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Provider: East Midlands Ambulance Service NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 17 July 2019

We rated safe, effective, responsive and well-led as good, and caring as outstanding.

We rated all four of the trusts core services as good.

  • The trust provided mandatory training in key skills to all staff and made sure everyone completed it.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Response times and time to answer calls in the EOC were generally better than the England average.
  • Trust performance in the seven-minute national standard for Cat 1 calls had improved significantly over recent months and was on an improving trajectory. The trust had implemented a new service and improved triage to maintain these improvements.
  • Staff interacted in a respectful and compassionate way with patients and those close to them. Staff showed support and an encouraging and sensitive attitude. We observed staff taking time to talk to patients and their relatives to gain further understanding of the patient’s needs.
  • Feedback from patients was continually positive about the way staff treated them. Comments from patients included “they were very caring and pleasant and careful with me”, very professional and courteous, sorted everything that I needed”, “and “very helpful, very reassuring”.
  • The service ensured patients were treated as individuals, with their needs and preferences being met. Staff respected people’s ethnicity, language, religious and cultural background
  • The service provided reflected the needs of the population served and they ensured flexibility, choice and continuity of care. Service capacity was planned to cope with differing levels and nature of demand in different localities
  • The service was accessible to all and took account of people’s individual needs. It identified and met the information and communication needs of people with a disability or sensory loss. Reasonable adjustments were made so that people with a disability could access and use services on an equal basis to others.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. There was clear leadership of the trust to drive and improve the delivery of high-quality person-centred care.
  • Most staff described how the culture had changed significantly over the last two years, this had been reflected in the national staff survey results. The morale amongst frontline staff had improvement significantly since our last inspection.
  • Most staff told us they were supported by management which had improved since our last inspection. We saw there were co-operative, supportive and appreciative relationships among staff, despite the challenges faced on a daily basis.
  • 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

Inspection areas

Safe

Good

Updated 17 July 2019

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

  • The trust provided mandatory training in key skills to all staff and made sure everyone completed it.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The trust-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

  • The trust had suitable premises and equipment and looked after them well.

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

Effective

Good

Updated 17 July 2019

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

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff worked together as a team to benefit patients.
  • Managers 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.

  • Response times and time to answer calls in the EOC were generally better than the England average.
  • Trust performance in the seven-minute national standard for Cat 1 calls had improved significantly over recent months and was on an improving trajectory. The trust had implemented a new service and improved triage to maintain these improvements.

Caring

Outstanding

Updated 17 July 2019

Our rating of caring improved. We rated it as outstanding because:

  • Staff interacted in a respectful and compassionate way with patients and those close to them. Staff showed support and an encouraging and sensitive attitude. We observed staff taking time to talk to patients and their relatives to gain further understanding of the patient’s needs.
  • Feedback from patients was continually positive about the way staff treated them. Comments from patients included “they were very caring and pleasant and careful with me”, very professional and courteous, sorted everything that I needed”, “and “very helpful, very reassuring”.
  • Patients told us how staff went the extra mile and their care and support exceeded their expectations.
  • There was a strong, visible person- centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted patient’s dignity. Patients were overwhelmingly positive about how staff had treated them with dignity and respect.
  • Staff recognised and respect the totality of patient’s needs. They always took people’s personal, cultural, social and religious needs into account.”.

Responsive

Good

Updated 17 July 2019

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

  • The service ensured patients were treated as individuals, with their needs and preferences being met. Staff respected people’s ethnicity, language, religious and cultural background
  • The service provided reflected the needs of the population served and they ensured flexibility, choice and continuity of care. Service capacity was planned to cope with differing levels and nature of demand in different localities
  • The service was accessible to all and took account of people’s individual needs. It identified and met the information and communication needs of people with a disability or sensory loss. Reasonable adjustments were made so that people with a disability could access and use services on an equal basis to others.
  • The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Well-led

