All inspections: West Midlands Ambulance Service University NHS Foundation Trust

West Midlands Ambulance Service University NHS Foundation Trust serves a population of around 5.6 million people. It operates in an area covering 5,000m² in the counties of Shropshire, Staffordshire, Herefordshire, Worcestershire, and Warwickshire. This includes Coventry, Birmingham, and the Black Country conurbation.

The service provides a 999 emergency ambulance response from 15 operational hubs across the region with a fleet of around 460 ambulances. In partnership with 2 local mental health trusts, the ambulance service operates mental health triage cars to help patients in crisis. The trust has 2 emergency operations centres (EOCs) taking and managing around 4,000 999 calls each day. One EOC is at Brierley Hill, alongside trust headquarters, and the other at Tollgate in Staffordshire.

The trust also provides patient transport services (PTS) for non-medical emergencies and completes around a million trips each year for patients in Birmingham, the Black Country, Coventry and Warwickshire, Cheshire, and Wirral. The service operates around 350 PTS vehicles and coordinates activity from dedicated control rooms.

The trust contacts with and commissions with 5 air ambulances run by independent charitable trusts, operates a Hazardous Area Response Team (HART), works with voluntary organisations, such as BASICS doctors, and has a network of around 750 community first responders.

The service employs around 6,800 staff, which reduced from around 7,600 the previous year after changes in service delivery (including the 111-contract moving to a new provider).

We carried out this inspection, with the core services announced on the morning of that visit, as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the trust overall as outstanding.

On this inspection we covered the well-led key question for the trust overall which was announced to coincide with our inspection of the core services.

We inspected 2 core services – EOC and Emergency and Urgent Care (or frontline emergency operations). We did not inspect Resilience (which includes the HART teams) or PTS on this occasion.

We carried out this short notice announced inspection on 21, 22 and 23 November 2022. We had an additional focus on the urgent and emergency care pathway for patients across the integrated care system in Worcestershire.

A summary of CQC findings for the overall urgent and emergency care services in Worcestershire.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective, and timely care.

Summary of West Midlands Ambulance Service University NHS Foundation Trust

As this was a focused inspection, we did not look at every question in our key lines of enquiry, we did not re-rate the service, at this time. This inspection was focused around system pathways and attendance at local hospitals. We did not visit any other regions during this inspection.

There is a process in place to continue monitoring services provided by West Midlands Ambulance Service University NHS Foundation Trust (WMAS).

At our previous inspection published in 2019, we rated emergency and urgent care services at the trust as Outstanding overall with safety rated as good and all other key questions as outstanding.

On this inspection we reviewed emergency and urgent care services. For this core service we looked at elements of the safety, effectiveness, caring, responsiveness, and leadership of the staff and those supporting the emergency departments on site.

For emergency and urgent care, we found:

Staff treated patients with compassion and kindness, respected their privacy and dignity, especially when moving them long distances from ambulance to the emergency department.
We saw an example of good patient care where an agitated vulnerable patient was taken from an ambulance to a quieter area.
Infection, prevention and control was good, and staff were ensuring equipment and personal hygiene were of a high standard.
Communication and multi-disciplinary team working were good. Staff maintained a focus on patient care and shared information appropriately.
Patients praised ambulance crews for the care and compassion given, particularly during the lengthy waits at hospital.
WMAS was supporting the system by supplying paramedics to aid in the care of patients in the emergency department.

However:

Response times and handover targets were not being met. Delays in handing patients over at hospitals meant that ambulances and crews could not be made available to attend other calls.
Lengthy delays at hospitals increased risk to patients, particularly those that had been lying on trolleys or stretchers in ambulances, for longer periods.
It was unclear who was responsible for the personal care of patients whilst waiting in the ambulance. Ambulance staff were not trained in personal care or to use some personal care equipment, even though they performed these tasks.
Alternative pathways, to avoid conveyance to hospital, were not always available or known to staff from outside the area.
Ambulance staff told us that communication about processes, like cohorting patients and sourcing nutrition for a patient waiting in an ambulance, was not clear.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

For our emergency and urgent care inspection, we met with staff operating in Worcestershire. We spoke with operational managers, paramedics, emergency care assistants, ambulance technicians and other members of staff on duty at the emergency department at local hospitals.

We spoke with 42 paramedics in total, 2 trainees, emergency care assistants and other support personnel, and the operational Manager and hospital ambulance liaison officer.

We spoke with 15 patients that had been brought in by ambulance, while on site at the emergency department.

We spoke with 13 paramedics, emergency care assistants and other support personnel, and 10 patients at another local hospital.

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

Emergency and urgent care services and resilience were rated as outstanding.
Emergency operations centre and patient transport services were rated as good.
We rated well-led at the trust as outstanding.

