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Provider: North West Ambulance Service NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 27 November 2018

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

  • The trust had an up to date duty of candour policy and procedure. Records we reviewed confirmed that duty of candour was reflected in the trust’s duty of candour guidance, policies were cross referenced and the description of incidents that required duty of candour consideration had been updated following our inspection in 2016.
  • The service provided safe care and treatment. There were processes and staff followed them to lessen risks to patients, staff and the public.
  • Since the inspection in 2016, the trust had undertaken a review of how it responded to risk and how it prepared crews. The trust had strengthened and developed the Paramedic team lead structure to support and advise ambulance crews to recognise a deteriorating patient.
  • The trust met the fit and proper person’s requirement Regulation 5 of the Health and Social Care Act. This regulation ensures that directors of NHS providers are fit and proper to carry out this important role.
  • The trust ensured that there was sufficient staff on duty at all times; including sufficient numbers of clinical supervisors at the individual sites to ensure patient safety.
  • Innovation was encouraged and staff were supported to join national improvement groups to influence changes in protocols, processes, equipment and training. There were examples of innovative practice that were being incorporated into national practices.
  • Service provision, locations and vehicles, were planned to meet the needs of the local population. This was based on the need to respond to major incidents at government defined sites of strategic importance, major incidents in other areas of the NWAS geographical region and provide mutual aid to neighbouring ambulance trusts in a timely manner.
  • We were informed by senior management that staff were debriefed following a serious incident. For example, a serious road traffic collision with multiple victims. This usually took place at a hospital and was known as a ‘Hot debrief’. The discussion centre around what went well and what improvements could be made. This was confirmed by operational staff we spoke with across the trust.

However:

  • We found that there was a lack of adequate assurance that ensured an effective process for overseeing and monitoring compliance with infection prevention and control procedures was embedded across the trust.
  • Staff in areas of the trust were not always supported to access mandatory training, as defined by the provider as part of their role.
  • The trust had medicines policies in place and we viewed the medicines management procedures 2017 to 2019 which also contained the standard operating procedures for the management of all general medicines used by the trust however, we saw issues with patient group directives and conflicting information given to staff on administering certain drugs.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RX7/reports.

Inspection areas

Safe

Good

Updated 27 November 2018

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

  • The trust had a major incident response plan, which we reviewed. This included; heatwave plan and pandemic plan. Action cards to manage major incident were carried in the ambulances and response cars. The cards gave chronological instructions to each member of staff on what to do and who to communicate with.
  • We were informed by senior management that staff were debriefed following a serious incident. For example, a serious road traffic collision with multiple victims. This usually took place at a hospital and was known as a ‘Hot debrief’. The discussion centre around what went well and what improvements could be made. This was confirmed by operational staff we spoke with across the trust.
  • The trust had an up to date Duty of Candour policy and procedure. Records we reviewed confirmed that duty of candour was reflected in the trust’s duty of candour guidance, policies were cross referenced and the description of incidents that required duty of candour consideration had been updated following our inspection in 2016.
  • Overall staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

However:

  • The corporate risk register showed risks such as national performance targets and financial overspend. One risk for March 2018 showed that the trust had not met national performance targets across the North West due to high demand and acute hospital pressures. Its current risk score was high, with moderate assurance. Senior managers we spoke with, confirmed that they were working on a ‘winter pressures’ plan and that this was being undertaken as part of multidisciplinary work with receiving trusts across the trust area.
  • During the inspection, we raised the concerns we had identified regarding infection control procedures with the trust and requested assurance that improvements would be made. The trust provided us with evidence that action had been taken and was being monitored to ensure sustained improvement and adherence to standards.
  • Since the 2016 inspection the trust had made progress in managing safeguarding issues but we found that that there were areas across the trust where safeguarding was not always fully understood. For example, on one patient record we looked at, staff had recorded the patient was living with Alzheimer’s and wouldn’t drink. We noted that staff had ticked that the patient had capacity and we found no consideration of best interest for the patient.
  • The trust had medicines policies in place and we viewed the medicines management procedures 2017 to 2019, which also contained the standard operating procedures for the management of all general medicines used by the trust but we saw issues with patient group directives and conflicting information given to staff on administering certain drugs.
  • We observed failure to follow infection prevention and control procedures on a number of emergency ambulances. This meant that not all was being done to protect patients from avoidable harm. We also found that there was a lack of adequate assurance that there was an effective process for overseeing and monitoring compliance with infection prevention and control procedures, across the regions.

