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Provider: East Midlands Ambulance Service NHS Trust Good


Inspection carried out on 02 Apr to 04 Apr 2019

During a routine inspection

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

CQC inspections of services

Service reports published 17 July 2019
Inspection carried out on 02 Apr to 04 Apr 2019 During an inspection of Resilience Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 02 Apr to 04 Apr 2019 During an inspection of Emergency and urgent care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 02 Apr to 04 Apr 2019 During an inspection of Patient transport services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 02 Apr to 04 Apr 2019 During an inspection of Reference: Emergency operations centre not found Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 17 July 2019
Inspection carried out on 21, 22, 23 February & 3 March 2017

During an inspection to make sure that the improvements required had been made

East Midlands Ambulance Service NHS Trust (EMAS) covers the six counties of Derbyshire, Nottinghamshire, Leicestershire, Rutland, Lincolnshire and Northamptonshire. This is an area which has a population of around 4.8 million people and covers approximately 6,425 miles. The trust employs 3,290 staff over 60 locations.

We carried out a follow up inspection of the East Midlands Ambulance Service NHS Trust from 21 to 23 February and 3 March 2017, in response to a previous inspection as part of our comprehensive inspection programme of East Midlands Ambulance Service NHS Trust in November 2015. In July 2016 we served the trust with a Warning Notice in which we required them to make significant improvements to the quality of health care provided. This was specifically in relation to ensuring there were sufficient staff with the right skill mix and sufficient vehicles as well as requiring the trust to ensure staff received appropriate training, support and appraisal to carry out their roles.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. As the trust were no longer commissioned to provide patient transport services in Lincolnshire we did not look at that core service.

During this inspection we looked at:

The safety and effectiveness of Emergency and Urgent Care Services.

The safety and effectiveness of the Emergency Operations Centres.

Safety, effectiveness and well led at provider level.

The overall rating for East Midlands Ambulance Service remains unchanged at requires improvement although safety for emergency and urgent care services is no longer inadequate but requires improvement.

Our key findings were as follows:

  • The trust had made significant improvements as required by the July 2016 warning notice. However we remained concerned about response times.
  • Response times for Red 1, Red 2 and A 19 calls were consistently below the national target and patients were not receiving care in a timely manner.
  • There were variable standards of incident investigation, limited recommendations, lack of learning at an organisational level and a lack of evidence that recommendations had been actioned.
  • There was a lack of consistency in the management of risk due to trialling a revised risk register proforma.
  • Staff did not know about the Duty of Candour requirements or their responsibilities under it and the trust had not consistently fulfilled their responsibilities under the Regulation.
  • We found pockets of concern about the potential bullying and harassment of staff who were not confident to report this. We found instances where policies and procedures relating to staff wellbeing were not followed in practice.
  • Not all staff had been trained on the use of and supplied with filtered face piece masks (FFP3). Those that had been supplied with a mask did not always have them available for immediate use.
  • The trust were not compliant with the requirements of the Fit and Proper Persons Regulation.
  • Whilst the trust had a clear vision and strategy, frontline staff were not aware of these.
  • Whilst training completion rates for statutory and mandatory training had significantly improved, mandatory training completion rates for equality and diversity and risk management modules were too low and there were challenges in two specific divisions around completion rates in general.
  • The trust had taken appropriate actions which had been successful in increasing the number of front line staff.
  • Standards of cleanliness had improved.
  • The majority of equipment and vehicle checks were appropriately completed.
  • There was an increased number of operational vehicles available to deliver emergency and urgent care services.
  • Medicines were stored securely and the management of controlled drugs was in line with the trust’s policy. However, we had some concerns about the lack of robust audit trail for access to controlled drugs on solo responder vehicles.
  • There were notable improvements in the security of patient records.
  • Potential risks to the service were anticipated and planned for in advance.
  • The trust had taken action to provide frontline staff with the knowledge and information they needed to respond to a major incident.
  • People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice.
  • Patient outcomes were mainly above or equivalent to national average levels.
  • Staff had received timely appraisals which had been perceived by most to be a meaningful process.
  • Improvements in training and development opportunities were evident and staff told us about them.
  • Where patients received care form a range of different staff, teams or services this was effectively coordinated.
  • Staff were confident in their understanding of the principles for patient consent and the Mental Capacity Act 2005 and they followed them.
  • There was a governance framework able to support the delivery of safe, high quality care.
  • There was a high level of confidence in and respect for the leadership of the acting chief executive.
  • There was increased confidence in the effectiveness of the board and frontline leaders were better equipped with skills and knowledge.
  • The culture of the trust from board to frontline staff was overwhelmingly patient focussed. Our inspection team observed caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.
  • Staff engagement and satisfaction had improved since our last inspection.