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

During our last inspection we found that mandatory training compliance was in breach of the Health and Social Care Act regulations. During this inspection we found that the service provided mandatory training in key skills to all staff and made sure everyone completed it.
During our last inspection we found the storage of medicines was in breach of the Health and Social Care Act regulations. Systems and processes to safely administer, record and store medicines were in place. During this inspection we found that the service used medical gases only.
Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
The service mostly controlled infection risk well. Staff used equipment to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. However not all vehicles we saw during inspection were visibly clean and this was not consistently monitored. This was rectified post inspection.
The design and use of facilities, premises, vehicles and equipment kept people safe. Staff managed clinical waste well.
Staff completed and updated risk assessments for each patient and removed or minimised risks.
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. Managers regularly reviewed staffing levels and skill mix.
Staff kept records of patients’ care and treatment. Records were clear, up-to-date, stored securely and available to all staff providing care.
The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team, the wider service and partner organisations. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
The service mostly provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
The service did not routinely carry or use any pain-relieving medication. However, some high dependency vehicles were equipped with medical gases used to relieve pain.
The service monitored response times. They used the findings to make improvements and achieved good outcomes for patients.
The service made sure staff were competent for their roles. Managers appraised staffs’ work performance. This was an improvement noted since our last inspection.
All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with other agencies.
Staff supported patients to lead healthier lives. Staff encouraged patients to attend important medical appointments.
Staff supported patients to make informed decisions about their transport. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Staff provided emotional support to patients, families and carers to minimise their distress.
Staff supported and involved patients, families and carers to decisions about their care during transport.
The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
The service was inclusive and took account of patients’ individual needs and preferences. The service made reasonable adjustments to help patients access services.
People could access the service when they needed it, in line with key performance indicators.
The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff, including those in partner organisations.
Managers at all levels in the service had the right skills and abilities to run a service providing sustainable care.
The service 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 service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
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 care would flourish.
The service had good systems to identify risks, plan to eliminate or reduce them.
The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
The service engaged well with patients, staff and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
The service was committed to improving services by learning from when things went well or wrong, promoting training and better ways of working.
Following our inspection, we highlighted areas of improvement to the trust. The trust responded positively and developed action plans to rectify concerns.

However, we also found areas for improvement:

We found that staff did not receive any feedback or confirmation following the report of a safeguarding concern.
We found some equipment had incorrect servicing dates on it. This was rectified post inspection.
Not all vehicles we saw during inspection were visibly clean and this was not consistently monitored. This was rectified post inspection.
Staff told us risk assessments undertaken by booking staff did not always provide sufficient information to keep patients safe. We saw this was a concern raised in the previous inspection; particularly in relation to working with patients who had mental health diagnoses.
New trust guidance issued to staff regarding patients with an active ‘do not attempt cardio pulmonary resuscitation’ was not fully compliant to national best practice guidelines.
A small number of staff told us they had received some training on sepsis, but they would not know how to identify this in a patient.
Following our inspection, we found that the trust had recorded five incidents involving taxi drivers. Only one of these had been directly reported by the taxi driver or firm involved. A protocol was in place for taxi firms to use to report incidents; however, we were concerned that not all drivers and firms were adhering to this. However, we did see some shared learning following one incident about ensuring all incidents are reported to WMAS. In addition, we noted an incident that occurred post our inspection was directly reported by the taxi driver; and was investigated thoroughly.
A small number of staff within a specific team did not feel supported.
We saw team meetings were recorded and information was disseminated inconsistently between teams.
Not all identified risks were formally recorded on the risk register.

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

The service provided mandatory training in key skills to all staff and made sure everyone completed it. The trust target for mandatory training compliance was met for all clinical staff in all subjects. The trust had set a target of 85% for completion of mandatory training courses.

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 controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

The design, maintenance and use of facilities, premises, vehicles and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

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. Managers regularly reviewed staffing levels and skill mix and gave bank and agency staff a full induction.

Staff kept detailed records of patients’ care and treatment. Electronic patient record forms (EPRF) were clear, up-to-date, and easily available to all staff providing care.

The service used systems and processes to safely prescribe and administer medicines.

The service used monitoring results well to improve safety. Staff collected safety information and made it publicly available.
The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team, the wider service and partner organisations. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients’ subject to the Mental Health Act 1983.
Staff assessed and monitored patients regularly to see if they were in pain, and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
The service monitored, and met, agreed response times so that they could facilitate good outcomes for patients. They used the findings to make improvements.
The service monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with other agencies.
Staff gave patients practical support and advice to lead healthier lives. Health promotion materials were available throughout the services and staff knew which services to signpost patients to. Health promotion was available and suitable for both patients and staff.
Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used to agree personalised measures that limit patients' liberty.
Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.

Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
The service was inclusive and took account of patients’ individual needs and preferences. The service made reasonable adjustments to help patients access services.
People could access the service when they needed it, in line with national standards, and received the right care in a timely way.
It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff, including those in partner organisations.
Managers of all levels within the ambulance services had the right skills and abilities to run a service providing quality and sustainable care.

The service had a vision of what it wanted to achieve and plans to turn it to action. Not all staff were able to recite trust values but staff we spoke with were able to demonstrate the values within their role.

Managers across the service promoted a positive culture that supported and valued their staff with shared values on patient care and improving the quality of care within the trust and their own hubs.

The governance arrangements within the ambulance service, were clear and operated effectively and staff understood their roles and accountabilities. However, investigations to some incidents raised were not always investigated thoroughly and robustly.