Effective

Good

Updated 27 November 2018

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

  • The service provided safe care and treatment. There were processes and staff followed them to lessen risks to patients, staff and the public.
  • The trust used the national early warning scores which determined the degree of illness of a patient and prompts critical care intervention.
  • Staff worked in a multidisciplinary way to benefit patients. Paramedics, clinical support staff, emergency medical technicians and other healthcare professionals supported each other to provide good care.
  • Services monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • The trust undertook audits to monitor and benchmark performance or review patient outcomes to monitor effectiveness of care at the time of inspection.
  • The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers in most areas, checked to make sure staff followed guidance.
  • Staff appraisal rates had improved since the last inspection but not to the expected levels in all areas we inspected.
  • There were a number of initiatives to try and reduce the number of patients requiring emergency transfer to hospital.
  • Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service.

However:

  • We found variable knowledge of staff in relation to the implementation of the Mental Capacity Act 2005.
  • The trust failed to reach the national quality standard for calls answered within 5 seconds, for 2017 to 2018.

Caring

Good

Updated 27 November 2018

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

  • Staff provided emotional support to patients to minimise their distress. We listened in on calls and noted staff reassuring patients who were anxious or upset. We noted that staff offered specialist support this was needed.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • During our inspection the staff consistently demonstrated compassion, kindness and respect towards callers and patients, including one caller who was in mental health crisis.
  • We noted that staff had a good rapport with their patients and those close to them.
  • Were possible staff involved patients and those close to them in decisions about their care and treatment.
  • Patients and relatives told us staff had explained things in a way they could understand.

Responsive

Good

Updated 27 November 2018

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

  • The service had long and short-term plans in place to ensure staffing levels were sufficient to meet anticipated demand for the service.
  • The trust engaged with the lead Clinical Commissioning Group to review performance and agree strategies to improve.
  • Action was taken to improve service delivery where gaps were identified. The trust had implemented several pilot schemes to try and improve the patient experience.
  • There was a comprehensive complaints system and all complaints were risk assessed and investigated appropriately.
  • Care and treatment was coordinated with other services and other providers. There was collaboration with partners to improve urgent care pathways and turnaround times.
  • There were systems to support patients to manage their own health and to signpost them to alternative services where they could access more appropriate care and treatment, for example GP surgeries and walk-in centres.
  • The trust provided a leaflet with information about making a formal complaint. This included clear information on how to complain, as well as details of local advocacy services available to support patients and carers make a formal complaint. Staff confirmed that leaflets were available on ambulances. Information on how to make a complaint was clearly displayed on the trust website.

However:

  • Turnaround times in accident and emergency departments remained an issue for the trust.

Well-led

Good

Updated 27 November 2018

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

  • The provider had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. The mission statement was: “The Right Care, at the Right Time and in the Right Place.”
  • Leadership team acknowledged the need to expand the current team; measures were in place to develop mangers into deputy positions. A training gap analysis had identified, the need for further training, accredited training packages were available to staff who wanted to progress into a management position.
  • Board development sessions were an integral part of the workforce policy/strategy, this was in readiness for succession planning and ensuring senior managers had a development pathway, should they consider an executive role.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The trust gathered feedback from a range of different patient groups using innovative methods including a patient engagement group. Feedback from significant events, internal and external incidents, health professionals and comments and complaints were used to push improvements.
  • Processes for investigating serious incident had improved since the last inspection; they were now linked to the national serious incident framework. The introduction of weekly “review of serious incidents” meetings meant serious incidents had become more visible to the board and reports supported learning.
  • Senior management representatives from different divisions attended monthly sub committees to discuss performance, risk, safety and quality in their area. Dashboards displaying this information acted as operational summaries. These were presented at the workforce committee and concerns were fed up to the board.

However:

  • There were variations in the culture both across the trust and within regions. Staff in most areas told us they felt very positive about the culture, but in some areas, staff said they felt there was a high degree of pressure and that focus was on performance targets rather than patient care.
  • Senior management recognised that there was a large variation of how managers collected and processed performance data across the region. Staff worked in different ways to capture information; this was not always consistent and did not always highlight poor practice effectively.
Checks on specific services

Emergency and urgent care

Good

Updated 27 November 2018

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

  • The service had a good network of staff who were adequately trained in safeguarding processes.
  • Staff told us they were always given time to make safeguarding referrals and were stood down to allow them to complete referrals.
  • We found good levels of cleanliness, hygiene and infection prevention and control (IPC) in NWAS ambulance stations and ambulances.
  • Ambulance crews had up to date satellite navigations and communication systems in their vehicles to guide crews to patient pickups and incidents.
  • The service had undertaken a full review of how it responded to risk and how it prepared crews. As well as using up to date clinical guidelines it has also developed new staffing structures in ambulance teams which provide support in responding to risk.
  • The trust had reviewed its staffing structure after our last inspection in 2016. In that inspection we found concerns about staffing mix as well as staffing capacity. We found significant steps had been taken to address shortfalls.
  • The trust had introduced new line management structures which had added Senior Paramedic Team Leaders (SPTLs) to support and advise ambulance crews.
  • Governance staff including a Clinical Quality Officer and a Corporate Consultant Paramedic ensure best practice is incorporated into staff and service guidelines.
  • Paramedics and emergency medical technicians had their driving licences checked annually by the trust. The Trust had a process in place to deliver required blue light driver check testing.

Resilience

Good

Updated 27 November 2018

We have not rated Resilience before. We rated it as good because:

The service provided safe care and treatment. There were processes and staff followed them to lessen risks to patients, staff and the public posed by the challenging environments and staff had to operate in. Staff followed national guidelines for the delivery of services and care and treatment.

The leadership of the service promoted a positive culture within the resilience service.

Innovation was encouraged and staff were encouraged were to join national improvement groups to influence changes in protocols, processes, equipment and training. There were examples of innovative practice, that were being incorporated into national practices.

There was effective collaborative working between trust staff and partner agencies to manage local, regional and national risks. This ensured paramedic care and treatment was available in a timely manner, to patients in challenging circumstances, such as major incidents and mass casualty incidents.

Training provision met the national guidelines. Staff were highly skilled in delivery paramedic care in a safe manner to patients in challenging and dangerous environments.

The service, location and vehicles, was planned to meet the needs of the local population. This was based on the need to respond to major incidents at government defined sites of strategic importance, major incidents in other areas of the NWAS geographical region and provide mutual aid to neighbouring ambulance trusts in a timely manner.

Emergency operations centre (EOC)

Good

Updated 27 November 2018

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

  • The service had a culture of reporting incidents, with staff knowing how to report an incident and having knowledge of the trust’s incident reporting processes. There was sharing of learning from incidents. This meant the service had improved opportunities to learn from incidents and improve patient safety.
  • The service ensured that there was sufficient staff on duty at all times. Including sufficient numbers of clinical supervisors at the individual sites to ensure patient safety.
  • The service ensured that the clinicians in the emergency operation centres held an appropriate level of safeguarding children training in line with national guidance.
  • The emergency operations centres had appropriate measures and systems in place to ensure service continuity in the event of a business continuity incident.
  • All emergency operations centre staff we met and observed consistently demonstrated compassion, kindness and respect towards callers and patients, including those in mental health crisis.
  • We observed positive examples of local leadership from the operating unit managers at all three operations centres. We saw that the leads of the service listened to staff and working to address concerns staff raised.
  • The trust has a working group designing a reporting mechanism, which will identify callers who have accessed the 999 systems at a set frequency. The trust leadership and operations centre managers are also currently working to produce a policy and procedure that will guide local managers through a consistent, safe and robust system of managing frequent callers.
  • We saw improvements since our last inspection. The trust has raised awareness among staff relating to the trust’s vision and strategy and how they can contribute to it.

However:

  • Turnaround rates were still proving problematic for the service, to try and improve turn round rates the trust has developed an Emergency Care Improvement Programme and is working with receiving trusts to try and improve this area.
  • In the Liverpool site the call-handling and dispatch rooms were located on two floors connected by a staircase. The urgent care desk and advanced paramedics, who provided support to the dispatchers, were in another part of the building. The building was visibly dated throughout; for example, there was staining on ceiling tiles in the corridors. We did however note that the development a new EOC building in Liverpool was well underway, although there was no definitive move in date at the time of inspection.