Good

Updated 17 July 2019

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

  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. There was clear leadership of the trust to drive and improve the delivery of high-quality person-centred care.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The majority of staff described how the culture had changed significantly over the last two years, this had been reflected in the national staff survey results. The morale amongst frontline staff had improvement significantly since our last inspection.
  • The majority of staff told us they were supported by management which had improved since our last inspection. We saw there were co-operative, supportive and appreciative relationships among staff, despite the challenges faced on a daily basis.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish
  • The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
Checks on specific services

Resilience

Good

Updated 17 July 2019

This is was our first inspection of the service where ratings were awarded so we cannot compare ratings with previous inspections. We rated it as good because:

  • The service had the right number of properly trained staff who were available to be deployed when they were needed. Patients were protected from avoidable harm and abuse. There were suitable premises and equipment which was kept clean and well maintained. There were good infection prevention and control measures including for the most serious threats. Good records were kept of patient’s care and treatment. There was good practice in dealing with medicines. Safety incidents were managed properly and the service learnt from them. However, we found concerns with the temperature at which medicines were stored,lack of paper forms on some ambulances and availability of major incident pocket books and smart cards.
  • Patients had good outcomes because they received good care that adhered to national guidelines and staff were competent. Patients’ condition including pain was monitored and responded to appropriately. Response times met national standards and teamwork with other agencies was very good. Staff understood the Mental capacity Act 2005, the Mental Health Act 1983 and applied there training properly.
  • While we were not able to observe care being given we found nothing that gave rise to any concerns.
  • The trust assessed local risks well alongside other emergency services and statutory agencies and had plans in place to deal with them. The trust prioritised the availability of the HART team and so they were available when people needed them. Complaints systems were in place and promoted as best they could be although patients rarely used them.
  • Leaders were knowledgeable and skilled and there was a positive culture across all the EPRR function. The trust had a vision as to the future of the EPRR function and had good plans to get there. There was a strong governance framework that together with rich information systems allowed good audit and risk assessment. The trust worked to engage with other staff outside of the EPRR function and with the public.

Emergency and urgent care

Good

Updated 17 July 2019

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

  • All staff we spoke with were aware of how to refer a safeguarding issue. Staff told us they were always given time to make safeguarding referrals and were stood down to allow them to complete referrals.
  • Ambulance crews had up to date satellite navigations and communication systems in their vehicles to guide crews to patient pickups and incidents. In addition, vehicles could be ‘talked-in’ from the operations centre if this was required.
  • Consumables were stored safely; stock levels were checked and stock rotated to ensure things were used in expiry date order. Equipment was available to suit all patients, for example child restraints and baby harnesses.
  • Staff showed awareness of responding appropriately to a deteriorating patient. A NEWS2 tool score card was witnessed in the same place onboard every EMAS vehicle. All staff are trained to both adult, paediatric and neonatal intermediate life support.

  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • All staff we spoke to told us they have protected time for meal breaks and are encouraged to take regular breaks. Staff told they did not feel pressurised to undertake extra shifts and overtime.
  • Staff we spoke with had access to the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) app on their personal mobile phones and said they used it regularly to receive updates and access relevant guidelines. Guidelines were followed across the trust.
  • Staff has full understanding of their roles and the limitations of it so if a paramedic was working as an emergency medical technician, accountability was clear.
  • Throughout our inspection we saw staff interact in a respectful and compassionate way with patients and those close to them. Staff showed support and an encouraging and sensitive attitude.
  • Staff were patient focused. Staff considered patients physical mental and social needs to ensure that their journey was comfortable and safe.
  • Services provided reflected the needs of the population served and ensured flexibility, choice and continuity of care and ambulance deployment was always aimed at meeting the needs of patients in a timely manner. Facilities and premises were all appropriate for the services delivered.
  • Leaders had skills, knowledge, experience and integrity when appointed and ongoing. All the staff we spoke with held the divisional managers in high esteem and told us they were visible and very approachable.

However:

  • Some staff were administering prescription only medicines to patients without a prescription.

Patient transport services

Good

Updated 17 July 2019

This is was our first inspection of the service where ratings were awarded so we cannot compare ratings with previous inspections. We rated it as good because:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right transport and care. Staff were up to date with their mandatory and safeguarding training.
  • Staff were patient focused. They completed and updated individual risk assessments and planned journeys to mitigate risks. Staff considered patients physical mental and social needs to ensure that their journey was comfortable and safe. Control centre staff and transport crews asked patients and relatives the right questions to ensure that patients were kept comfortable and safe and took action to assure themselves of the safety of patients who were unexpectedly not at home for pick up
  • The incident reporting system was well understood. Incidents were investigated and the service learned from them. The service learned from complaints.
  • The service provided reflected the needs of the population served and they ensured flexibility, choice and continuity of care. It provided for a range of individual patient needs and disabilities.
  • Most people generally had timely access to transport and the service took action to resolve issues where this was not the case.
  • The service had a clear vision and reflected the trust’s values. They had an action plan to improve performance against key performance indicators, and clear governance arrangements to ensure that performance and quality issues were addressed. The service invited feedback from patients and staff and used this to benefit patients.

Reference: Emergency operations centre not found

Good

Updated 17 July 2019

  • Staff had received adequate training to keep people safe from harm including children and vulnerable persons. Premises were visibly clean and tidy, well equipped and well maintained.
  • There were robust procedures in place for assessing and responding to patient risk using accredited risk assessment systems and experienced clinical staff.
  • Staffing levels had improved since our last inspection and continued to improve through a rolling programme of recruitment.
  • Patient records were comprehensive, accurate and contained up to date information.
  • Staff gave advice on medicines within the remit of their role.
  • Incident management was embedded in the service, staff were familiar with incident reporting systems. Staff understanding of incident management had improved since our last inspection.
  • Care and treatment incorporated evidence based best practice.
  • Arrangements were in place for staff to access clinical support and advice if needed and an annual plan of audit was in place which included local and national benchmarking audits.
  • Staff used pain assessments tools housed within the clinical assessments software and gain pain relief advice within the remit of their role.
  • Response times, time to answer calls, were generally better than the England average.
  • The service monitored patient outcomes, the trust was better than the England average for hear and treat incidents.
  • Staff were competent to perform the duties of their role, there was adequate role preparation training followed by a period of supervision.
  • Multidisciplinary working was evident through the EOC centre, particularly with other health care organisations, primary care and social services.
  • Robust systems were in place to manage frequent callers which was an improvement since our last inspection.
  • Most staff had an understanding of the Mental Capacity Act and obtaining patient consent, assessment systems included mental capacity tests.
  • Staff were polite and respectful at all times despite the challenging nature of some calls.
  • Staff communicated with callers in a way they could understand and involved family and carers when appropriate.
  • Service were planned to meet the needs of local people using historical data and forecasting tools.
  • Systems were in place to enable people from diverse backgrounds and with communication difficulties to access the service.
  • Call flow was continuously monitored and Resourcing Escalatory Action Plans were embedded into the day to day running of the service.
  • Complaints were managed within timescales and learning identified from complaints was shared with staff.
  • Leaders and managers were knowledgeable, visible and approachable and staff told us they felt valued and supported.
  • There were clear vision and values which were reflected in a strategy which had been developed with staff and public involvement.
  • There was a culture of openness and honesty enhanced by whistle blowing policies and freedom to speak up guardian.
  • There was good governance of the service including risk and information management. Recruitment practices followed best practice, risks were identified with mitigating actions and information was managed according to Data Protection rules.
  • The trust had engaged with staff, patients and the public in several ways to gather views and comments on the service.
  • A high priority had been given learning, improvement and innovation and the trust proactively shared best practice with other NHS services and organisations.

However:

  • Assessment systems did not incorporate up to date risk assessments for mental health or sepsis.
  • Medicines governance group terms of reference did not include reference to medicines advice given by EOC staff.
  • Outcome data was not collected for mental health patients.
  • Some staff had not attended Mental Capacity Act training or mental health awareness training.
  • Some staff were unaware of the on call clinical support arrangements.
  • Staff at the Lincoln EOC left their work stations without locking their screens.
  • EMAS Promotional material was not available in other languages.