The service had a system in place for identifying risks, planning to eliminate and reduce risks and the ability to cope with expected and unexpected challenges within the ambulance services
Management collected, analysed, managed, and used information to support individual hubs activities using secure systems with security to safeguard all processes in use.

Staff engaged well with patients, staff, and the public and local organisations to plan and manage appropriate services and collaborated with partners’ organisations effectively.

Ambulance service was committed in improving services by learning from things that have gone well and when things go wrong, promoting training, research, and innovation.

However:

Documentation around medications was variable and temperatures for the storage of medicines was inconsistent at some hubs. The trust was aware of the concerns and plans to address these issues were being actioned.

In some instances, investigations into incidents relating to staff misconduct were not investigated thoroughly.

West Midlands Ambulance Service NHS Foundation Trust (WMASFT) is one of 10 ambulance trusts in England and provides services to the following six counties:

Herefordshire

Shropshire

Staffordshire

Warwickshire

West Midlands

Worcestershire

WMASFT serves a population of approximately 5.6 million, covers 5,000 square miles and provides services to 26 NHS trusts.

The services employs over 4,500 staff including Paramedics, Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners) and is supported by approximately 1,000 volunteers, over 63 sites and responds to around 3,000 '999' calls each day. WMAS operate from 16 fleet preparation hubs across the region and a network of over 90 Community Ambulance Stations.

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of two emergency operation centres (EOC), based at: Millennium Point, Brierley Hill (Trust HQ) and Tollgate Drive, Stafford where clinical advice is provided and from where emergency vehicles are dispatched if required.

In addition, the trust provides a patient transport services, employing 400 staff, a Hazardous Area Response Team of 49 staff and provides clinical teams to three air ambulances. Air Ambulance services in the region were provided by the Midlands Air Ambulance Charity. Paramedics and doctors on the service are funded by the charity but are provided by WMAS. The Air ambulance service was not included as part of this inspection.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We carried out our announced inspection between 27 June 2016 to 1 July 2016 and conducted unannounced inspections on 13 and 14 July 2016. We inspected the following core services unannounced:

Patient Transport Services

Hospital Ambulance Liaison Officer (HALO) at one NHS trust.

Emergency and Urgent Care

Overall, the trust was rated outstanding. We rated safe, responsive and well led good and we rated effective and caring as outstanding.

Our key findings were as follows:

Safe

Incidents were reported in line with trust guidance and staff received feedback following untoward incidents.

All staff did not fully understand the process or the terminology for duty of candour, but were fully aware of the need to be ‘open and honest’ regarding incidents.

There were reliable systems, processes and practices in place across the majority of areas to keep patients and staff safe and safeguard from abuse and avoidable harm.

Emergency and Urgent Care services (EUC) and Resilience services surpassed the trusts mandatory training targets of 85%, however, PTS did not meet this target, for example PTS Stoke scored between 34 and 54%, as the staffing levels were not sufficient to provide relief for staff to attend training.

Records were stored securely, with a clear audit trail.

Staff were competent in their roles and provided with timely appraisals and learning opportunities. We saw consistently high standards of cleanliness and infection control prevention in the majority of the ambulance hubs, community stations, control rooms and vehicles.

Across the majority of areas, the supply of equipment, storage and maintenance was good. In Worcester, we found there was confusion regarding whose responsibility it was to test the defibrillator therapy cable. We escalated this the same day and it was quickly resolved with the senior management team.

The trust medicine management policy was in place and the majority of staff followed the policy on a daily basis.

There was a strong culture of improving medicine safety with clear governance pathways to ensure that learning was acted upon throughout the trust.

There was a good skill mix and level of staff to meet the needs of patients and keep people safe across all areas.

All of the staff we spoke with told us they had either received training or were booked on to participate in response to major incident training and that was part of the mandatory training programme. Resilience staff attended 68 multi-agency exercises between February 2015 and June 2016. These included firearms sieges, flooding, simulated explosion and fire in a nightclub premises, readiness exercises for international sporting events, and communications exercises.

However, we also saw;

We saw challenges around Prescription only Medicines (POM's). For example, at one of the Worcester hubs we visited, we counted 56 recording errors between the 13 April and 29 June 2016, which staff had not been reported as incidents.

We inspected an HDU vehicle at PTS Stoke and saw not all CD’s were stored appropriately.

In PTS, we saw staff did not always carry out equipment checks and sterile environments were not always maintained.

Staff were not aware of incidents that had affected change so learning was not always shared, which potentially meant missed opportunities to improve patient care trust-wide.

PTS staff did not consistently lock ambulances when parked at the hubs or outside homes when collecting patients.

Within EUC Erdington hub we saw dirty equipment and sluice area, where under the sink and floors were soiled and visibly dirty.

Effective

Between April 2015 and March 2016 the trust was the only ambulance trust to meet all national targets for response times for the most immediately life threatening calls and answering 999 calls.

The trust was part of a national pilot designed to change the way that ambulances respond to patients and was actively working with external providers and services to improve patient outcomes.

The trust was a part of an operational delivery network, it was developed to manage the care and treatment for patients with major trauma.

The design and functions of the regional co-ordination centre (RCC) within the EOC provided excellent specialist support for the local community.

