You are here

Provider: London Ambulance Service NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 23 May 2018

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

  • We rated safe in the emergency operations centre (EOC) and well-led in emergency and urgent care (EUC) as requires improvement. We rated caring as outstanding in the EUC. In both EOC and EUC we rated effective and responsive as good. Well-led was rated as good in EOC. In rating the trust, we took into account the current ratings of the Emergency Preparedness Resilience and Response service and 111 services, which were not inspected this time.
  • We rated well-led for the trust overall as good.
  • At this inspection we found the trust had made significant improvements, in particular and of note were those related to well-led.

Inspection areas

Safe

Good

Updated 23 May 2018

Our rating of safe improved. We rated it as good because:

  • Across both core services there had been improvements in the procedural arrangements around incident reporting, investigating these and learning as a result. Local and executive leadership was much more focused on safety and there were strengthened arrangements for the oversight of safety matters, including identifying and responding to patient risks.
  • Significant work had been taken to address previous concerns around medicines reconciliation, and staff were clear on their responsibilities to follow required practices.
  • Staff had sufficient equipment to enable them to deliver safe care and treatment. Arrangements were in place to ensure ambulances were serviced, cleaned and re-stocked.
  • Infection prevention and control practices had been strengthened since our last inspection and staff understood their responsibilities. Monitoring of staffs adherence with safe practices was taking place, and action was taken where improvement was required.
  • Staff understood and met their responsibilities with regard to patient records. There had been some improvements to the way in which frontline staff could access and complete records, and work in this area was ongoing.
  • There were suitably safe and established arrangements for responding to major events.

However:

  • Staffing levels remained a concern in the emergency operations centre, particular recruitment and retention of call handlers. This put enormous pressure on the staff and impacted on their ability to complete mandatory training subjects, as well as their general well-being. We had continuing concerns of the low levels of safety training completed by EOC staff.

Effective

Good

Updated 23 May 2018

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

  • People who required support from the services had their needs assessed and responded to in line with legislation, standards and evidence based practices. Staff understood their responsibilities to obtain informed consent.
  • In addition to highly trained ambulance personnel, staff with specialised skills and expertise including; maternity, mental health and safeguarding were available to advise and support staff.
  • Staff were provided with skills related training and development opportunities. They had opportunities to discuss their performance and agree development objectives.
  • The outcomes of services provided were monitored and evaluated through a range of methods. Where improvements were required these were addressed. The recently introduced ambulance response programme had started to show some positive performance outcomes, although it was too early to make an informed opinion of its effective working.
  • There was strong emphasis on multidisciplinary working. Staff supported one another to ensure patients, including those who had particular needs associated with mental health, or at the end of life were met.

However:

  • Whilst staff in EOC had opportunities to meet with their manager to discuss performance and development, they did not always have an annual performance review. This was because the timing of this fell at a period of high activity and demand.
  • Although staff had training on mental health awareness and related topics, there was notable variation in staffs knowledge, ability and confidence when dealing with people in mental health crisis.

Caring

Outstanding

Updated 23 May 2018

Our rating of caring stayed the same. We rated it as outstanding because:

  • Staff working across all parts of the service demonstrated care which was consistent with the underpinning values of the trust. Patients were treated with a calm and professional manner, with kindness and empathy.
  • Staff afforded patients privacy and respected their dignity. Where staff had the opportunity to provide patients with choices they did so through the sharing of information and checking individuals understanding.
  • The immediate physical and emotional needs of patients were considered and taken into account by staff. Staff ensured the results of their initial assessment were discussed with their patients and they were informed of any treatment or action required. Family were involved as appropriate.
  • Staff often went above and beyond their expected duties in order to meet patient needs. We saw and heard about examples of the commitment of staff from patients.

Responsive

Good

Updated 23 May 2018

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

  • The trust had focussed on developing the service in order to meet the changing needs of the population. There were a range of ways in which the ambulance service were able to provide a response to patients and these were based on generally well defined measures. A number of pathways were in place to ensure patients treatment and care was appropriate to their needs. Clinical expertise was available to ensure treatment and care was optimised.
  • The trust had worked proactively to find ways of improving the handover of patients between ambulance staff and emergency department staff. The initial results of the work undertaken showed an improving picture, despite the winter pressures experienced during the introductory period.
  • There were appropriate supportive systems to enable staff to respond to patients whose first language was not English. Staff were able to respond to patients who had particular complex needs, and could make reasonable adjustments in order to deliver the required level of care.
  • The processes for responding to and investigating complaints had been strengthened since the last inspection.

However:

  • There was room for improvement in the completion of the complaints process end to end within expected time frames and staff statement writing.
  • Patients with mental health needs were not always able to access the most appropriate service when conveyed by ambulance staff. There was an opportunity to work with external agencies to address this.

