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Other CQC inspections of services

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

Inspection carried out on 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

Inspection carried out on 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

Inspection carried out on 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

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

Inspection carried out on 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

Inspection carried out on 7-10, 17, 20, 22 June 2016

During a routine inspection

South Western Ambulance Service NHS Foundation Trust is one of 10 ambulance trusts in England. On March 1, 2011 the trust became the first ambulance service in the country to become a Foundation Trust, and acquired Great Western Ambulance Service in February 2013. It provides services in the following geographical area:

• Cornwall

• Isles of Scilly (IOS)

• Devon

• Dorset

• Somerset

• Wiltshire

• Gloucestershire

• The former Avon area (Bristol, Bath, North and North East Somerset and South

• Gloucestershire)

The area is made up of approximately 5.3 million people with an additional 17.5 million visitors per year and covers 10,000 square miles (around 20% of mainland England). It spans 13 Clinical Commissioning Groups and serves 18 acute trusts.

The trust employs over 4,000 mainly clinical and operational staff, including Paramedics (1,788), Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners), plus GPs and around 2,785 volunteers (including community first responders, BASICS doctors, fire co-responders and volunteer PTS drivers).

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of three emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. In addition, the trust also provides patient transport services, hazardous area response teams, NHS 111 services for the people of Cornwall, Devon and Dorset, urgent and emergency care at one minor injuries unit in Devon and out of hours GP services in Gloucestershire and Dorset. The service also provides clinical teams for six air ambulances.

In 2014/15 the trust responded to 867,505 emergency and urgent incidents, received 918,227 NHS 111 calls, helped 155,965 patients calling their out of hours service and completed 99,907 patient transport journeys.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We undertook our announced inspection between 6-10 June 2016 and conducted unannounced inspections on 17, 20 and 22 June 2016 and inspected the following core services:

Emergency Operations Centres

Urgent and Emergency Care

Patient Transport Services


Emergency and Urgent Care

Out of Hours

Overall, the trust was rated as requires improvement. We rated caring as outstanding and rated responsiveness as good. Safety, effectiveness and well led was rated as requires improvement.

Our key findings were as follows:


  • Not all staff were reporting incidents, particularly when they were verbally abused by callers and in some areas staff did not routinely report incidents related to patient safety. Some staff felt that due to the demands on the service they did not have time to report all incidents.However, the trust had taken steps to make the reporting process more straightforward by providing a link within the electronic patient record. This allowed staff to complete incident forms without having to return to the ambulance station.
  • Feedback to staff following incident reporting did not always take place. Whilst not in all areas, some groups of staff were unable to identify learning from incidents that had occurred during the twelve months preceding our inspection.
  • Some incidents were logged and resolved but not reported on the trust wide incident reporting system. This meant that managerial oversight of the themes occurring from all incidents was not comprehensive.
  • Some areas of the service was significantly below the trust’s target for updating mandatory training. Within these services, 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.
  • Medicines systems used by staff were not always safe and trusts policies, procedures and protocols were not always followed. Within the urgent care centre, prescription pads were not monitored sufficiently in order to prevent misuse.
  • 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. This meant that unauthorised people could access the ambulances
  • Cleanliness and control of infection was not being managed effectively. Clinical waste was not always disposed of as required. The trust was not meeting its targets for cleaning of vehicles or stations. Infection control training for staff was not meeting the trusts targets for the number of staff who had completed this.
  • Within patient transport services, there were several vehicles with ripped seat covers and one with a hole in the internal wall. These defects meant that the vehicle could not be cleaned adequately to prevent the spread of infection.
  • In patient transport services, not all staff were completing vehicle daily inspection checklists. Checklists were not reviewed effectively to enable the safety of vehicles to be assured. Only 21.3%of vehicles had been consistently deep cleaned every eight weeks or less during the twelve months preceding our inspection.
  • There was insufficient space in the urgent care centre waiting area for the number of people attending the centre.
  • Safeguarding arrangements for vulnerable adults were not sufficiently robust within the minor injuries unit.
  • Patient confidential information was not always stored securely.
  • Some staff within patient transport services provided treatment for patients but no records of these interventions were completed. These treatments included administering Entenox (nitrous oxide and oxygen gas mixture) and adjusting oxygen.
  • At the time of our inspection, emergency preparedness drills had not been completed on the patient transport boat on the Isles of Scilly. However, the emergency preparedness drills are part of the Domestic Safety Management Plan for the Star of Life that went live in June 2016. The first drill is scheduled for September 2016.
  • Within the minor injuries unit, the environment and use of facilities was not designed to ensure the safety of children. Initial clinical assessment of patients was undertaken by experienced healthcare assistants. However, they did not use an assessment framework to do this and there was no competency assessment to ensure their practice was safe. Computer errors in patient records could not be corrected. This sometimes led to an incorrect diagnosis or medicines dose remaining on patient records.