All staff were actively engaged in activities to monitor and improve quality and outcomes. The trust encouraged widespread opportunities to participate in benchmarking, peer review, accreditation and research.

Within Resilience, credible external bodies such as a Joint Emergency Services Interoperability Programme (JESIP) and National Ambulance Resilience Unit (NARU) recognised high performance. The continuing development of staff skills, competence and knowledge was recognised by the trust as being integral to ensuring high quality care. Managers proactively supported their staff to acquire new skills and share best practice. Hazardous Area Response Team staff had protected training time. One week in seven was dedicated to training.

Data provided by the trust showed that 96% of EUC staff had attended Mental Health Conditions training in 2015/16, which was significantly better than the trust target of 85%.

However, we also saw;

All NHS ambulance services must respond to 75% of Category A/Red emergency calls. We found local performance data for emergency calls that were immediately life threatening showed variation across areas. Birmingham and Black Country achieved 83.5 and 81.8% respectively. However, Coventry and Warwickshire achieved 72.3%, West Mercia 69.8%, and Staffordshire 68.0%.

Staff at PTS Stoke needed more mental health training to support patients with a mental health condition. The trust board took immediate and remedial action to address concerns raised.

Caring

Staff across all areas staff consistently demonstrated kindness, compassion and respect towards patients, relatives and carers. All patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.

Staff recognised when patients required further information and support and this was provided at all times.

Staff asked questions in a calm manner and demonstrated an empathetic approach to information gathering when communicating with patients, relatives and carers. This was observed during EUC and PTS with staff and patient interaction and in the EOC with call handlers during telephone conversations.

Callers who were distressed and overwhelmed were well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.

There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP

Staff made sure people had understood the information given back to them by telephone advisors.

Staff took time to interact with patients and supported them and their relatives and carers. They treated patients with dignity and respected their privacy at all times.

Feedback from people who use the service, those who are close to them and stakeholders were consistently positive about the way staff treated people.

There was a strong, visible person centred culture. Staff and management were fully committed to working in partnership with people and find innovative ways to make it a reality for each person using the service.

Communication with children and young people was age appropriate and effective.

Staff were highly motivated and inspired to offer kind and compassionate care; they displayed determination and went the extra mile to achieve this. For example, one staff member arranged for a patients’ cat to be cared for whilst the patient was in hospital, which alleviated the patient’s anxiety and they agreed to leave their home and go to hospital.

Responsive

The trust planned and delivered services in a co-ordinated and efficient way that responded to the needs of the local population. For example, PTS had a good escalation and planning process for the next day’s journey. The plans detailed monitoring of transport times, cancellations and aborts, action they take to prevent breaches of the contract and remedial actions should they occur.

People’s individual needs and preferences were central to the planning and delivery of tailored services. This was particularly evident within EOC and Resilience where services were flexible, provided choice and ensured continuity of care.

We saw strong evidence of multi-disciplinary team working across all areas to support people with complex needs. For example EOC staff were trained to use type talk (which was a text relay service for patients with difficulty hearing or speaking) they could also use voice over internet protocol (VOIP) to receive 999 calls.

We observed staff conversing with patients with mental health issues and interacting with them in a way that met their individual needs.

Community First Responders (CFRs) within EUC services worked efficiently across the region particularly in rural areas to support ambulance staff with responding to life threatening emergencies. The trust used Rapid Response Vehicles (RRVs) effectively to ensure emergency treatment started as soon as possible.

EUC’s ‘make ready’ team freed up ambulance staff to attend to calls throughout their shift rather than spending time preparing and cleaning vehicles.

The trust managed and reviewed patients’ complaints appropriately and people who used services were involved with service improvements.

Hazardous Area Response Team had been given additional staff and equipment in order to provide the trust response to bariatric patient’s needs.

However, we also saw;

Specialist bariatric equipment was not always readily available across all areas.

Across EUC and PTS there were limited tools in place to assist patients with learning disabilities and people living with dementia staff felt that they would benefit from receiving training in regards to this.

Information about how to raise concerns or make a complaint about services was limited on ambulances for EUC and we saw complaints information on most PTS vehicles. PTS Managers across some areas dealt with complaints at a local level, which meant there were missed opportunities for trust-wide learning.

EUC staff we spoke with told us generally target response times were achievable and the only reason they would not meet some targets would be as a result of the wide geographical area. We saw these figures were being monitored internally, however more work was required to achieve the set targets so that people living in rural areas were not continually disadvantaged. For example, we observed the ambulance crew respond to a call in Rugby whilst they were in Coventry the journey time between the two areas was 35 minutes.

Well led

The overall rating for the well led domain was rated ‘good’. The ‘Good’ rating was due to overwhelming evidence during the inspection period and information supplied by the trust before and after the inspection that supported strong senior leadership of the organisation.

Staff were aware of the robust five-year strategic plan and the trust’s vision and values were well in-bedded across all areas.

Operational staff demonstrated passion and commitment to provide high-quality care and they ‘lived’ the strategy daily.

Clinical governance, risk and quality management were effective. We were confident that the governance, risk and quality boards influenced and impacted services at an operational level.

