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Inspection Summary


Overall summary & rating

Good

Updated 6 September 2019

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

Inspection areas

Safe

Good

Updated 7 June 2018

We did not inspect this domain at this visit. It was rated good at our inspection in December 2016.

Effective

Requires improvement

Updated 6 September 2019


Caring

Good

Updated 7 June 2018

We did not inspect this domain at this visit. It was rated good at our inspection in December 2016.

Responsive

Good

Updated 7 June 2018

We did not inspect this domain at this visit. It was rated good at our inspection in December 2016.

Well-led

Good

Updated 6 September 2019

We rated the service as good for leadership.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care. However, the significant staffing issues meant that leaders recognised delivering quality care was becoming harder.

  • The leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

  • The Trust had communicated with commissioners, regulators and other stakeholders its decision to withdraw from the contract to provide NHS 111 services across Dorset at the end of their contract or before if another provider could be sourced. Staff had been informed of this decision on 10 July 2019 and this information was released to the public shortly afterwards. The Trust explained an awareness that this was due to difficulty to manage the high turnover of staff associated with the service. The Trust gave assurances that an action plan remains to continue to recruit staff with an aim to hand over a safe service to a new provider.

  • Leaders had the experience and skills to deliver the service strategy and address risks to it. For example, the leadership structure within the communications centre worked well. Accountability was shared between operational and clinical leaders.

  • There was a clear leadership structure and rotas were available to ensure senior management was accessible throughout the operational period, with an effective on-call system that staff were able to use. For example, staff always had access to a duty manager for operational leadership and a clinical team leader for clinical advice 24 hours a day, seven days a week.

  • Feedback from staff indicated senior leaders at all levels were not always visible or approachable. Local managers had tried new strategies to improve their visibility. For example, representatives from the leadership team had introduced a rota for managers to take it in turns to work alongside the health advisors and clinicians on the ground floor of the building. Managers informed staff by email and bulletin which managers were rostered to be available. Staff feedback about this approach was mixed, depending on the manager. During the inspection management availability information was displayed on a screen in the communication centre.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. For example, 350 leaders from across the Trust had been invited to attend the Aspire, Connect, Transform Leadership development programme which began in July 2019 and was due to be completed by March 2020. This was a mandatory programme for leaders to attend.

  • There had been an increased promotion of the Freedom to Speak Up Agenda with roadshows, meetings for staff. Freedom to speak up ambassadors were present within the building and there was a dedicated Twitter feed established.

Vision and strategy

The service had a Trust wide ‘Mission, Vision, Values and Goals’ statement which set out a strategy to attempt to deliver high quality care and promote good outcomes but had recognised they were unable to deliver this strategy for the NHS 111 service.

  • The Trust wide vision and set of values was clear and had been developed jointly with patients, staff and external partners.

  • NHS 111 staff were aware of and understood the vision, values and strategy and their role in achieving them but were also aware the Trust were unable to continue with the service.

Culture

The service promoted a culture of high-quality sustainable care but recognised their limitations in fully implementing this.

  • Staff felt respected, supported and valued by their colleagues, although less so by some of the management team. Staff said they were proud to work for the service.

  • The service focused on the needs of patients.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

The Trust had listened to staff feedback and had commissioned a cultural review in October 2018 which found:

  • The attempt to introduce a new rota review was not popular with staff and had not been handled well.

  • There remained reports of bullying within the organisation

  • Strained working relationships and friction identified in the NHS 111 part of the Trust.

  • Staff expressing concerns that there was no equity when treating staff who were involved in incidents.

  • Allegations that no other unions were recognised by the Trust

Findings were shared with staff, the board and external organisations, including CQC. An action plan was implemented and kept under review. At the time of inspection 28 of the 49 actions had been completed within timescales. These included staff development plans, reviewing of policies, review of training and induction, engagement programmes and review and implementation of welfare processes. The remaining 22 actions were ‘on track and due to be completed between August 2019 and December 2019’. Staff were aware of this review and programme and said they were beginning to see improvements, including more visible management, introduction of mental first aid processes and review of policies.

  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. We looked at seven adverse incidents and saw that all of these had been managed with openness, honesty and transparency. The duty of candour was demonstrated in all of these examples, although timescales missed in a small number where contact information for patients relatives was not readily available and required to be sourced by the provider.