  • There was a good system in place for reporting incidents, carrying out investigations, providing feedback to staff, learning and making improvements. In places the culture for incident reporting was very positive.
  • Within the majority of services there were reliable practices for safeguarding people from abuse.
  • Patients’ records were held securely on electronic systems and special notes were available to help support and protect patients and staff.
  • When calling, the risks to patients were assessed with approved triage systems. Decisions were monitored and revised by clinicians when appropriate, or risks changed.
  • There had been a good implementation of the pilot for the ambulance response programme. This triage system was being trialled by the service to assess the safety, effectiveness, and responsiveness of the service should it move away from time-target based responses to sending the right response, first time.
  • 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 in the emergency operation centres.
  • There was a good skill-mix among the staff within emergency operations centres, and there were plans to broaden the experience in future.
  • Staff training met the national requirements set out by the National Ambulance Resilience Unit (NARU).
  • Within emergency and urgent care saw that staff regularly cleaned their hands and we observed staff cleaning their vehicles at the end of shifts. The vehicles we checked were visibly clean and equipment and vehicles were serviced in line with manufacturer’s instructions to make sure they were fit for purpose.


  • Within the emergency operation centres, 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. Some senior staff had not had appraisals for a number of years, but the organisation was not aware of this, and not addressing it. This issue had been on the trust’s risk register for over nine years.
  • The rate of annual performance appraisals within emergency and urgent care 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.
  • Staff in patient transport services did not participate in the learning development review process and compliance with appraisals was low
  • Due to other training priorities, there had been a reduction in the number of calls audited for their quality and safety. The emergency operation centres had not been able, therefore, to determine if the handling of incoming calls was effective at all times. However, we recognised this was being addressed, and improving.
  • The service was struggling with rising call volumes and this had resulted in more calls being abandoned.
  • Response times for most categories were consistently below the England average. The proportion of Red 2 calls responded to within 8 minutes was worse than the England average from April 2015 to January 2016. The trust had not met the national target of 75% since October 2014. From May 2015 the data provided showed a steady decline in performance.
  • From February 2015 to January 2016 the proportion of A19 calls responded to within 19 minutes was mainly worse than the England average. The national standard of 95% was not met for 10 of these 12 months.
  • 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.
  • Not all staff were competent in providing treatment and care to patients with mental health issues.
  • Within patient transport services, competencies of intermediate care assistants to administer Entenox (nitrous oxide and oxygen gas mixture) and perform cardiac monitoring had not been refreshed. Standard operating procedures were not accessible to staff when they were out and about transporting patients. Staff were not informed when patients were diabetic and this meant that staff did not have access to important information that may be needed by emergency crews attending to assist. The process of gaining consent was not recorded.


  • There were evidence-based systems to provide assessment and advice for patients. The emergency operations centre teams were using national guidelines and following best practice protocols to assess people’s needs and provide the right service.
  • Staff had the skills and knowledge to deliver effective advice and guidance. There were internal and external development opportunities and training available for staff.
  • There was multidisciplinary work between teams and other local stakeholders. Hazardous area response teams, critical care and the air operations teams worked more closely together as ‘special operations’ to enhance the care patients received. 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 internally.
  • There was good access to information with special notes being used to provide effective outcomes for people where there were known risks or other issues.
  • The service was performing within its target for ‘hear and treat’ calls, although this was above (not as good as) the England average.
  • 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.
  • The service provided evidence based care and treatment in line with national guidelines such as the Joint Royal Colleges Ambulance Liaison Committee and the National Institute for Health and Care Excellence.
  • The trust had developed an initiative to reduce the number of patient transfers to hospitals. There were pathways to prevent hospital transfers and staff had received additional training to enable them to treat patients at home. This had reduced the number of hospital transfers.
  • The patient transport service was achieving the targets identified in key performance indicators for commissioner satisfaction and patient satisfaction and the service was working well with local acute hospitals to provide useful information that enabled wards to plan better for patient arrivals and departures
  • Business continuity plans were developed in line with International Standardisation Organisation (ISO) standards.
  • 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.
  • Within the minor injuries unit (urgent and emergency care), pain relief was administered quickly and effectively. X-ray results were reviewed by a specialist radiology doctor within 24 hours and there was a low rate of unplanned re-attendances.
  • Clinical audits took place within the minor injuries unit and the information gained was used to improve care and treatment. The learning needs of staff were identified at six-weekly clinical supervision sessions and at annual appraisals.


  • Staff in all areas consistently demonstrated a high level of compassion, kindness and respect towards people, whether callers, patients or relatives/ carers. At all times patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.
  • 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 recognised when patients required further information and support and this was provided at all times.
  • Staff made sure people had understood the information given back to them by telephone advisors. Staff asked questions in a calm approach but with empathy and clarity. Staff recognised it was hard for people calling the service to interact over a telephone line, but staff got the best information and gave the best responses they could when they were otherwise not able to see the patient. Distressed and overwhelmed callers were well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.
  • There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP
  • Staff took time to interact with patients and were supportive to them and to their relatives/carers and treated patients with dignity and respected their privacy at all times.
  • Staff showed understanding of the challenges faced by patients and their carers
  • Communication with children and young people was age appropriate and effective.


  • The emergency operations service was operating a responsive ‘hear and treat’ service to ensure the best use of limited resources. Resources were used where they were most needed.
  • The trust had been commended for its service to reduce and respond to frequent callers and to reduce unnecessary admissions to emergency departments
  • There was service planning to meet the immediate urgent and emergency care needs of local people. There was flexibility, choice and continuity of care which was reflected in the types of services we saw. Most patients had timely access to initial assessment, diagnosis or urgent treatment.
  • The ambulance response project or ARP started 19 April 2016. The expected outcome of ARP was to ensure that the most appropriate response vehicle was sent to each patient’s correct location rather than just meeting a time target by sending the nearest vehicle. Call centre staff would provide additional time to triage patients on the phone when it was clinically safe and appropriate to do so, and this helped them to decide on the best vehicle to send. 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
  • Reasonable adjustments were in place for some patients. 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.
  • Two new Patient Transport Service bases had been opened at Weston Super Mare and Soundwell ambulance stations to meet local need. There was a ‘24/7’service which consisted of one vehicle and a crew available between 6p.m.and 6a.m. Escorts were encouraged to accompany patients living with dementia or learning disability or for patients whose first language was not English. This enabled staff to meet the patient’s individual needs
  • The resilience facilities were purpose built and located to cover the majority of the SWAST operational area.
  • SWAST was supported by five air ambulance charities with six aircraft providing good air ambulance coverage.
  • The events team took the lead for assessing, planning and resourcing public events to minimise the effect on the trust’s normal business.
  • 99.8% of patients attending the minor injuries unit were treated, discharged or transferred within four hours in the year ending March 2016. The average time to treatment was 49 minutes. Waiting times were constantly monitored in real-time by clinical staff.
  • Complaints were handled with sensitivity and time was taken to provide a considered response within most core services. There was learning and improvements made when people complained about the service they received, though not all complaints were being responded to in the time required.


  • It wasn’t easy for patients or people close to them to know how to complain or raise a concern. Staff gave a variety of responses of how patients could make a complaint describing that patients could telephone or submit their concerns online on the trust website. Not all vehicles had complaints forms or information for patients to read or take away with them.
  • There were no communication aids or hearing loops within patient transport vehicles. Staff did not use interpretation facilities when patients did not speak English as their first language. Instead they relied upon patients bringing an escort for the journey. However, staff could access the language line for translation services whilst at the ambulance base.
  • The triage systems used within the emergency operations centres did not prompt staff to ask whether a person was vulnerable, such as living with dementia or a learning disability.
  • The HART teams were able to respond quickly to emergencies within their area, except within Cornwall due to the distance from Exeter.
  • Within the minor injuries unit, X-ray services were not always available when patients needed them. The x-ray department closed at 5pm during the week and was only open for four hours a day at weekends. Although patients told us they did not mind returning the next day, there was a possibility of delayed treatment.

Well led

  • Quality, in terms of patient outcomes and experience, did not feature highly at operations meetings, although a quarterly quality report had recently been introduced.
  • Within most areas, risks to quality and safety were well understood at a local level but were not locally recorded and 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. We saw little evidence that the risk register was regularly discussed at service line or division or actions to mitigate risks reviewed. There were some risks on the risk register that had remained there too long without resolution. This included the poor performance in staff appraisals which had been added in 2007 and staff turnover added in 2013.
  • We were concerned about a lack of local oversight in respect of infection control. This highlighted a disconnection 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. Staff morale and motivation was mixed. Some worrying messages had emerged from the 2015 staff survey in relation to frontline ambulance staff. Staff dissatisfaction was reflected by results which showed that a significant proportion of staff felt unwell due to work related stress, felt pressurised to work despite not feeling well enough to perform duties, and had experienced musculoskeletal problems as a result of work activities. The survey also highlighted that a significant proportion of staff suffered physical violence and/or harassment, bullying or abuse from patients, their relatives or other members of the public. Local action plans had recently been developed but this was work in progress. The leadership was not aware of when the levels of professional support given to staff were failing.
  • There was a culture in which there was an unspoken expectation that staff would work longer hours than they were contracted to work. Staff told us they regularly finished their shifts late, missed their meal breaks, arrived early for work to undertake vehicle checks and undertook activities such as reading email updates and bulletins and undertaking training in their own time.
  • The intensity of work undoubtedly contributed to staff absenteeism and high levels of staff turnover. There was a variable degree of and formality in one-to-one support for staff.
  • There was a limited approach to obtaining the views of patients and staff were not engaged in this process.
  • The 2013/2014 integrated business plan included was some evidence of forward planning for service improvement in the patient transport service. However at a local level, leaders appeared demotivated to effect improvement.. As a result there was no forward vision of service improvement at a local level. Staff did not feel valued by their employers or by the managers of their service where the culture was described as insensitive to the needs of staff.
  • Some aspects of governance related to safety issues were not adequately monitored within patient transport services, for example, infection control. Risk registers did not capture all known risks, including clinical risks and the governance processes did not identify a lack of incident report. Identified training needs were not acted upon.

  • There was very limited oversight of quality in the Patient Transport Service other than performance against key performance indicators. Some aspects of governance related to safety issues were unclear and were not monitored effectively.


  • There was a clear vision and credible strategy for the emergency operations service. The leadership reflected the values of the service and were open, approachable and supportive. The service was innovative and looking for ways to improve and sustain.
  • There was a clear vision in place for the EPRR teams, especially special operations and where they wanted to take the service over the coming five years.
  • The governance framework had clear responsibilities.
  • The trust had introduced the 'Staying Well' service in December 2015 in response to a year-long staff consultation and staff requests for a coordinated support system, with an emphasis on mental health. There was a peer support network introduced in April 2016 and the trust had 38 trained peer supporters. Staff could also access 'fast track' physiotherapy treatment, which was funded by the trust.
  • There was a well-publicised mission statement and a set of core values within emergency and urgent care. Whilst not all staff could articulate these, they consistently demonstrated their commitment to delivering high quality care to patients.
  • Leaders of the patient transport service had ensured that all staff were fully informed about the outcome of the tendering process. Performance of the service against the key performance indicators was monitored effectively.
  • Staff within the EPRR teams attended/chaired a wide variety of national groups and committees to lead and share best practice.
  • The trust conducted traumatic risk monitoring and the ‘staying well service’ were available to staff should they need it.
  • 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 to be used by operational commanders during major incidents

We saw several areas of outstanding practice including:

  • The trust was influencing service improvements at a national level, for example the ambulance response programme.
  • The Aspire programme, developed by the trust, was providing excellent opportunities for personal and career development to all staff.

  • At times, outstanding professionalism and grace under pressure among the emergency medical advisors in the Bristol and Exeter emergency operation centre (clinical hub) teams. We heard staff being criticised, shouted at, called abusive names and threatened. All of this was disruptive to staff and unsettling. The staff remained calm, and handled the callers with courtesy and patience.
  • Staff in the emergency operations centres showed outstanding compassion and understanding to people in difficult and stressful situations. Staff made a genuine connection with patients and others who were scared or anxious and developed an, albeit temporary bond, with the person trying to help them. Staff would, appropriately, say “take care” and “all the best” to people, and this was often repeated back to staff by people who had appreciated their friendliness and warmth.
  • Although the emergency operation centres’ call-quality audit programme was not completed as often as required because of other priorities, and staff shortages, it had been previously commended and recognised for its quality. There was, nevertheless, an outstanding quality to the audits when they were being undertaken. This included the feedback, which was delivered with thoughtfulness, professionalism and the intention for staff to do well. There had been changes based on staff being asked how they found the process to make it more empathetic for those being examined.
  • There was an outstanding and commended programme to manage frequent callers to the service. This was helping to release the organisation’s limited resources to more appropriate situations. There was strong multidisciplinary working to support frequent callers with the service promoting the issue among the wider community and partner organisations.
  • At the time of our inspection the service had just embarked on a trial, known as the Ambulance Response Programme. This 12-week pilot aimed to improve response times to critically ill patients, making sure the best response was sent to each incident first time and with the appropriate degree of urgency. The trust was one of two ambulance services nationally participating in this trial.
  • The introduction of Right Care had resulted in 56.8% of patients, who called for an ambulance, being treated at the scene or referred to other services, rather than being conveyed to hospital emergency department.
  • Operational staff took time to interact with patients and were supportive to them and to their relatives/carers. Staff treated patients with compassion and dignity and respected their privacy at all times.
  • The range of staff support schemes provided showed a commitment to improving staff wellbeing and we received positive feedback from staff who had used these services. The introduction of a fast track physiotherapy service had resulted in a reduction in sickness absence due to musculoskeletal injury.  
  • The trust had a dedicated events team to manage the assessment, planning and resourcing for public events.
  • The trust produced a newsletter called “twentyfourseven” published for members of the public with news, long-service awards for staff, notable events taken place or coming up in the trust’s area, and success stories. These newsletters were available on the trust’s website. The high-quality publication provided the public with good information about the service and its achievements. 

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

Importantly, the trust must:

  • Ensure mandatory training for all staff, including safeguarding for vulnerable people, is updated and maintained in accordance with the trust’s target.
  • Ensure staff appraisals are completed each year to meet the trust’s target. The organisation must also ensure it is aware of those staff who have not had an appraisal for many years, and offer support and recognition where warranted.
  • Ensure risk registers are aligned with operational risks and that risk registered are reviewed regularly to monitor and mitigate risks
  • Ensure work intensity and fatigue is monitored and actions put in place to mitigate risks to staff
  • Ensure governance meetings at local levels contain a strong focus upon quality and safety. This will include performance reports on training, appraisals, patient outcomes, complaints and incidents relevant to the local level. Actions from addressing any shortcomings or changes must be recognised and completed. Leaders of the Patient Transport Services must ensure that staff are encouraged to report incidents and that feedback and learning from incidents is shared with the team. Incidents should be an integral part of the governance process and viewed as a positive opportunity for learning.
  • Ensure patient transport service engage in a regular programme of audit including infection control, safety of vehicles. These audits should be recorded and an agreed action plan documented and progress monitored through the governance processes.
  • Ensure accurate, contemporaneous and complete record of all treatment undertaken by Patient Transport Services staff and that across all services records are stored securely at all times to prevent unauthorised access.
  • Ensure adequate guidelines and protocols are in place to guide staff in their clinical decisions regarding adjustment of oxygen therapy.
  • Ensure a system is put into place which informs patient transport service crews of any important clinical information relating to the patients they convey, such as when a patient has diabetes.
  • Ensure that healthcare assistants who undertake initial clinical assessment of patients are assessed as competent before working independently
  • Ensure that all staff are familiar with their responsibilities in regard to the safeguarding of vulnerable adults and that robust reporting arrangements are in place.
  • Ensure partly administered controlled medicines no longer required are disposed of in accordance with the service standard operating procedures and that medicines are stored securely in the back of ambulances and cars when the crew is not present.
  • Review the management of clinical waste in ambulance stations to avoid risks to staff.
  • Ensure infection control issues identified in this report are addressed.
  • Ensure complaints are handled effectively. Information and guidance about how to complain must be available and accessible to everyone who uses the service in a language and format to meet the needs of the people using the service, for example those who were hearing or sight impaired.
  • Take action to meet locally agreed thresholds in respect of Ambulance Clinical Quality Outcomes.

In addition the trust should:

  • Ensure all staff have the time and resources to directly report incidents, and all staff recognise and respond to their duty to report them in a timely way following trust policy.
  • Make improvements to the delays in investigating and reporting on serious incidents within the period granted.
  • Be clear as to how the feedback from serious incidents is disseminated to staff in future.
  • Extend the infection control policy in the emergency operations centres so the procedures for staff around the use of hand gels were clear and consistent for all members of the teams.
  • Consider implementing occasional test or practice runs for IT system failures in the emergency operations centres when most convenient and safe to do so.
  • Continue with the work to provide commonality among the systems used within the emergency operations centres.
  • Ensure all emergency operations centres staff are aware of the need to have clinical input into the decision to stand down an ambulance from a scene.
  • Consider possible solutions for emergency operations centres staff from having outdated special notes linked to an address where the notes were no longer relevant.
  • Undertaken a staff review within the emergency operations centres to review the percentage of relief cover modelled against the increasing call volumes. Ensure staff can be released for training, holidays, special leave, and sickness, for example, without this affecting the quality of the service and pressure on remaining staff.
  • Remodel the staffing rotas to take account of the known or predictable changes in seasonal demand.
  • Ensure the major incident room in Exeter is not being used for other things preventing it being established for its purpose at immediate notice.
  • Re-focus upon the emergency operations centres call-quality audit programme to provide staff with good feedback, encourage improvement, and reward excellence.
  • Provide some relevant and useful mental-health training to all emergency operations centres staff.
  • Improve the response to stroke patients so at least 57% of patients reach a hyper acute stroke centre within 60 minutes of their call to the service.
  • Look for methods for emergency operations centres staff to spread out their continuing despatch education throughout the year and not just prior to their recertification being due.
  • Consider specific training or guidance for emergency operations centres staff for communicating with young children.
  • Ensure there is a formal handover period factored into the working pattern of the emergency medical dispatchers in the emergency operations centres.
  • Establish one-to-one sessions for staff and line managers to take place within the emergency operations centres on a regular basis. Ensure these are taking place and add value to the staff concerned and the organisation.
  • Ensure all staff who do not have direct access to emails or the trust’s intranet are kept up-to-date and well informed of new or updated information at all times.
  • Review how a patient’s mental health status is determined. Triage protocols do not proactively determine if the person is living with dementia or might have a learning disability.
  • Develop and nurture valuable connections between staff in the emergency operations centres in Bristol and Exeter.
  • Review security for all staff working in the emergency operations centres, when the surrounding area was largely unoccupied by other people, were able to leave the offices safely.
  • Work to develop a more positive culture within patient transport services. This includes taking action to listen to all groups of staff in a forum that is perceived to be safe and confidential, and addressing the development needs of staff in leadership positions.
  • Ensure exit interviews are conducted and take action to address concerns identified by staff within these exit interviews.
  • Ensure regular staff meetings occur within patient transport services and these are recorded for the benefit of those staff unable to attend.
  • Ensure the environment in the urgent care centre is safe for children.
  • Ensure that there is sufficient space in the waiting area and that waiting patients can be viewed by staff at all times.
  • Review the lighting for vehicles reversing onto the quay in St Agnes to ensure safety of staff and patients when reversing onto the quay to meet the boat.
  • Review the audit of the services provided on the Isles of Scilly undertaken in June 2015, to ensure actions identified have been implemented.
  • Review the provision, availability and contact ability of community first responders on the Isles of Scilly.
  • Ensure that patient transport services monitor compliance with The National Institute for Health and Care Excellence (NICE) Quality Standard QS72 Renal Replacement Therapy services for Adults.

  • Ensure the handheld electronic patient care record devices are fit for purpose in all areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 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.

Inspection carried out on 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.

Inspection carried out on 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.