The trust was focused on achieving response time performance targets, and this was reflected in the governance framework used to monitor performance.

Through staff interviews and observations we saw that there was a high standard of leadership at the trust, with strong leadership from the CEO. All the executive directors were well engaged and interacted with each other appropriately.

The vast geographical area covered by the trust, meant it was not always practical for the CEO and other executives to meet frontline staff on a regular basis. We saw that the leadership team recognised this and encouraged staff to engage with them in other ways such as direct email.

The trust was actively involved in effective public engagement to recruit staff from Black and Minority Ethnicity (BME) population.

There was a mostly positive, open and honest culture among all staff groups. In the main, managers supported staff well and staff told us they felt listened to.

There were high levels of staff satisfaction across EOC, PTS and Resilience and staff were proud of being a part of the trust and their role within it.

Staff at all levels were actively encouraged and supported to explore innovative ways of working with a common focus on improving quality of care and people’s experiences.

Across all areas staff gave examples of how they had worked together to support each other. They told us that they talked openly with each other and their managers and their managers were open and honest with them.

Managers were extremely proud of the calibre and commitment of staff on the HART team. Managers were clear that they believed the success of the HART team rested with the ability of staff to perform professionally in extraordinary circumstances and situations, and their role was to provide them with the facilities and training to enable them to do so.

The trust provided a counselling and support service for staff who required support following attendance at traumatic or upsetting calls. There was a 24-hour helpline, staffed by volunteers from within the service. All volunteers were trained before joining the team.

However, we also saw;

A governance framework supported the delivery of the strategy and good quality care. However, we found this was not always effective or consistent across all areas. For example, there were instances in Coventry and Warwickshire and throughout West Mercia where staff were unclear of who had responsibility for tasks such as the checking of defibrillator test cables and auditing prescription only medicines management. Once escalated to the trust, remedial action was quickly taken and staff were advised accordingly.

Risk registers did not always reflect each hub’s risks. For example, there were insufficient middle managers across EUC to ensure staff were fully supported. We saw the impact of this as not all managers had the time to respond to their staff’s concerns. This was particularly evident in the Worcestershire hub where the area manager was responsible for 196 staff and this was against the operating model of one manager to 100 staff-.This risk was placed on the risk register, however, there were no actions to reduce this risk.

In West Mercia there were five area managers, two on sick leave and a third on annual leave with acting area managers in place. Bromsgrove hub also struggled to provide adequate managerial staff support and Lichfield hub had one area manager and no area support manager (ASO). Thismeant that the area manager was managing over 100 staff. This was a similar picture at the Donnington hub. Managing this large number of staff meant they were unlikely to be able to provide sufficient staff oversight and appropriate supervision.

We saw several areas of outstanding practice including:

The trust was shortlisted in 2015 for two national awards including; Enhancing Care by Sharing Data and Information and Improving Outcomes through Learning and Development.

HALO’s across all divisions had developed innovative and forward thinking ideas to reduce hospital admissions and ambulance call-outs which proved to be very effective. HALOs work in partnership with the Emergency Department practitioners to support the effective and efficient management of patient streams, particularly patient handover and ambulance turnaround times within the department, helping emergency crews to become available earlier to respond to the next incident.

The trust encouraged online engagements with patients and provided patients with clear and concise tools to self-care and recognise life-threatening conditions.

Paramedic availability throughout the service, and plans to increase this further meant that highly qualified staff could provide emergency care to patients.

The functions within the Regional Co-ordination Centre provided effective support for complex incidents within the trust’s geographical region and externally through the Midlands Critical Care Network.

The trust looked at innovative ways of engaging with the local population, for example, the Youth Council Strategy and the Youth Cadet scheme.

All operational staff on the HART team were required to be qualified paramedics and to maintain their accreditation which was in line with NARU best practice. Not all trusts followed this guidance.

The only exception to protected training was if the team was required to deploy to a major incident to support the duty team [this is another area of best practice in the UK

Compliance with NARU and Joint Emergency Services Interoperability Programme JESIP guidance was seen to be very strong and reflected industry best practice.

During 2015 the MERIT team were peer reviewed by the Trauma Network; and they were graded as providing recognised best practice in nine out of ten criteria, which is a recognition of best practice.

The NHS England Core Standards return for 2015/16 was 100%, which is an area of outstanding practice.

The sharing of the trust forward planning for New Year’s Eve represented an area of outstanding practice.

WMAS was an integral part of the Emergency Response Management Arrangements (ERMA) and acted as the host and regional ‘GOLD’ - control centre for all Emergency Service providers during the first hour of any large-scale emergency incident. Gold Control plans were in place to assist in coordinating any such response. This is unique in an ambulance service and represents an area of best practice nationally.

The trust provided staff with major incident aide memoire cards and were in the process of developing electronic versions. The aim was to increase efficiency and confidence of staff when dealing with major incidents.

The HART staff were committed to improve their personal skills and provide a comprehensive service to exceed normal working practices in support of casualties.

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

Importantly, the trust must:

Improve staff attendance at mandatory training ensuring it is monitored and actively supported.

Safely store all medication on high dependency vehicles.