  • The provider had introduced a new approach and had rebranded the management of serious incidents and the significant event process to focus on a culture of continuous learning and improvement and the development of an open, reflective workforce. The system was now called ‘Review, Learn, Improve’ (RLI).

  • Staff we spoke with told us they were able to raise concerns about clinical issues and were encouraged to do so. Staff said that any learning was communicated by email or within the development days.

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual 1-1 meetings appraisals during the in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Some staff were positive about the imminent changes to the contract and saw this as an opportunity for development. For example, leaders had offered staff the opportunity to become emergency care assistants in the emergency and urgent care service.

  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.

  • There was a strong emphasis on the safety and well-being of all staff. Following feedback from staff and monitoring of sickness there had been 130 Mental Health First Aiders trained and introduced across the trust.A revised Health and Wellbeing Policy together with a Critical Illness toolkit was introduced to help manage sickness in a more person centred way.

  • The service actively promoted equality and diversity and had recently revised their Dignity and Respect at work policies to ensure the staff member was treated as an individual. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.

  • The relationships between staff and leadership teams was mixed. For example, a number of staff told us that managers at a local level were supportive and caring, whereas others said this support and care was not as effective in previous years. Staff said the timing of communications about the changes to the contract had not worked well as several staff were unable to attend the meeting. Staff felt they had not been supported well during the rota review. However, some of the staff we spoke with were excited about the changes and saw the new contract as a fresh start.

Staff told us demand had increased during evening periods and peaked at weekends. All staff we spoke with told us they felt under pressure citing there were not enough staff to meet the demand. They told us this impacted upon working relationships because staff felt they were too busy to greet one another or enquire into each other’s well-being. However, staff told us that the team were friendly, and others said the service was a good place to work.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The service made sure that correct governance procedures were in place prior to implementing service wide changes. For example, the further recruitment of band two service advisors was on hold until the clinical effectiveness group had signed off the governance for the introduction of this new role.

  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. For example, the quality manager attended the Trust Partnership board meeting to discuss pertinent risks, for example, staffing and call performance.

  • Staff were clear on their roles and accountabilities including in respect of safeguarding.

  • Leaders had established proper policies, procedures, standard operating procedures and activities to ensure safety and assured themselves that they were operating as intended.

  • The provider monitored trends in feedback, compliments, complaints and adverse incidents as part of the wider ranging governance processes. There had been a slight reduction in the number of complaints. For example, 39 complaints had been received by the Trust in 2018/19 compared with 42 in 2017/18. Themes included call back delays, concerns with the NHS Pathways process and callers not being happy with the information provided. The Trust had received 14 plaudits for the NHS 111 service. These included positive feedback of assessment, prompt service and care provided and relating to caring, professional, sensitive and understanding staff.

  • The provider monitored statistics relating to adverse incidents. Data showed between March 2018 and July 2019 the number of incidents ranged between 10 per month and 32. Monitoring of the processing of these took place and showed there was a reduction of 126 outstanding incident investigations between January and July 2019 to 34 at the time of the inspection.

Managing risks, issues and performance

There were clear and effective processes for monitoring, managing risks, issues and performance and were in progress where shortfalls had been identified.

There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety. For example:

  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse. Staff managed effective conversations whilst delivering he script of the triage tool. Health advisors gave advice to callers to follow if their condition worsened.

  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. Patients were prioritised appropriately for care and treatment, in accordance with their clinical need. Call advisors could locate a clinician in the room for advice when needed using a speed dial system on their computer. We saw health advisors used instant messaging to flag any patients who were particularly vulnerable. For example, a health advisor asked the clinician to prioritise the review of a small baby with persistent high temperature lasting three days.

The provider had processes to monitor current and future performance of the service and were aware where performance was poor. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA (Medicines and Healthcare products Regulatory Agency) alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level, with the local CCG as part of contract monitoring arrangements and was shared with the Care Quality Commission (CQC) and NHS 111 staff via a weekly email.

Comprehensive risk assessments were in place to monitor the risks within the service. For example, the Trust had recognised:

  • The potential inability to meet NHS 111 performance, because of demand and/or resources, resulting in the failure to meet performance targets for call answering (95% within 60 seconds) and calls abandoned, or delay in contact by a clinician or increase in 999 transfers. In response, controls had been introduced; including comfort calls for patients waiting, staff overtime incentives, ongoing targeted recruitment and use of escalation plans. Data showed call answering rates, although remaining under the 95% target had not consistently fallen month on month. For example, in April 2018 rates were at an average of 89% dropping to 64% in January 2019 but starting to increase to 70% in May 2019 and 71.1% in June 2019. In addition, call abandonment rates were met in four of the 14 weeks between April 2019 and July 2019 and the Trust were lower than the national lowest average for all 14 weeks monitored.

  • The increased ‘clinical call back times’ which could affect patient safety. As a result, the Trust had increased the recruitment and use of remote clinical staff from two staff to over 32 staff, continued with the daily operational conference call weekly reporting of staff numbers, continued reporting of concerns to the county commander and executive team.There was ongoing communication with stakeholders: commissioners, Dorset Healthcare Trust and other providers to discuss clinical support patients might need.

  • The providers had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. However, the information technology systems used locally in Dorset, did not always work well to facilitate seamless care. For example,

  • Health advisors could not access the booking system for out of hours treatment centre appointments. The Trust had ‘workaround’ solutions to address this.

  • Clinicians could advise patients to go to the emergency department. However, local emergency departments had chosen to not receive notification of these incoming referrals.

  • When the triage system identified calls as category one emergencies, these calls were automatically redirected to the emergency ambulance service. However, there were times when this electronic transfer system did not work, and health advisors were required to manually facilitate the transfer of the call.

Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.

  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

  • The service used performance information which was reported and monitored, and management and staff were held to account.

  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses and improvements were underway.

The service submitted data or notifications to external organisations as required.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture.

  • Patient experience surveys were used to shape services. 677 surveys were returned in 2018/19. Of these 91% of respondents reported they were likely to recommend the NHS 111 service.

  • Managers had taken steps to improve staff engagement following a reported unsuccessful review of the staff rota. In the weeks prior to our inspection, clinicians had met with the deputy director of patient safety and local managers to reconsider a way forward for managing the rota. Clinical staff planned to trial self-rostering and another meeting was planned in October 2019 to monitor progress against this goal.

  • There were opportunities for staff to engage with the leaders regarding service developments. For example, leaders arranged several staff engagement events to discuss the rota review. However, staff attendance and participation at these events had been poor.
  • Staff were able to describe the systems in place to give feedback or raise concerns. This included verbally to their line manager or through use of the ‘Datix’ system which was an electronic system to escalate concerns. Staff also added there was a whistleblowing policy and ‘speak up guardians’ within the organisation. Staff felt confident that serious issues were addressed appropriately. However, feedback about whether their general concerns were listened to was mixed. Of the 23 staff that answered this question 17 said no, three were mixed and added it depended upon the manager and three said yes. The 17 staff told us although the leadership team may listen there was little confidence that the leadership team would act on this. We saw the provider had attempted to introduce a rota review and noted this was discontinued after consultation with staff.

The service was transparent, collaborative and open with stakeholders about performance. For example, sharing the recent performance report and staff culture review findings with the CCG and CQC. The Trust had shared concerns with the CCG, board and CQC that they were missing national targets. Action plans were shared to show mitigation to maintain as safe a service as possible. For example, we were told that staff attrition figures were well below national targets. The provider gave assurances and demonstrated evidence of continuous advertising of jobs, review of job description and skill mix, use of agency and overtime incentives and successful roll out of clinical remote working.

The Trust continued to monitor staff turnover rates which at the point of inspection were at 40% and sickness rates at 9%. The Trust also monitored staff compliance with attendance at learning and development days. For the period April 2018 to April 2019, 72% of staff attended, this equated to 91.5% of clinicians and 60% of non-clinicians. A tactical decision had been made by the Trust to hold more than required training courses to account for the calculated dropout rate.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service. The Trust had rebranded the serious incident process to focus on learning and sharing from where things went wrong and to further promote a culture of reporting and learning.

  • Staff knew about improvement methods and had the skills to use them.

The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements. For example, learning from RLI’s was shared outside the organisation. For example, investigation from an RLI had identified a gap in the assessment of children presenting with dark green vomit. Leaders had proactively collaborated with NHS Pathways to influence changes to the tool to ensure future versions incorporated the learning. The team had participated in testing the new versions of the tool. Where necessary, the service made changes to protocols to incorporate learning from RLIS’s, such as the addition of a ‘work-around’ for staff to follow where the algorithm did not meet patient safety needs.

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

There was a strong culture of innovation evidenced by the number of pilot schemes and joint working the provider was involved in. For example, working proactively with NHS Pathways to improve and introduce additional safety checks and options following learning from significant and adverse events.

Checks on specific services

Emergency operations centre (EOC)

Good

Updated 6 October 2016

We rated the emergency operation centres, overall, as good because:

  • There was a good system for reporting incidents, carrying out investigations, providing feedback to staff, and learning and making improvements.
  • There were reliable practices for safeguarding people from abuse.
  • Patients’ risks were well assessed and monitored and good records maintained.
  • The service was able to respond to major incidents and change priorities in times of extreme pressure. There were protocols for staff to follow in high-risk situations to keep staff and the public safe.
  • The service had recognised the growth in call volumes and was responding by increasing staffing levels above establishment levels.
  • Staff had the skills and knowledge to deliver effective advice and guidance. Evidenced-based systems were well integrated. There were internal and external development opportunities and training available for staff.
  • There was multidisciplinary work between teams in the EOC and partner organisations.
  • All staff demonstrated outstanding compassion, kindness, and respect towards callers and patients often under a high level of pressure. In 120 calls we listened to, without exception this was consistently demonstrated.
  • There was a strong and visible patient-centred culture with all staff wanting to help people by showing them kindness and respect.
  • The caring of all staff was outstanding, despite them not knowing who they were going to be speaking with next, and how they would be required to respond. This was notable particularly with a significant crisis for a patient with mental health needs, and how staff acted promptly to give them strong and compassionate support.
  • The needs of local people were met by good planning and delivery of services.
  • There were procedures and protocols for supporting people in vulnerable circumstances.
  • Resources were used where they were most needed. The trust had been commended for its service to reduce and respond to frequent callers.
  • The trust was prioritising resources with a good ‘hear and treat’ service.
  • There was learning and improvements made when people complained about the service they received. Complaints were handled with sensitivity and time taken to provide a considered response.
  • There was a clear vision and credible strategy for the service. The leadership reflected the values of the service and were open, approachable and supportive.
  • The governance framework had clear responsibilities and most risks were understood and managed.
  • There was a strong wellbeing and support service for staff and good engagement with staff and the public.

However:

  • The service was significantly below the trust’s target for updating mandatory training.
  • Staff were not being assessed for their competency and performance and the service was significantly below the trust’s target for completing these appraisals each year.
  • The levels of staffing were not sufficient to provide relief at all times when staff were training, on holiday, off sick, or taking special leave.
  • There was a lack of quality review at local level.
  • The leadership was not aware of when the levels of professional support given to staff were failing.
  • There were missed opportunities for better integration with the staff working in the different EOCs.

NHS 111 service

Good

Updated 6 October 2016

Overall, we rated the urgent care service (Tiverton Minor Injuries Unit) as good because:

  • Safety performance was monitored and reported to senior managers on a monthly basis. Openness and transparency about safety was encouraged.
  • There were sufficient staff to treat and care for the patients who attended.
  • Nurses and paramedics were well qualified and demonstrated the skills that were required to carry out their roles effectively and according to best practice. They worked collaboratively with multidisciplinary teams from community services and acute services at neighboring hospitals
  • Staff used evidence based guidelines in order to ensure effective treatment was delivered.

  • Feedback from patients and those close to them confirmed that staff were caring and kind.

  • We observed staff taking trouble to maintain people’s privacy, dignity and confidentiality. They demonstrated empathy towards people who were in pain or distressed and were skilled in providing reassurance and comfort.
  • Services were planned to meet the needs of all patients, including those who were vulnerable or who had complex needs.
  • 99.8% of patients were treated, discharged or transferred within four hours in the year ending March 2016. The average time to treatment was 49 minutes.
  • There was a cohesive strategy for the urgent care centre and this was supported by the staff who worked there.
  • Clinical leaders were respected by staff. They were knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them. They promoted a strong sense of teamwork.
  • Governance arrangements were well structured with risks and quality being regularly monitored and action taken if necessary.

However:

  • The environment and use of facilities was not designed to ensure the safety of children.
  • There was no competency framework for, or formal assessment of, staff in the initial clinical assessment of patients.
  • Safeguarding arrangements for vulnerable adults were not sufficiently robust.
  • There was insufficient space in the waiting area for the number of people attending the centre.

Resilience

Outstanding

Updated 6 October 2016

Overall we rated resilience planning as outstanding because:

  • There were robust systems in place to keep equipment and vehicles clean, well maintained and fit for purpose.
  • The numbers of staff, the training they received and the policies they followed was compliant with national recommendations from the National Ambulance Resilience Unit (NARU).
  • The EPRR teams worked well and had good co-ordination with a range of other agencies including NHS Providers, other emergency services, local authorities, commercial operators, voluntary organisations and the different departments within SWAST.
  • Specialist computer applications had been developed for managing staff training records (i-auditor) and for use in major incidents (Commander).
  • The special operations team were supported by six air ambulances provided by five charities providing cover for the whole of the geographical area covered by SWAST.
  • Staff treated patients with respect, patience and sensitivity. The paramedics were calm and professional in their approach but remained friendly to quickly build a rapport with the patient.
  • Staff took time to listen to patients and their families and consistently explained what they were doing and continually offered reassurance.
  • Robust governance and assurance systems were in place across the EPRR teams to share information across the teams and the trust board.
  • Leaders were both supportive and visible, inspiring and motivating staff across all EPRR teams. Staff welfare was of great importance and various services such as traumatic risk monitoring and the ‘staying well service’ were available to staff should they need it.
  • There was a proactive approach to change and innovation. A dedicated events team had taken responsibility for planning, resourcing and managing SWAST attendance at public events.
  • A computer application ‘SWAST Commander’ had been developed for iPad and Android platforms. This was used by operational commanders during major incidents.

Patient transport services

Requires improvement

Updated 6 October 2016

We gave an overall rating of requires improvement for the patient transport services. This was because:

  • There was a lack of consistency around incident reporting. There was no evidence of feedback or learning from incidents during the 12 months preceding our inspection.
  • There were infection control risks caused by vehicle defects such as ripped seat covers and punctured internal walls.
  • Vehicle daily inspections (VDI) were not consistently completed on a daily basis. VDI checklists were not reviewed or audited leading to a lack of assurance regarding vehicle safety.
  • Staff administered nitrous oxide and oxygen gas mixture (a medical gas that is used to relieve pain) to patients. There were no clinical pathways or set protocols to guide the clinical reasoning of staff using this gas. Staff did not record when they gave this treatment to patients. Leaders of PTS could not provide assurance that this gas was administered safely. Immediately following our inspection, the trust withdrew this treatment from PTS.
  • Staff administered oxygen to patients and adjusted oxygen levels according to their assessment of the patients need during their journey. There was a flowchart for staff to guide their clinical reasoning, but this was insufficiently comprehensive. Staff did not record their interventions.
  • Staff did not participate in the learning development review process and compliance with appraisals was poor.
  • The process of gaining patient consent for treatment was not documented.
  • There was very limited oversight of quality in the PTS other than performance against key performance indicators. Some aspects of governance related to safety issues were not monitored effectively.
  • Staff told us they did not feel supported or valued by their management team or their employer.
  • Staff described the culture as insensitive and poor communication was frequently highlighted by staff as a concern.

However:

  • The service had performed well against the key performance indicators set by commissioners. These related to patient and commissioner satisfaction, timeliness and responsiveness of journeys and management reporting.
  • Managers were working closely with local hospitals to improve turnaround time when dropping off and collecting patients.
  • Compliance with mandatory training was good at 95.9%
  • There were high levels of patient satisfaction and low numbers of complaints reported.
  • Staff showed compassion and understanding toward patients and carers.

Emergency and urgent care

Requires improvement

Updated 6 October 2016

We rated the emergency and urgent care service as requires improvement because:

  • Medicines systems used by staff were not always safe and trust policies, procedures and protocols were not always followed by all staff.
  • Ambulances and rapid response cars were not always secured when staff were escorting patients into emergency departments at hospitals or tending to patients at other locations.
  • Feedback to staff following incident reporting did not always take place.
  • Cleanliness and control of infection was not managed effectively .Clinical waste was not always disposed of as required. The trust was not meeting its targets for cleaning of vehicles or stations.
  • Patient confidential information was not always stored securely.
  • Response times for most categories were consistently below the England average.
  • From April to October 2015 the average proportion of patients who received angioplasty (unblocking of a coronary artery) following ST segment elevation myocardial infarction within 150 minutes was worse than the national average.
  • The average proportion of patients assessed face to face who received an appropriate stroke or transient ischaemic attack care bundle in April to October 2015 was worse than the national average.
  • The rate of annual performance appraisals was variable, ranging from 38.4% for specialist paramedics to 87.7% for paramedics. This was below the trust target of 90%. The quality of the appraisals was also variable.
  • Not all staff were competent in providing treatment and care to patients with mental health issues.
  • Quality, in terms of patient outcomes and experience, did not feature highly at operations meetings, although a quarterly quality report had recently been introduced. Risks to quality and safety were well understood at a local level but were not locally recorded and local accountability for managing these risks was not defined. Risk registers maintained at directorate and corporate levels did not align with the risks and worries described to us by staff and managers. There was a lack of local oversight in respect of infection control. This highlighted a disconnect between different reporting lines.
  • Whilst the trust had made significant efforts to support staff wellbeing, their efforts were somewhat overshadowed by the intensity of work, due to relentless and increasing demand on the service and the pressures this placed on staff. There was a culture in which there was an unspoken expectation that staff would work longer hours than they were contracted to work. The intensity of work undoubtedly contributed to staff absenteeism and high levels of staff turnover.

However:

  • There was a genuine culture where staff could report incidents and these were viewed as learning opportunity. Staff felt they were well supported when involved in incidents.
  • Safeguarding of adults, children and young people was given sufficient priority. Staff knew how to recognise and report allegations or incidents of abuse.
  • Staff recognised and responded in a timely way to the changing condition of patients.
  • Feedback from patients and those close to them was consistently very positive. We accompanied crews on emergency and urgent calls and spoke with patients and relatives in emergency departments. Without exception, patients, relatives and other healthcare professionals told us that ambulance staff acted with care and compassion.
  • Staff were passionate about their patients’ care and wellbeing. We saw numerous examples where staff ‘went the extra mile’ to ensure their patients’ comfort and wellbeing.
  • Staff adopted a person-centred approach when attending to patients and supporting those close to them. Staff considered the needs of the individual and took actions to promote their dignity, showed consideration for individual preferences and promoted independence by actively involving patients in decisions about their care and treatment.
  • The service provided evidence based care and treatment in line with national guidelines
  • The proportion of Red 1 calls responded to within 8 minutes was better than the England average for 16 out of 19 months between July 2014 and January 2016.
  • From April to October 2015 the average proportion of patients with ST elevation myocardial infarction who received an appropriate care bundle was better than the national average.
  • There were pathways to prevent hospital transfers and staff had received additional training to enable them to treat patients at home.
  • Consent was obtained from patients prior to treatment or care being given.
  • Staff took time to interact with patients and were supportive to them and to their relatives/carers. Staff treated patients with compassion, respect and dignity.
  • Most patients had timely access to initial assessment, diagnosis or urgent treatment.
  • Staff feedback on issues which prevented ‘right care’ from being delivered was captured with over 5,000 incidents highlighted up to the date June 2016. This was used to identify further changes required to improve patient care.
  • The service was leading on the national ambulance response project or ARP which commenced 19 April 2016. The full impact of the ARP project was not known during the inspection period, as it was still in pilot phase.
  • The trust used a network of volunteer community first responders, responders such as fire co responders, doctors and others including trust staff that could supplement core ambulance resources.
  • Action was taken to remove barriers to patients with physical disability, those with reduced mobility or those who had bariatric needs who found it physically hard to use or access services. The trust also ran blue light days where people with a learning disability could familiarise themselves with ambulance vehicles, equipment and staff to understand the service better. This also enabled staff to better understand the needs of people with learning disabilities. Translation services were available and were used.
  • Complaints and concerns were taken seriously and listened to but not always responded to in a timely way
  • There was a well-publicised mission statement and a set of core values which staff consistently demonstrated in their commitment to delivering high quality care to patients.
  • Local managers were visible, accessible and supportive to staff. Staff felt valued and supported.
  • The trust's management recognised staff wellbing as a priority and had made significant efforts to support staff. A range of staff support schemes had been developed and staff who had used these services spoke positively about the support they had received.
Other CQC inspections of services

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