We saw several areas of outstanding practice including:

  • The trust had run a highly effective recruitment campaign and received a national award for equality and diversity in recruitment.
  • The trust were trialling a pre-hospital sepsis treatment in North and North East Lincolnshire. Where patients presented with the symptoms of sepsis, blood cultures were taken and a pre-hospital dose of intravenous antibiotic therapy administered to the patient. This saved valuable time and provided prompt lifesaving treatment. The results of the study had not been published at the time of our inspection but early indications showed positive outcomes for patients. The trust was the only ambulance trust in England providing pre-hospital care to this group of patients.
  • The trust had extended the provision of a mental health triage car in Lincolnshire and also to include patients in Derbyshire increasing the provision of appropriate care and treatment for patients with mental health conditions.
  • We observed caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.

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

Importantly, the trust must:

  • The trust must ensure patients receive care and treatment in a safe way by meeting national and locally contracted response time targets for Red1, Red2 and A19 categorised calls.
  • The trust must take steps to improve EOC call taking response times therefore reducing the number of calls abandoned and the length of time callers are waiting on the phone.
  • The trust must ensure all staff know how to report incidents. The trust must ensure serious incidents are appropriately and consistently investigated with lessons learnt acted upon and shared widely.
  • The trust must ensure all staff understand the Duty of Candour Regulation and their responsibilities under it.
  • The trust must ensure all staff access and attend mandatory training with particular focus on compliance rates for equality and diversity and risk management training.
  • The trust must ensure all staff are fitted for and trained in the use of a filtered face piece mask to protect them from air borne infections.
  • The trust must increase the percentage of frequent callers who have a specific plan of care.
  • The trust must ensure there are systems in place to ensure staff have received, read and understand information when there are updates to trust policies, procedures or clinical practice.
  • The trust must ensure they comply with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014).

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 16 – 20 November and 3 December 2015

During a routine inspection

The East Midlands Ambulance Service NHS Trust (EMAS) is one of 10 ambulance trusts in England providing emergency medical services to Derbyshire, Nottinghamshire, Lincolnshire, Leicestershire, Rutlandand Northamptonshire, an area which has a population of around 4.8 million people. The trust employs around 2,900 staff who are based at more than 70 locations including ambulance stations, an air ambulance station, emergency operations centres (EOCS) and support offices across the East Midlands.

The main role of EMAS is to respond to emergency 999 and urgent calls, 24 hours a day, 365 days a year. 999 calls are received by the emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. Other services provided by EMAS include patient transport services (PTS) for non-emergency patients between community provider locations or their home address and resilience services which includes the Hazardous Area Response Team (HART).

Every day EMAS receives around 2,000 calls from members of the public dialling 999. In 2014-15 they provided a face to face response to 643, 115 emergency calls. The service provided by EMAS is commissioned by 22 separate Clinical Commissioning Groups with one of these taking the role asco-ordinating commissioner.

Our announced inspection of EMAS took place between 16 to 20 November 2015 with unannounced inspections on 3 December 2015. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected three core services:

• Emergency Operations Centres

• Urgent and Emergency Care including the Hazardous Area Response Team (HART) and the air ambulance.

• Patient Transport Services

Overall, the trust was rated as requires improvement. Caring and Responsive were rated as good. Effective and Well Led were rated as requires improvement and Safe as inadequate. We have taken enforcement action against the provider in this respect.

Our key findings were as follows:

  • The trust was working hard to improve response times for emergency calls but these were consistently below the national target.
  • There were insufficient staff and a lack of appropriate skill mix to meet the needs of patients in a timely manner.
  • Standards of cleanliness and infection control, although inconsistent in some trust buildings were generally good on ambulances.
  • All staff, especially those at the frontline were passionate about and committed to providing high quality, safe care for patients. At the same time they were open and honest about the challenges they were facing.
  • Whilst the trust were working hard to recruit staff, they were finding it a challenge to retain staff and overall numbers were only increasing minimally.
  • Staff morale was low and they often did not feel valued. There was an unrelenting demand for emergency services combined with a lack of staff and resources to meet the need.
  • Frontline leaders did not have the capacity or in some cases the skills to support teams and individuals and fulfil the requirements of their roles.
  • Many staff were not receiving performance development reviews (appraisals), clinical supervision (where appropriate) or mandatory training.
  • There was a clear statement of vision and values driven by quality and safety. The trust board functioned effectively.
  • Without exception the Chief Executive was held in high regard by staff for her visible, open approach.

We saw several areas of outstanding practice including:

  • We observed many examples of non-clinical staff supporting patients and saving lives in what were extremely difficult and stressful situations. Staff remained calm and gave callers confidence to deliver life-saving treatment.
  • The trust had introduced ‘change Wednesdays’ in the emergency operations centre (EOC) to avoid daily contact with staff about minor changes to policies and systems. Staff were confident any changes to policies or procedures would take place on the same day every week.
  • The trust were the best performing ambulance trust in England for the number of calls abandoned before answered.
  • A mental health triage car was available in Lincolnshire between 4pm and midnight, staffed by a paramedic and a registered mental health nurse from a mental health trust. They could assess the needs of the patient and provide appropriate care which in some cases avoided hospital admission or the use of a Section 136 detention under the Mental Health Act 1983.
  • The trust had a joint ambulance conveyance project working with six fire and rescue services in their region. This was the first service of its kind for an ambulance service nationally.
  • The trust, in partnership with six fire and rescue services across the region, had introduced a regional emergency first responder (EFR) scheme. This was the first regional service of its kind of an ambulance service nationally.
  • A project was in place to improve treatment for patients in acute heart failure. Crews had been issued with continuous positive airway pressure (CPAP) machines. The CPAP machine improves oxygen saturation levels in these patients.
  • Staff in patient transport services (PTS) had direct access to electronic information held by community services including GPs. This meant they could access up to date information about patients including their current medication.
  • The patient advice and liaison service had recruited existing patients to report to them about their planned journeys and experiences of patient transport services (PTS). They called this a ‘secret shopper’ programme.
  • Staff name badges included their name in braille to assist patients with visual impairment. Guide dogs were allowed to accompany visually impaired patients.
  • The Chief Executive was praised by all staff for her visible, open approach and her commitment to engaging staff face to face.

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

Importantly, the trust must:

  • Ensure staff report all appropriate incidents which are then appropriately and consistently investigated.
  • Ensure learning from incidents, investigations and complaints is shared with all staff.
  • Ensure all staff receive statutory and mandatory training.
  • Ensure all domestic, clinical and hazardous materials are managed in line with current legislation and guidance.
  • Ensure vehicle and equipment checks are carried out to the determined frequency.
  • Ensure there are sufficient emergency vehicles to safely meet demand.
  • Ensure medicines, including controlled drugs are stored and managed safely.
  • Ensure paper patient report forms are stored appropriately and securely in trust premises and in such a way on trust vehicles as to maintain patient confidentiality
  • Ensure there are sufficient numbers of staff with an appropriate skill mix to meet safety standards and national response targets.
  • Ensure arrangements to respond to emergencies and major incidents are practised and reviewed in line with current guidance and legislation.
  • Ensure response times meet the needs of patients by reaching national target times.
  • Ensure all staff receive appropriate non-mandatory training to enable them to carry out the duties they are employed for.
  • Ensure all staff receive an annual appraisal.
  • Ensure service level agreements are in place to monitor the quality of taxi service provision for patient transport services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Organisation Review of Compliance