Professor Sir Mike Richards

Chief Inspector of Hospitals

West Midlands Ambulance Service NHS Foundation Trust (WMASFT) is one of 10 ambulance trusts in England and provides services to the following six counties:

Herefordshire
Shropshire
Staffordshire
Warwickshire
West Midlands
Worcestershire

WMASFT serves a population of approximately 5.6 million, covers 5,000 square miles and provides services to 26 NHS trusts.

The services employs over 4,500 staff including Paramedics, Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners) and is supported by approximately 1,000 volunteers, over 63 sites and responds to around 3,000 '999' calls each day. WMAS operate from 16 fleet preparation hubs across the region and a network of over 90 Community Ambulance Stations.

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of two emergency operation centres (EOC), based at: Millennium Point, Brierley Hill (Trust HQ) and Tollgate Drive, Stafford where clinical advice is provided and from where emergency vehicles are dispatched if required.

In addition, the trust provides a patient transport services, employing 400 staff, a Hazardous Area Response Team of 49 staff and provides clinical teams to three air ambulances. Air Ambulance services in the region were provided by the Midlands Air Ambulance Charity. Paramedics and doctors on the service are funded by the charity but are provided by WMAS. The Air ambulance service was not included as part of this inspection.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We carried out our announced inspection between 27 June 2016 to 1 July 2016 and conducted unannounced inspections on 13 and 14 July 2016. We inspected the following core services unannounced:

Patient Transport Services

Hospital Ambulance Liaison Officer (HALO) at one NHS trust.

Emergency and Urgent Care

Overall, the trust was rated outstanding. We rated safe, responsive and well led good and we rated effective and caring as outstanding.

Our key findings were as follows:

Safe

Incidents were reported in line with trust guidance and staff received feedback following untoward incidents.
All staff did not fully understand the process or the terminology for duty of candour, but were fully aware of the need to be ‘open and honest’ regarding incidents.
There were reliable systems, processes and practices in place across the majority of areas to keep patients and staff safe and safeguard from abuse and avoidable harm.
Emergency and Urgent Care services (EUC) and Resilience services surpassed the trusts mandatory training targets of 85%, however, PTS did not meet this target, for example PTS Stoke scored between 34 and 54%, as the staffing levels were not sufficient to provide relief for staff to attend training.
Records were stored securely, with a clear audit trail.
Staff were competent in their roles and provided with timely appraisals and learning opportunities. We saw consistently high standards of cleanliness and infection control prevention in the majority of the ambulance hubs, community stations, control rooms and vehicles.
Across the majority of areas, the supply of equipment, storage and maintenance was good. In Worcester, we found there was confusion regarding whose responsibility it was to test the defibrillator therapy cable. We escalated this the same day and it was quickly resolved with the senior management team.
The trust medicine management policy was in place and the majority of staff followed the policy on a daily basis.
There was a strong culture of improving medicine safety with clear governance pathways to ensure that learning was acted upon throughout the trust.
There was a good skill mix and level of staff to meet the needs of patients and keep people safe across all areas.
All of the staff we spoke with told us they had either received training or were booked on to participate in response to major incident training and that was part of the mandatory training programme. Resilience staff attended 68 multi-agency exercises between February 2015 and June 2016. These included firearms sieges, flooding, simulated explosion and fire in a nightclub premises, readiness exercises for international sporting events, and communications exercises.

However, we also saw;

We saw challenges around Prescription only Medicines (POM's). For example, at one of the Worcester hubs we visited, we counted 56 recording errors between the 13 April and 29 June 2016, which staff had not been reported as incidents.
We inspected an HDU vehicle at PTS Stoke and saw not all CD’s were stored appropriately.
In PTS, we saw staff did not always carry out equipment checks and sterile environments were not always maintained.
Staff were not aware of incidents that had affected change so learning was not always shared, which potentially meant missed opportunities to improve patient care trust-wide.
PTS staff did not consistently lock ambulances when parked at the hubs or outside homes when collecting patients.
Within EUC Erdington hub we saw dirty equipment and sluice area, where under the sink and floors were soiled and visibly dirty.

Effective

Between April 2015 and March 2016 the trust was the only ambulance trust to meet all national targets for response times for the most immediately life threatening calls and answering 999 calls.
The trust was part of a national pilot designed to change the way that ambulances respond to patients and was actively working with external providers and services to improve patient outcomes.
The trust was a part of an operational delivery network, it was developed to manage the care and treatment for patients with major trauma.
The design and functions of the regional co-ordination centre (RCC) within the EOC provided excellent specialist support for the local community.
All staff were actively engaged in activities to monitor and improve quality and outcomes. The trust encouraged widespread opportunities to participate in benchmarking, peer review, accreditation and research.
Within Resilience, credible external bodies such as a Joint Emergency Services Interoperability Programme (JESIP) and National Ambulance Resilience Unit (NARU) recognised high performance. The continuing development of staff skills, competence and knowledge was recognised by the trust as being integral to ensuring high quality care. Managers proactively supported their staff to acquire new skills and share best practice. Hazardous Area Response Team staff had protected training time. One week in seven was dedicated to training.
Data provided by the trust showed that 96% of EUC staff had attended Mental Health Conditions training in 2015/16, which was significantly better than the trust target of 85%.

