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Provider: London Ambulance Service NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 3 January 2020

Our rating of the trust stayed the same. We rated it as good because:

  • There were enough front-line ambulance staff to care for patients and keep them safe. Staff had training in the key skills needed for their role. Most staff understood how to protect patients from abuse and managed their safety well. Managers monitored the effectiveness of the service and made sure staff were competent in their roles.
  • The services-controlled infection risks and followed professional practices with this regard. Staff understood their duty to raise concerns and report incidents and near misses. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff assessed risks to patients, acted on them and kept good care records of treatment and care provided. Information was shared where required in a safe manner with other health agencies. Staff provided good care and treatment, gave patients pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers and helped patients and their carers find further information and to access community and advocacy services.
  • There were systems to alert staff to specific safety or clinical needs of a person using the service and to provide additional support. Steps were taken to respond to capacity issues by transferring calls between sites.
  • Services were available seven days a week. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service engaged well with patient groups and the wider community to plan and manage services and all staff were committed to improving services continually.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Most staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.
  • Leaders used a range of monitoring tools to measure performance and achievement of national targets. Action was taken where improvements were needed. Complaints were responded to in line with the trust’s standards.
  • The service promoted equality and diversity in daily work and provided opportunities for career development. There was a general culture of inclusivity and of teamwork across services.

However:

  • Despite the trust having increased the staffing in the Emergency Operations Centres, there was a lack of consistency in staffing levels and the rota system was unreliable. This impacted on staff’s ability to respond to incoming telephone calls to the Emergency Operations Centres. Temporary agency staff used in IUC did not always have the required level of skill needed to provide a responsive service to callers. The availability of clinical advisors in the EOC impacted on staff’s ability to get advice as quickly as needed.
  • The incident reporting culture had continued to improve and there was evidence of improvements made as a result of learning from such events. There was however, some variation in EOC staffs understanding and use of the incident reporting process. Although learning from incident review processes was communicated in several ways, staff working in EOC and the IUC reported not having time to read some communications and therefore, were not aware of some updates.
  • Although mandatory safety training rates had improved since the last inspection, some expected targets had not been met. Staff working in EOC had educational breaks built into their shifts but reported not having enough time to update themselves or complete on-line learning.
  • Line managers in EOC and IUC were not always assessing their staff’s competencies following the completion of mandatory training and regarding expected practices within their roles. There were gaps in some of the role specific training of IUC staff.
  • Although appraisal rates had improved in EOC, some staff did not have the opportunity to have feedback on their performance through supervision or an annual review.
  • Whilst staff had access to policies, procedural guidance and other useful information, where updates to these resources was required, action had not always been taken to do this. However, we saw systems had been put in place to address this area as soon as the matter was brought to the executive’s attention.
  • Although the trust had done work to improve safety and security, some areas and vehicles were still not secured to a consistent standard. The provision of equipment had improved to front line vehicles and staff, there were some items which remained less available or were not yet provided and some items had passed the expiry date. This was like our previous findings.
  • The stock rotation of some locally managed medicines and consumables needed to be tightened to ensure out of date stock was identified and removed.
  • The servicing of vehicles was not always happening in a timely way causing reduced availability to staff.
  • Although people could access the service when they needed it, there were regular delays in responding to initial telephone calls made by the public to the EOC.
  • Team meetings did not routinely take place for the sharing of information and one-to-one meetings were cancelled in IUC due to demands on the service. Opportunities were sometime missed to help staff understand the priorities of the service and what was being done to manage these and other issues.
  • Several staff in EOC were not fully aware of the trust’s vision or how they could contribute to its achievement. Senior leaders were not as visible and approachable as staff expected, although the executive team had carried out several staff engagement activities to address this.
Inspection areas

Safe

Requires improvement

Updated 3 January 2020

Our rating of safe went down. We rated it as requires improvement because:

  • Whilst staffing levels within the Emergency operations Centre (EOC) had improved since our last inspection, the staffing numbers and rota system in use did not enable calls to be responded to as quickly as expected and to a consistent level. The trust was however, working to address the rota and annual leave policy to improve this. The trust was working to improve staffing in the Integrated Urgent Care (IUC) service, but the departments remained short of substantive staff on a regular basis.
  • Improvements had been made in the completion rates of mandatory safety training since the last inspection. Despite this some of the trust’s own expected targets had not yet been met in a relatively small number of subjects. The transfer of knowledge related to safeguarding vulnerable people had not been taken on board by all staff working in the EOC, and this was not being assessed by line managers.
  • Whilst there was a very well-structured incident reporting system and process, several staff in the EOC were not fully aware of this. The trust had several ways of sharing information, although staff in working in the EOC and IUC reported not having time to read information circulated. Learning from investigations and complaints was not always shared through one-to-one meetings, as a result of these being cancelled in IUC when service demands took precedence.
  • Medicine storage temperature monitoring was not always carried out. Medicines which were out of date were identified in vehicles. Medicines which needed to have a start date recorded on them but did not contain this information. Some simple medicines were not returned to the original packaging after use.
  • As we found at our previous inspection, some essential equipment items were not always available. Some equipment items had gone passed the expiry date, suggesting that checks were not being completed fully.
  • The security and accessibility to some parts of the trust and vehicles continued to be a concern.
  • The servicing of vehicles was not always happening in a timely way, which at times reduced vehicle availability to staff.

However:

  • There were enough front-line staff with the right skills and abilities to deliver safe treatment and care to patients. Staff in all areas were provided with access to training to ensure they were able to fulfil their roles.
  • Infection prevention and control practices were undertaken by staff according to the trust’s guidance. Staff assessed the needs of patients and considered safety concerns and risks. They completed patients’ records to a good standard and shared important information with other care providers where required.
  • Safeguarding information was readily available to staff. The arrangements were very well established and there were high levels of reporting through the trust’s safeguarding team. The trust worked with external agencies about safeguarding when required.
  • There was a well-defined and easily accessible process for speaking up and there was in the main, a good culture of reporting incidents. These were reviewed and investigated, and learning was shared via a range of methods, although not everyone took responsibility to read such important information.

Effective

Good

Updated 3 January 2020

Our rating of effective stayed the same. We rated it as good because:

  • The service provided care and treatment including pain relief based on national guidance and evidence-based practice. Care pathways were used by staff where appropriate. Front line staff had access to information via electronic devices. Managers checked to make sure staff followed professional standards of practice and other guidance. They provided clinical information updates through the trust’s main intranet page and other means.
  • The service monitored, and mostly met, agreed response times so that they could facilitate good outcomes for patients. The monitoring of services and performance was well established. Staff were generally aware of what was required of them in order to deliver the services efficiently. Data was collected, reviewed and used to make improvements when required.
  • Staff worked in a collaborative way with one another and external agencies to ensure the needs of patients were assessed and responded to. Where advice about patients’ health needs was required, staff provided this information. Staff received training on consent, the Mental Capacity act (2005) and supported patients to make informed decisions about the treatment and care.

However:

  • Whilst staff had access to training and development opportunities, line managers did not always have the opportunity to hold discussions with their staff or annual performance reviews due to activity levels. The competencies of staff were not always being assessed in EOC or IUC by their line managers.
  • Information that was provided to staff to help them in their roles was not always updated in light of changes in practice. The trust had taken action to address this.

Caring

Good

Updated 3 January 2020

Our rating of caring went down. We rated it as good because:

  • Most staff spoke with patients and attended to them with compassion and kindness. Their privacy and dignity was respected, and staff took into account patients individual needs. Staff demonstrated compassionate, empathetic care to patients and members of the public in often difficult and challenging circumstances.

  • Emotional support was provided over the telephone or directly to patients, families and carers. Staff recognised and considered patients’ personal, cultural and religious needs. They provided advice and used a range of supportive tools to delivery care safely and responsively.

  • Staff supported and involved patients, families and carers to understand the situation and the required actions of staff. They involved those who were important to the patient in making decisions about their care and treatment.

Responsive

Good

Updated 3 January 2020

Our rating of responsive stayed the same. We rated it as good because:

  • Services were planned and organised around the needs of the populations served by the trust. The trust worked with a wide range of other stakeholders to evaluate and improve its services.
  • The trust’s resource escalation action plan (REAP) enabled it to monitor increasing operational activity and manage surges in demand. There was good engagement with other acute trusts at times of high activity and the trust worked hard to avoid unnecessary hospital conveyances.
  • Staff worked in ways which were inclusive and took account of people’s individual needs and their choices. Staff had access to additional resources to support them in delivering treatment and care. In addition to the expertise of front-line staff there was support available to deliver advice and care through specialist staff, including mental health, end of life and maternity.
  • Peoples complaints were acknowledged, investigated and responded to in line with the trust’s own complaints policy. Learning from complaints was shared with relevant staff, although staff did not always read information provided by leaders.

However:

  • At times of high demand and pressure staff working in the call centres were not always able to respond to incoming calls as quickly as they would like. There were safety mechanisms in place to ensure patients of priority were responded to as soon as possible.

Well-led

Good

Updated 3 January 2020

Our rating of well-led of the service stayed the same. We rated it as good because:

  • Leaders of service areas understood what was expected of them and their staff and managed the priorities and key outputs needed to run the service safely and efficiently. Leaders in service areas were visible and approachable. Leaders supported staff to develop their skills and take on additional responsibilities. Leaders encouraged an open and honest culture, which valued the contributions of staff and fostered inclusivity.
  • Most staff understood what the trust’s vision was and what they wanted to achieve. A range of staff had been involved in the strategy and most understood it was focused on developing and sustaining services, which were aligned to local plans within the wider health economy. Leaders and the majority of staff understood and knew how they contributed to the strategic aims and assisted in monitoring progress.
  • Staff generally felt respected, supported, and valued. The staff survey for 2018 saw improvements in several areas and was responded to by more staff than previously. Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders and teams used systems to manage performance outcomes effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. There were arrangements to support staff to cope with unexpected events.
  • Performance information was collected and reviewed by service level leaders. Where improvements had been made information was shared with staff. Areas which needed to improve were identified and communicated accordingly.
  • Staff were encouraged to actively and openly engaged with patients and the wider community. They collaborated with partner organisations to help improve services for patients and to highlight the impact of health issues and matters such as knife crime.
  • Staff recognised the importance of learning and improving services. Leaders shared information including learning from adverse situations and from complaints in a range of ways. Leaders had a good understanding of quality improvement methods and the skills to use them. Staff were encouraged to be innovative and participation in projects and research.

However:

  • Although there were regular opportunities to meet, discuss and learn from the performance of the service, staff in the Emergency Operations Centre (EOC) and Integrated Urgent Care (IUC)/111 reported not always having feedback of learning from incidents. They reported not having time to read information cascaded from senior leaders. Further, one-to-one meetings and team meetings were not always carried out as expected.
  • Leaders within the EOC did not routinely apply leadership practices to monitor and assess staff’s competencies and their understanding of the organisational services. They did not always communicate effectively so that staff understood the trust’s aims and how they impacted on these.
  • Some leaders in EOC reported being confused about the responsibilities for attending joint meetings between the different core services or how often meetings took place. Leaders did not have a clearly defined responsibility to raise incidents which impacted on both EOC and IUC/111 and as a result shared learning was not always happening.
  • Several staff in EOC reported the executive team as being less visible than they expected, despite several engagement activities having been carried out.
Checks on specific services

Emergency and urgent care

Good

Updated 3 January 2020

Our rating of this service stayed the same. We rated it as good because:

  • Risk assessments were undertaken for each patient. Risks were managed well.

  • Mandatory training was provided in key skills and most completed it as required.

  • Patients who were at risk of deterioration where quickly identified and managed accordingly.
  • On the whole the service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Records were clear and up-to-date, we found they were stored securely and were easily available.

Patient safety incidents were managed well. Staff understood their responsibility with regards to incident reporting. Incidents were investigated and learning was shared with staff.

  • All patients were partners in their care, they were supported by staff to understand their treatment and to make decisions about their care.

  • Patients were provided with information on how to make healthier lifestyle choices.

  • Staff were supported by clinical experts who gave advice to ensure patients received the correct treatment and care.
  • Date was used by the service to analyse how it was performing. Data was accessible to staff when it was needed.

However

  • Security at station was still an issue, stations and vehicles were left unlocked. Certain pieces of equipment were routinely not available for staff to use as part of their daily work.
  • Fleet staff did not receive training in the new ambulance vehicles the service were introducing to the fleet.
  • The storage of medicines in kit bags needed to improve. The stock rotation of some consumables needed to be tightened to ensure out of date stock was identified and removed.
  • The trusts policies and procedures were not always updated in a timely manner.

  • Managers were not always visible and approachable for staff and patients. Staff were not always supported by managers to develop their skills.

Emergency operations centre (EOC)

Requires improvement

Updated 3 January 2020

Our rating of this service went down. We rated it as requires improvement because:

  • The service did not have always have enough staff working within both EOC’s.
  • Not all staff understood how to protect patients from abuse. However, the service worked well with other agencies when abuse was highlighted.
  • The design, maintenance and use of facilities, premises and equipment did not always keep staff safe.
  • Staff did not always have opportunity to learn from incidents and managers did not always ensure actions from patient safety incidents were implemented and monitored.
  • Managers did not always appraise staff’s work performance and did not always hold supervision meetings with them to provide support and development.
  • At the time of inspection, staff did not always have access to updated policies.
  • Staff did not always feel leaders understood and managed the priorities and issues the service faced. Leaders were not always visible and approachable in the service for staff.
  • The service did not always operate effective governance processes. Staff were clear about their roles and accountabilities but did not always have regular opportunities to meet, discuss and learn from the performance of the service.

However:

  • All those responsible for delivering care worked together as a team to benefit patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • It was easy for people to give feedback and raise concerns about care received.
  • Staff were overwhelmingly positive about the culture within both EOC’s and the inclusivity of the organisation.
  • The trust employed a mental health nurse (RMN) who was available within EOC to offer support and guidance to staff on matters relating to patients experiencing mental ill health.

Reference: Emergency operations centre not found

Good

Updated 23 May 2018

  • Staff provided care and treatment based on national guidance and evidence. They cared for patients with compassion, involved patients and those close to them in decisions about their care and treatment, and provided emotional support.
  • There were appropriate methods and processes to respond and manage risks to patients. Staff understood their roles and responsibilities in relation to safeguarding vulnerable adults and children.
  • Staff knew how to report incidents; managers shared learning from incidents and the trust carried out detailed investigations, feeding back to patients and families where appropriate.
  • The trust set quality performance targets, and reviewed these regularly against internal and external targets. The trust had governance, risk management, and quality measures to improve patient care, safety, and their outcomes.
  • During our previous inspection in February 2017 we reported on a computer aided dispatch (CAD) outage on New Year’s Eve 2017. However, the trust had reviewed the resilience and robustness of the system. The systems processes had been improved, although more work was planned.

  • There was good local leadership at both Waterloo and Bow emergency operations centre. The service had developed a five year strategy for emergency operations. There was an inclusive and constructive working culture within EOC services.
  • Senior managers had identified risks to the retention of call taking and dispatch staff. Work was in progress on an enhanced pay package for these staff grades.
  • Services were planned to meet local needs, and managers monitored the effectiveness of care and treatment through local and national audits.
  • The trust managed complaints and ensured staff had opportunities to learn from when things went wrong.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. This was an improvement since our last inspection.

However:

  • The EOC had regular periods where they were not able to meet the required number of planned staffing hours. There was poor retention of new dispatch and call taking staff, and staff turnover rates were above the trust’s target.
  • From April 2017 to October 2017, only 44% of staff working within the emergency operations centre at the trust had received an appraisal; this did not meet the trust target of 85%.
  • Mandatory safety training compliance rates did not meet the trust targets for some subjects.
  • From August 2017 the percentage of abandoned calls was higher than the England average.
  • Between November 2017 and January 2018 call answering times were below the England average. However, as the new ambulance response programme (ARP) measures were only introduced to London Ambulance Service (LAS) in November 2017, there was only three months of data available.
  • Managers told us there was very little time available for managerial tasks due to operational demands.