Well-led

Good

Updated 23 May 2018

Our rating of well-led improved. We rated it as good because:

  • The trust had worked hard to reinforce the organisational vision and its strategic aims, and most staff understood how they contributed to the achievement of this. A great deal of work had gone into engaging with a broad range of staff, stakeholders, patient groups and representatives to the development of a new strategy. Information arising from this was shared through various channels.
  • Local governance arrangements had been improved and there was a higher level of awareness and understanding of the value and importance of reporting, reviewing and learning from incidents, for managing risks and performance outcomes. Staff mostly understood their responsibilities and what they were accountable for.
  • The culture had improved since the previous inspection and staff were generally proud to work for LAS. The best patient care was what staff strived to provide, and generally staff were able to speak up and bring matters to the table where they could not provide the right care or things went wrong.
  • Staff worked collaboratively with others in order to improve its services and to bring about future sustainability. There were some excellent examples of positive engagement with stakeholders, external agencies, patients and the public. Work related activities arising from this engagement were in evidence.

However:

  • There were some notable leadership behaviours and cultural variations amongst staff in both EOC and EUC, which less senior staff were aware of. These were further impacted on by the level of dissatisfaction felt by some managers and disconnect they felt between the expectation of them and what could be delivered in reality. This was similar to what we found at our last inspection.
  • There was still a lack of consistency in how managers dealt with important areas of staff related welfare and well-being, including staffs absence from work management. Where good ways of working had been identified, this was not always shared to the benefit of others.
  • Some frontline staff did not recognise or take the opportunity to participate in the work that was taking place to develop the service. As a result they reported not being aware of the emerging strategy and of not having met or seen members of the executive team.
  • Staff recognised the trusts had worked hard to address the bullying and harassment culture that had been present; despite this, some staff reported the bullying culture had returned in the last few months.
  • The trust was aware of the need to improve its compliance with the workforce race equality standards and had been working proactively to address this. There remained concerns amongst some black and minority ethnic (BME) staff that opportunities for them to progress were still being hampered.
Checks on specific services

Ambulance emergency and urgent care

Good

Updated 23 May 2018

Our rating of this service improved. We rated it as good because:

  • There were much stronger governance arrangements in place compared to our findings at the last inspection. The trust had taken action on key areas of concern we had raised, and were continuously focussed on quality, patient safety, risks, and performance.
  • The reporting of low level incidents had improved and generally staff were more engaged with reporting incidents of all levels. There was more oversight at a local level and managers were able to assess themes and trends associated to their sectors. This meant they were able to take actions and share learning to staff.
  • The management of medicines had continued to improve on our findings of the 2017 inspection. New style drug rooms were being installed which meant tighter controls for the tracking and tracing of medicines.
  • Infection control prevention (IPC) practices had improved and there were more robust quality assurance processes regarding the monitoring and management of IPC.
  • The trust had more effective processes for managing risks. At a local level, managers were more empowered to oversee and manage their risks.
  • There was better scrutiny at a local level for staff mandatory training and staff were taking greater responsibility for completing the required training subjects.
  • Equipment availability had improved, and there were better systems for the supply and maintenance of equipment.
  • Major incidents were managed well. There were systems in place to ensure effective command and control protocols were followed by staff.
  • The trust performed well for the majority of patient outcomes. The trust had effective systems to monitor and take action to improve patient outcomes.
  • The trust had worked hard to implement the ambulance response programme (ARP). Initial performance information showed the trust was ranked fourth out of ten acute ambulance trusts, within the short space of time they had been adhering to the new standards.
  • There was access to professional expertise and clinical guidance. Support was available to frontline staff through suitably experienced specialists, such as mental health nurses and a maternity consultant midwife.
  • Staff provided excellent care to patients. We observed numerous occasions when staff went beyond their call of duty to ensure patients were cared for in a compassionate, kind, and dignified manner.
  • There were stronger quality measures in place at a local level, with greater oversight of performance and areas for improvements. Action was taken to address any shortcomings in a measured and responsive way.
  • Through the hospital handover project, the trust had lead on introducing ways of improving patient access and flow during patient handover at hospitals.

However:

  • At a local level, managers were unhappy with the clarity of their role and the extra workload they had received. The clinical team leaders (CTL) were still unhappy with the unclear boundaries within their role. This had not improved since our last inspection.
  • Local managers felt pressurised and on occasions harassed by the ‘middle management’ tier of the organisation.
  • Some staff were not happy with the way in which their managers addressed sickness and absence. They felt the approach to the trust policy was punitive. This had not improved since our last inspection.
  • Staff told us they did not have sufficient time to make the necessary vehicle checks at the start of their shift. This had not improved since our last inspection. The majority of staff were unhappy with the late finishing of their duties. They frequently ran late at the end of their shifts.
  • Patients had limited access to the appropriate mental health facilities and for the majority of cases; patients were conveyed to emergency departments. Although, this was beyond the control of the trust, this placed immense pressure on staff and was not always in the best interests of patients.
  • Hospital handover delays meant ambulances were ‘stacked’ at hospitals awaiting the receiving trust staff to accept and take over the care of the patient. As a result, ambulance staff were not able to respond to patient calls made during this time.
  • Complaints were not always dealt within the local time frame.

Emergency operations centre (EOC)

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.