However, we also saw;

All NHS ambulance services must respond to 75% of Category A/Red emergency calls. We found local performance data for emergency calls that were immediately life threatening showed variation across areas. Birmingham and Black Country achieved 83.5 and 81.8% respectively. However, Coventry and Warwickshire achieved 72.3%, West Mercia 69.8%, and Staffordshire 68.0%.
Staff at PTS Stoke needed more mental health training to support patients with a mental health condition. The trust board took immediate and remedial action to address concerns raised.

Caring

Staff across all areas staff consistently demonstrated kindness, compassion and respect towards patients, relatives and carers. All patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.
Staff recognised when patients required further information and support and this was provided at all times.
Staff asked questions in a calm manner and demonstrated an empathetic approach to information gathering when communicating with patients, relatives and carers. This was observed during EUC and PTS with staff and patient interaction and in the EOC with call handlers during telephone conversations.
Callers who were distressed and overwhelmed were well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.
There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP
Staff made sure people had understood the information given back to them by telephone advisors.
Staff took time to interact with patients and supported them and their relatives and carers. They treated patients with dignity and respected their privacy at all times.
Feedback from people who use the service, those who are close to them and stakeholders were consistently positive about the way staff treated people.
There was a strong, visible person centred culture. Staff and management were fully committed to working in partnership with people and find innovative ways to make it a reality for each person using the service.
Communication with children and young people was age appropriate and effective.
Staff were highly motivated and inspired to offer kind and compassionate care; they displayed determination and went the extra mile to achieve this. For example, one staff member arranged for a patients’ cat to be cared for whilst the patient was in hospital, which alleviated the patient’s anxiety and they agreed to leave their home and go to hospital.

Responsive

The trust planned and delivered services in a co-ordinated and efficient way that responded to the needs of the local population. For example, PTS had a good escalation and planning process for the next day’s journey. The plans detailed monitoring of transport times, cancellations and aborts, action they take to prevent breaches of the contract and remedial actions should they occur.
People’s individual needs and preferences were central to the planning and delivery of tailored services. This was particularly evident within EOC and Resilience where services were flexible, provided choice and ensured continuity of care.

We saw strong evidence of multi-disciplinary team working across all areas to support people with complex needs. For example EOC staff were trained to use type talk (which was a text relay service for patients with difficulty hearing or speaking) they could also use voice over internet protocol (VOIP) to receive 999 calls.
We observed staff conversing with patients with mental health issues and interacting with them in a way that met their individual needs.
Community First Responders (CFRs) within EUC services worked efficiently across the region particularly in rural areas to support ambulance staff with responding to life threatening emergencies. The trust used Rapid Response Vehicles (RRVs) effectively to ensure emergency treatment started as soon as possible.
EUC’s ‘make ready’ team freed up ambulance staff to attend to calls throughout their shift rather than spending time preparing and cleaning vehicles.
The trust managed and reviewed patients’ complaints appropriately and people who used services were involved with service improvements.
Hazardous Area Response Team had been given additional staff and equipment in order to provide the trust response to bariatric patient’s needs.

However, we also saw;

Specialist bariatric equipment was not always readily available across all areas.
Across EUC and PTS there were limited tools in place to assist patients with learning disabilities and people living with dementia staff felt that they would benefit from receiving training in regards to this.
Information about how to raise concerns or make a complaint about services was limited on ambulances for EUC and we saw complaints information on most PTS vehicles. PTS Managers across some areas dealt with complaints at a local level, which meant there were missed opportunities for trust-wide learning.
EUC staff we spoke with told us generally target response times were achievable and the only reason they would not meet some targets would be as a result of the wide geographical area. We saw these figures were being monitored internally, however more work was required to achieve the set targets so that people living in rural areas were not continually disadvantaged. For example, we observed the ambulance crew respond to a call in Rugby whilst they were in Coventry the journey time between the two areas was 35 minutes.

Well led

The overall rating for the well led domain was rated ‘good’. The ‘Good’ rating was due to overwhelming evidence during the inspection period and information supplied by the trust before and after the inspection that supported strong senior leadership of the organisation.

Staff were aware of the robust five-year strategic plan and the trust’s vision and values were well in-bedded across all areas.
Operational staff demonstrated passion and commitment to provide high-quality care and they ‘lived’ the strategy daily.
Clinical governance, risk and quality management were effective. We were confident that the governance, risk and quality boards influenced and impacted services at an operational level.
The trust was focused on achieving response time performance targets, and this was reflected in the governance framework used to monitor performance.
Through staff interviews and observations we saw that there was a high standard of leadership at the trust, with strong leadership from the CEO. All the executive directors were well engaged and interacted with each other appropriately.
The vast geographical area covered by the trust, meant it was not always practical for the CEO and other executives to meet frontline staff on a regular basis. We saw that the leadership team recognised this and encouraged staff to engage with them in other ways such as direct email.
The trust was actively involved in effective public engagement to recruit staff from Black and Minority Ethnicity (BME) population.
There was a mostly positive, open and honest culture among all staff groups. In the main, managers supported staff well and staff told us they felt listened to.
There were high levels of staff satisfaction across EOC, PTS and Resilience and staff were proud of being a part of the trust and their role within it.
Staff at all levels were actively encouraged and supported to explore innovative ways of working with a common focus on improving quality of care and people’s experiences.
Across all areas staff gave examples of how they had worked together to support each other. They told us that they talked openly with each other and their managers and their managers were open and honest with them.
Managers were extremely proud of the calibre and commitment of staff on the HART team. Managers were clear that they believed the success of the HART team rested with the ability of staff to perform professionally in extraordinary circumstances and situations, and their role was to provide them with the facilities and training to enable them to do so.
The trust provided a counselling and support service for staff who required support following attendance at traumatic or upsetting calls. There was a 24-hour helpline, staffed by volunteers from within the service. All volunteers were trained before joining the team.

