulations in the Effective and Well led domains.

At this inspection we found:

  • A clear management structure was in place with proactive engagement and involvement of front line staff to influence and participate in improvements and change.

  • Continued positive feedback from patients.

  • A continued low number of complaints and no outstanding adverse incident reports.

  • An improved and a sustained improving trend of key metrics to demonstrate patients were accessing and receiving timely care and treatment.

  • Evidence of appropriate support, auditing and monitoring of staff to demonstrate they had the necessary skills and knowledge to undertake their roles.

  • A continued implementation of staff recruitment and induction

  • An investment in equipment used at the hub; IT equipment had been replaced and repaired.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

7, 8 and 20 December 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a comprehensive follow up inspection of the NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust (SWASFT) on 7, 8 and 20 December 2016. Overall following the December 2016 inspection, SWASFT NHS 111 service is rated as requires improvement.

The SWASFT NHS 111 service had previously been inspected in March 2016 and August 2016. The full reports for these inspections can be seen on our website www.cqc.org.uk

SWASFT NHS 111 service provides a telephone service to a diverse population for Dorset and Cornwall.

NHS 111 is a telephone-based service where callers are assessed, given advice and directed to a local service that most appropriately meets their needs. For example, this could be a GP service (in or out of hours), walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance, pharmacy or home management

At the March 2016 inspection, the service was rated as inadequate overall. The main issues identified at the inspection included insufficient numbers of staff and NHS 111 calls were not responded to in a timely and effective manner.

At the inspection in August 2016 we found that positive steps had been taken to address the identified issues. The key finding following the August 2016 inspection was a significant improvement in the approach of the Trust’s the day to day and strategic running of the NHS 111 service that was not previously seen.

Our key findings were as follows:

  • The Trust had significantly improved their systems in place to mitigate safety risks across the NHS 111 service and was now aligned to the SWASFT vision with safety and quality. We found that the Trust had recognised the need to improve the NHS 111 service. The NHS 111 service was monitored against the National Minimum Data Set for NHS 111 services and adapted National Quality Requirements. Performance against indicators was improving but still below national targets.
  • Callers received a safer, more effective and responsive service than they had previously. However, patients were still at risk of potential harm as call answering performance and calls abandoned was still below national targets.
  • Opportunities for learning from internal and external incidents were identified and discussed to support improvement. This included joint reviews with the NHS Pathways team for improvements in the assessment system.
  • Staff took action to safeguard patients and were aware of the process to make safeguarding referrals. Safeguarding systems and processes were in place to safeguard both children and adults at risk of harm or abuse, including frequent callers to the service.
  • Staff were trained to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a Department of Health approved 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). Call audit activity had improved but still required further improvement to meet the NHS Pathways licence and to allow the service to identify areas of development and learning.
  • The Trust developed the operational staff knowledge and skills and recognised the need to continue with the programme of staff support. The appraisal programme had been revised and delivered and operational staff received more frequent supervision, support and training to perform their roles.
  • Staff commented that the service was safer and this had improved job satisfaction. There had been new staff recruitment at various levels although there was still a notable turnover of staff.
  • Patients using the service were supported effectively during the telephone assessment process. Consent to the assessment was sought and their decisions were respected.
  • The Trust responded effectively to complaints and to patient and staff feedback. Although there was still a large number still being investigated.
  • Senior staff demonstrated a much improved understanding of governance and how to effectively run an NHS 111 service. This included identification and management to safely mitigate risks.
  • The Trust demonstrated positive development of leadership and management systems to deliver significant progress in improving the NHS 111 service.

However improvements are still required.

There were areas of practice where the provider MUST make improvements.

The provider must:

  • Ensure systems are effective for patients to always access timely care and treatment.
  • Ensure that all staff have the necessary skills and knowledge to undertake their roles.

The area where the provider should make improvements:

  • Continue with the implementation of the staff recruitment to ensure the service is staffed to full capacity.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

17, 18 and 19 August 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced inspection of the NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust (SWAST) on 17, 18 and 19 August 2016. This was to follow up on warning notices the Care Quality Commission served following an announced comprehensive inspection in March 2016.

The warning notice was served relating to regulation 12 Safe care and treatment and regulation 18 Staffing respectively of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notices was 8 July 2016. The Trust had kept us regularly informed on action being taken.

During the March 2016 inspection we visited both call centres and the SWASFT Headquarters. The March 2016 inspection highlighted several areas where the provider (SWAST) had not met the regulations. These included:

  • Insufficient staff were employed and those employed were not deployed or supported effectively.
  • NHS 111 calls were not responded to in a timely and effective manner. There was a lack of systems to ensure associated risks were mitigated for the safety of patient’s health and welfare.

At this inspection in August 2016 we found that positive steps had been taken to address the identified issues. We have focused on the warning notice findings in respect of the safe and effective domain and have not re-rated the Trusts provision of the NHS 111 service. The full report published on 16 June 2016 should be read in conjunction with this report.

Our key findings were as follows:

  • The Trust had a clear vision that had improvement of service quality and safety as its top priority. The Trust had fully embraced the need to change and there was good evidence of team working. The Trust had actively sought to learn from the previous Care Quality Commission inspection, other NHS 111 providers, performance data, complaints, incidents and feedback.
  • There were now systems in place to assess and monitor risks within the NHS 111 Service provided by SWAST and a number of steps had started to mitigate those risks. For example, recruitment and deployment of staff.
  • The Trust had reviewed and subsequently de-established the role of Non Pathways Advisors (NPAs). Existing NPAs had been offered conversion training to become call advisors.
  • The Trust had introduced systems to monitor and increase the number of appropriate and effective call audits performed to ensure all staff were following the NHS Pathways system and local standard operating procedures (SOPs). The Trust action plans intended to use completed call audits to identify individual and Trust wide areas of development and learning as the number of call audits increased.
  • We saw evidence to show the Trust had started to introduce systems to ensure associated risks were mitigated for the safety of patient’s health and welfare. This included attempts to increase the number of staff within the NHS 111 call centres. NHS 111 calls were still not responded to in a timely and effective manner. The Trust was aware that it was too early to see systems fully embedded and to demonstrate that the new systems and processes were effective.

Overall there has been significant improvement in the approach of the Trust to the day to day and strategic running of the NHS 111 service that was not previously seen.

However the provider must:

  • Ensure staff have further performance observation and support to ensure the needs of callers are correctly responded to.
  • Reduce risks to callers by improving delays in call abandonment, initial answering of calls, warm transfer and returning calls by a clinician.

The NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust rating remains inadequate until a full comprehensive inspection of the Trusts NHS 111 service is carried out by the Care Quality Commission.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

8, 9 and 12 March 2016

During a routine inspection

We carried out a comprehensive inspection of the NHS 111 service provided by South Western Ambulance Service NHS Foundation Trust (SWASFT) on 8, 9 and 12 March 2016.

Overall the Trust’s NHS 111 service is rated as inadequate.

There were two call centres, one at the Headquarters based in Exeter (referred to in the report as Devon), the other in St Leonards (referred to in the report as Dorset). We visited both call centres and the SWASFT Headquarters. SWASFT NHS 111 provides a telephone service to a diverse population for Dorset, Devon and Cornwall.

NHS 111 is a telephone-based service where callers were assessed, given advice and directed to a local service that most appropriately meets their needs. For example, this could be a GP service (in or out of hours), walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance, late opening pharmacy or home management.

The Care Quality Commission bought forward this comprehensive inspection due to intelligence we received; this included information received from former and current staff as well as patients raising concerns about the way the NHS 111 service was operated by SWASFT. The concerns included alleged ineffective use of systems and processes, staff levels and recruitment processes, lack of staff training and support, and the way complaints and significant events were managed.

Our key findings were as follows:

  • The Trust had limited systems in place to mitigate safety risks across the NHS 111 service. When incidents and significant events were identified, investigated and reported, due to factors such as substantial staffing shortages and limited forward planning to meet expected demand on the service, these factors often prevented systems being followed and lessons being learnt.
  • The NHS 111 service was monitored against the national Minimum Data Set for NHS 111 services and adapted National Quality Requirements. SWASFT were not consistently meeting these targets in most areas. Performance against some indicators such as calls being answered in 60 seconds were regularly at unacceptable levels. Necessary action to identify and improve callers’ outcomes was not taken.
  • There was also insufficient assurance to demonstrate callers received effective or responsive care and treatment. For example we saw evidence of urgent callers waiting for long periods to receive a call back from a clinical advisor. Despite being aware of issues, the Trust had not reviewed the calls in detail to identify the root cause.
  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example emergency and urgent callers were not being assessed in relation to their medical needs in a timely manner.
  • SWASFT NHS 111 worked closely with all the Clinical Commissioning Groups who commissioned the service. NHS Dorset Clinical Commissioning Group, NHS Kernow Clinical Commissioning Group and NHS Northern, Eastern and Western Devon Clinical Commissioning Group.
  • Staff were trained to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a Department of Health approved 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). However, once trained there were limited systems in place to monitor staff usage of NHS Pathways, for example inadequate levels of call audits were conducted by the Trust meaning that poor performance could not effectively be identified and managed in a timely way. Also, serious incidents and opportunities for learning could have been missed.
  • The Trust did not develop staff knowledge, skills or experience to enable them to deliver good quality care and treatment. Staff did not always receive appraisals, supervision, support or sufficient training to perform their roles.
  • There were low levels of staff satisfaction and high levels of stress. There had been a high turnover of staff and significant sickness levels impacting on the service. Some staff were declined their annual leave requests as a result.
  • Staff were supported to report issues and concerns but said often nothing was done by the Trust and no action was taken to change the factors that created the issues and concerns.
  • Generic work station risk assessments were in place. However we saw examples of workstations (desks, computers and chairs) in both centres which were not appropriate for long periods of work or adjustable for individual members of staff. Staff told us safety in regard of workstations was not routinely monitored.
  • The leadership within the organisation was variable and staff were confused on the leadership structure including who their line managers were. Staff told the inspection team the two call centres mostly worked separately to each other.
  • There was eagerness by operational staff for continuous improvement and development of the service, but a lack of resources meant that improvements were not always implemented.
  • We did not receive assurance from the leadership or governance processes in place that high quality care was being provided by the service. Senior staff did not demonstrate an extensive understanding of governance and its importance for the effective running of the service. This meant that they were unable to identify and mitigate risks effectively.
  • During our inspection we found sections of staff, notably advisors and first line managers to be highly dedicated to and proud of the important work they were undertaking. However, they were also open and honest about the challenges they were facing on a daily basis. They were largely supportive of their immediate managers but found some senior managers and Board members to be remote and lacking an understanding of the issues they were experiencing.

There were areas of practice where the provider MUST make improvements.

The provider must:

  • Continue to review staff numbers ensuring patients can access timely care and treatment when first accessing the service and when receiving a call back.
  • Review the roles and responsibilities of Non Pathway Advisors ensuring callers consistently receive the correct level of advice when accessing the service.
  • Ensure that the call queues, awaiting initial assessment and a clinical advisor call back are robustly monitored and managed by staff with clinical authority to intervene and allocate resources. This will ensure patients are being assessed and receive consultations within recommended timescales.
  • Implement a consistent performance monitoring system for staff across both sites to identify and investigate poor performance.
  • Identify individual and personal development needs of all staff including an appraisal programme.
  • Increase the number of appropriate and effective call audits to ensure all staff are following the NHS Pathways system and local standard operating procedures (SOPs) allowing the service to identify areas of development and learning.
  • Ensure all employees work at desks which have been suitably assessed for safety and ensure any work station risk assessments are followed up.
  • Implement a clear leadership structure and staff made aware of their lines of management.

    P rofessor Steve Field CBE FRCP FFPH FRCGP

    Chief Inspector of General Practice

11, 12, 13, 14, 15, 16 February 2014

During a routine inspection

During our inspection we visited six ambulance stations across the South West region, the Trust Headquarters and a hospital with an accident and emergency Unit. We listened to call handlers dealing with emergency calls. We spoke with 10 patients and 6 relatives. We spoke with 38 staff including call handlers, managers and ambulance crews. We also spoke with commissioners.

Patients we spoke with were positive about their experience of using the service. Comments included 'kind', 'professional' and 'caring'. One patient told us 'They do a fantastic job.' All of the patients we spoke with spoke highly of the staff.

We saw that staff were professional and able to demonstrate how they obtained patient's consent for treatment and the process they followed if a patient refused care or treatment. All of the patients we spoke with told us that their consent had been obtained prior to treatment. One patient told us 'They asked my permission and explained themselves well.'

We saw the provider had suitable well maintained equipment, facilities and vehicles which ensured patient's safety while they received treatment. There was equipment suitable for treating child patients as well as adults. Patients spoke highly of treatment received. One said 'I would give them 11 out of 10.'

We found the service was well-led with arrangements in place to monitor quality and effectiveness in the provision of care. A robust complaints system was in place.

22, 23, 24 January 2013

During a routine inspection

We (the Care Quality Commission) spoke with seven patients and two relatives. We spoke with managers, non clinical staff, call handlers and front line staff. In total we spoke with 40 ambulance staff. We also visited two local hospitals and spoke with three staff. It was not appropriate for the inspection team to observe front line staff at the scene of an emergency or during patient transport. We did listen to call handlers during 999 calls. We visited four ambulance stations and a training college.

All the patients and relatives we spoke with were very complimentary about their experience. One patient said their experience was 'absolutely first class' and described staff as 'calm and reassuring'. Another patient said the standard of care was 'excellent'. They described the staff as 'efficient and very kind'. One patient summed up their experience by saying 'It was everything you could want it to be.'

Staff were professional and demonstrated how they treated patients with respect and dignity. One member of staff said 'We listen to the patient. It's drummed in. We explain what we're going to do and keep the family up to date.' All the staff we spoke with felt well supported to perform their role.

Records showed that appropriate procedures were followed with regard to the safeguarding of vulnerable adults and child protection.

Structures and processes were in place to manage service quality and risk. We saw evidence of the outcomes of these systems.