However, we also saw;

A governance framework supported the delivery of the strategy and good quality care. However, we found this was not always effective or consistent across all areas. For example, there were instances in Coventry and Warwickshire and throughout West Mercia where staff were unclear of who had responsibility for tasks such as the checking of defibrillator test cables and auditing prescription only medicines management. Once escalated to the trust, remedial action was quickly taken and staff were advised accordingly.

Risk registers did not always reflect each hub’s risks. For example, there were insufficient middle managers across EUC to ensure staff were fully supported. We saw the impact of this as not all managers had the time to respond to their staff’s concerns. This was particularly evident in the Worcestershire hub where the area manager was responsible for 196 staff and this was against the operating model of one manager to 100 staff-.This risk was placed on the risk register, however, there were no actions to reduce this risk.
In West Mercia there were five area managers, two on sick leave and a third on annual leave with acting area managers in place. Bromsgrove hub also struggled to provide adequate managerial staff support and Lichfield hub had one area manager and no area support manager (ASO). Thismeant that the area manager was managing over 100 staff. This was a similar picture at the Donnington hub. Managing this large number of staff meant they were unlikely to be able to provide sufficient staff oversight and appropriate supervision.

We saw several areas of outstanding practice including:

The trust was shortlisted in 2015 for two national awards including; Enhancing Care by Sharing Data and Information and Improving Outcomes through Learning and Development.

HALO’s across all divisions had developed innovative and forward thinking ideas to reduce hospital admissions and ambulance call-outs which proved to be very effective. HALOs work in partnership with the Emergency Department practitioners to support the effective and efficient management of patient streams, particularly patient handover and ambulance turnaround times within the department, helping emergency crews to become available earlier to respond to the next incident.
The trust encouraged online engagements with patients and provided patients with clear and concise tools to self-care and recognise life-threatening conditions.
Paramedic availability throughout the service, and plans to increase this further meant that highly qualified staff could provide emergency care to patients.
The functions within the Regional Co-ordination Centre provided effective support for complex incidents within the trust’s geographical region and externally through the Midlands Critical Care Network.
The trust looked at innovative ways of engaging with the local population, for example, the Youth Council Strategy and the Youth Cadet scheme.
All operational staff on the HART team were required to be qualified paramedics and to maintain their accreditation which was in line with NARU best practice. Not all trusts followed this guidance.
The only exception to protected training was if the team was required to deploy to a major incident to support the duty team [this is another area of best practice in the UK
Compliance with NARU and Joint Emergency Services Interoperability Programme JESIP guidance was seen to be very strong and reflected industry best practice.

During 2015 the MERIT team were peer reviewed by the Trauma Network; and they were graded as providing recognised best practice in nine out of ten criteria, which is a recognition of best practice.
The NHS England Core Standards return for 2015/16 was 100%, which is an area of outstanding practice.
The sharing of the trust forward planning for New Year’s Eve represented an area of outstanding practice.

WMAS was an integral part of the Emergency Response Management Arrangements (ERMA) and acted as the host and regional ‘GOLD’ - control centre for all Emergency Service providers during the first hour of any large-scale emergency incident. Gold Control plans were in place to assist in coordinating any such response. This is unique in an ambulance service and represents an area of best practice nationally.
The trust provided staff with major incident aide memoire cards and were in the process of developing electronic versions. The aim was to increase efficiency and confidence of staff when dealing with major incidents.
The HART staff were committed to improve their personal skills and provide a comprehensive service to exceed normal working practices in support of casualties.

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

Importantly, the trust must:

Improve staff attendance at mandatory training ensuring it is monitored and actively supported.
Safely store all medication on high dependency vehicles.

West Midlands Ambulance Service University NHS Foundation Trust

All Inspections

15 - 17 August 2023, 3-5 October 2023

During a routine inspection

15 - 17 August 2023, 3-5 October 2023

During an inspection of Emergency and urgent care

15 - 17 August 2023, 3-5 October 2023

During an inspection of Emergency operations centre (EOC)

21, 22 and 23 November 2022

During an inspection of Emergency and urgent care

24 Apr to 26 Apr 2019

During a routine inspection

24 Apr to 26 Apr 2019

During an inspection of Patient transport services

24 Apr to 26 Apr 2019

During an inspection of Emergency and urgent care

27 June -1 July 2016

During a routine inspection

Professor Sir Mike Richards

27 June -1 July 2016

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals