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Provider: South East Coast Ambulance Service NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 15 August 2019

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

  • Safe, effective, caring, responsive and well led were good.
  • Emergency and urgent care services were rated as outstanding overall. The service was rated as good for safe, effective, responsive and outstanding for caring and well led. This was an improvement from our last inspection.
  • The emergency operations centre was rated as good overall. It was rated good for safe, effective, caring, responsive and outstanding for well led. This was an improvement from our last inspection.
  • The 111 service was rated as good overall. It was rated as good for safe, caring, responsive, well led and requires improvement for effective. This was the same as the last inspection.
  • In rating the trust, we took into account the current ratings of the service not inspected this time.

Inspection areas

Safe

Good

Updated 15 August 2019

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

  • The trust had made a number of changes following the last inspection which improved the safety of the service and were fully embedded.
  • Patient safety incidents were managed consistently throughout the trust. 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 mandatory training in key skills including the highest level of life support training to all staff and made sure everyone completed it. The trust had improved its oversight of training data, so it had a good understanding of which staff had 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 had improved the way it provided feedback about safeguarding incidents to staff.
  • 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.
  • The trust had clear systems and processes to safely prescribe, administer, record and store medicines. We found a high standard of audit and quality control processes to monitor the management and administration of medicines. We saw outstanding practice in the management of controlled drugs.
  • The trust had 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. However, staffing levels were not always fulfilled due to shortages of certain staff grades.
  • The trust used monitoring results well to improve safety. Staff collected safety information and made it publicly available.

However,

  • Staffing levels for clinical staff remained low in the emergency operations centre. This affected the service’s ability to offer clinical advice to emergency medical advisors, carry out welfare checks and carry out audits. To address this, the trust implemented a number of initiatives to reduce the risk to patients. They had carried out a demand and capacity review, surge management plan, made improvements to the dispatch system and had introduced a variety of roles to reduce the impact on staff.

  • The figures for safeguarding training children and vulnerable adults’ level two training for emergency operations staff indicated they were below the trust target.

Effective

Good

Updated 15 August 2019

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

  • The trust consistently 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 patient’s subject to the Mental Health Act 1983.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief advice in a timely way. This was carried out in line with best practise and had improved since the last inspection.
  • The trust monitored and met some agreed response times so that they could facilitate good outcomes for patients. They used the findings to make improvements.
  • Services monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • The trust 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. Staff had completed appraisals in line with trust targets.
  • 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 make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • There were processes to audit the quality of care being delivered according to evidence- based guidelines. However, the required number of clinical call audits was not being met.

However,

  • Patients were not always able to access care and treatment from the 111 service within an appropriate timescale for their needs as performance fell below target in relation to abandoned calls and call answering times.

Caring

Good

Updated 15 August 2019

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

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. From April 2018 to March 2019, the trust scored 100% recommended on six months, for the friends and family’s test.
  • Feedback from people who used the service, those who were close to them and stakeholders was continually positive about the way staff treated people. People told us staff go the extra mile and their care and support exceeds their expectations.
  • There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. People’s emotional and social needs were seen as being as important as their physical needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

  • The trust was committed to supporting its staff following traumatic experiences and events. Leaders were trained in and had specialist skills to debrief and support staff. A range of services were available for staff to be signposted to.

Responsive

Good

Updated 15 August 2019

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

  • The trust had developed their relationships with all system partners to contribute to an improvement in patient pathways and experiences.
  • Services for patients were 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 trust had developed a wide variety of services specific to the needs of different members of the population.
  • The trust 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. The trust had worked collaboratively with system partners to reduce hospital handover delays, despite the increase in numbers of patients being attended to. They had developed a wide range of initiatives to reduce conveyances to hospital and ensured patients were seen in the most appropriate environment, by the most appropriate health care professional.
  • 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. The trust had improved its response to complaints times.

Well-led

Good

Updated 15 August 2019

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

  • Several changes in the leadership had happened at our last inspection and some leaders that were new to the organisation had now embedded into their role. These changes had a positive impact on the organisation.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
  • The trust collected reliable data and analysed it. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.
Checks on specific services

Resilience

Good

Updated 8 November 2018

We rated it as good because:

  • Much progress had been made since the last CQC inspection to ensure the service met national standards and SECamb was able to provide an effective and timely response to planned events and catastrophic incidents.
  • The number of paramedics in the HART had increased, ‘all technicians had undergone the required training and qualified as paramedics’ and this was in line with the National Ambulance Resilience Unit (NARU) guidance. There was a dedicated and skilled team of the Hazardous Area Response Team (HART) paramedics who cared strongly about the work they did.
  • Hazardous Area Response Team (HART) specific training was well attended, well managed and they were an accredited training centre for water rescue and rope rescue.
  • Security at the team sites was robust and staff had received up-to-date training in all safety systems, processes and practices.
  • Appraisal rates were higher than the trust’s benchmark and staff were positive about the training they had attended.
  • There was effective partnership working with organisations across Kent, Surrey and Sussex for major events along with multiagency training.
  • Staff were using evidence based practice and working to national guidance for HART/CBRN/Marauding Terrorist Fire Arms Attacks (MTFA).
  • Although we were unable to observe EPRR providing care, SECamb provided us with examples of positive feedback from patients/public about care delivered by EPRR staff.
  • Staff were positive about their immediate line and local managers but some still felt more could be done to improve communication and take action in response to feedback from staff.

However:

  • Safety concerns were not addressed quickly enough. Learning from significant events attended by EPRR staff was sometimes shared but learning was slow to disseminate and the trust was slow to act on responses from national incidents such as the Kerslake Report, Grenfell and their own operational exercises.
  • The trust business continuity plan was not aligned with other trust policies and plans. There was no collaboration across the trust to ensure that widespread organisational business continuity management was effective.
  • Response times were not monitored for Hazardous Area Response Team (HART) operations so the trust had no assurance that national targets were being met.
  • The leadership structure was confusing, staff felt demoralised by changes that had occurred and when asked struggled to explain the reporting lines.

Emergency and urgent care

Outstanding

Updated 15 August 2019

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

  • The service was good in safe, effective, responsive, well led and was outstanding in caring. Four out of five domains had improved since our last inspection.

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

  • Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Key services were available seven days a week.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work.Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Emergency operations centre (EOC)

Good

Updated 15 August 2019

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

  • The service improved to good in safe, effective, responsive and well led, remained good for caring.

  • The service had implemented a demand and capacity review model to improve and increase staffing within the centre. We found the service had actively looked at ways to increase staff and attract the right people to apply for specific centre roles.

  • The service provided care and treatment based on national guidance and evidence-based practice. The trust continuously reviewed policies to reflect national guidance. We found both centre site staff were aware of current policies and there had been an improvement in how staff access and record that they have read updated or new guidance.

  • The computer aided dispatch system was introduced in July 2017 prior to our previous inspection. Following recommendations given during our last inspection the trust had improved the dispatch system to provide better information in regard to the patients age, gender and condition. Clinicians told us that this new update was working well to triage and prioritise patients within the clinical stack.

  • A clinical safety navigator (CSN) had been newly introduced during our last inspection of the service. The CSN role was to have full oversight of the clinical stack, prioritise and triage patients to make sure all patients received a clinical review or a welfare call within targeted timeframes. During our last inspection we found staff did not understand the role of the CSN and there were no clear guidelines for the role in place. However, we found during this inspection, the trust had a clear policy in place for the role and responsibility of the CSN. We found clinicians fully understood the role of the CSN and recognised this was an important role in managing the clinical stack under times when there were high pressures and long waits within the service.

  • The Manchester Triage system was fully embedded and used by registered clinical staff. Clinicians recognised the benefits of the system as it had increased clinical hours on average of 127 per week since January 2019. Manchester triage enabled clinicians to assign a clinical priority to patients, based on presenting signs and symptoms, without assuming the underlying condition.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. There was a strong, visible person-centered culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.

  • Staff provided emotional support to patients, families and carers to minimise their distress. Staff were always calm when patients or callers were anxious. We observed team leaders supporting staff during difficult calls with patients.
  • We found that since our previous inspection the trust had put a number of initiatives in place to manage the risks to ‘no send’ patients during times when surge management was active. The new surge management plan had been reviewed to improve how category three and four calls were managed more effectively.
  • During our last inspection, we found that there was not a clear oversight of long lying patients or elderly fallers. The update to the dispatch system gave better oversight to the age of the faller and a clearer oversight of where the patient was, the environment around them and if they were supported due to the free field text on the dispatch system. Clinicians told us that this enabled them to triage a patient and to prioritise the patient to a category two.
  • The time taken to review complaints had improved significantly from the previous year with complaints taking on average 17.1 days to review compared to 33 days the previously. This met the trust target of 25 days.
  • The leaders within the centre service showed they had integrity, were knowledgeable, experienced and well respected by all staff we spoke with during our inspection. There were comprehensive and successful leadership strategies in place to ensure delivery and to develop the desired culture. Staff told us they knew who to approach for guidance and advice and they described the service leaders and senior staff as approachable.
  • We found leaders had a clear oversight of the centre risk register and potential risks to service delivery and safety. During our last inspection, leaders were unclear as to the extent of the poor quality of the voice recordings. However, we found the leaders were clear that the voice recordings were no longer a risk. There was clear monitoring of voice recordings and a new telephony system was in place which recorded calls clearly.

However:

  • The service did not have enough clinicians in post to meet the demands of the service. Staff felt there were not enough clinicians to manage the demand of the service within the centre. We observed clinical staff rotas which showed there was a lack of clinicians and the senior clinical operations manager (SCOM) recognised the concerns also.

  • We reviewed clinical audits which showed us clinical welfare calls were not completed within the specified timeframe. This was likely to be due to lack of clinicians and high demand on the service.

  • Staff told us that the service was often in surge management. We were told there was mostly large numbers of patients waiting within the clinical stack and we found there were not enough clinicians at times to meet the demand. This raised concerns that the service was unable to effectively manage the demand of the service and was a risk to patients. For example, the risk of deterioration to health for category three patients such as elderly fallers.

Reference: Emergency operations centre not found

Requires improvement

Updated 8 November 2018

At our previous inspection we rated this service as requires improvement.

Our rating of this service stayed the same. We rated it as requires improvement because:

  • We found a lack of systems and processes to effectively identify and manage the level and severity of risk for calls waiting in the stack. This was despite the introduction of a clinical navigator role. Following our inspection, the trust had updated the clinical safety navigator guidelines and shared with the clinical teams. A working group had been established to provide a bi weekly update to provide intensive support to clinicians and the ‘clinical stack’ to reduce waiting times for callers.
  • Patients classified as category three (elderly fallers and long lying patients) were at high risk of deterioration as a result of experiencing long delays. Staff did not report this through the incident reporting system. However, this was raised with the trust who took immediate action to audit and improve incident reporting as a result.
  • Calls could not be audited in line with the NHS pathways contract. We identified concerns with the call recording system which resulted in poor audit quality, calls merged together, and partially recorded calls. We raised this with the trust who put systems and processes in place to audit the frequently of these calls as well as a paper record of all conjoined calls to help future retrieval.

  • Sickness rates within the emergency operation centre (EOC) exceeded trust target despite the trust having raised sickness rate targets since our last inspection. The trust had introduced a human resources advisor to provide support to the EOC staff to reduced absence. However, it was too early to comment on the impact of the initiative.
  • The national Ambulance Response Programme introduced by the trust in November 2017, measured the time it took from receiving a 999 call to a vehicle arriving at a patient’s location. The trusts performance from December 2017 to May 2018, time in which 50% of calls were answered were 29.8 seconds longer in December, and 2.6 seconds longer for the remaining five months than the England average.
  • The trust consistently performed worse than the England average between December 2017 to May 2018, when looking at the data of time within which 95% of calls were answered. The trust were 251 seconds longer than the England average in December and 62.7 seconds longer than the England average in May. However, under the new metrics the trust showed a steady improvement.
  • Data measured showed us the proportion of patients re-contacting 999 within 24 hours of original emergency call closed with telephone advice, had a consistently higher proportion of patients than the England average from June 2017 to November 2017. A decline in trust performance, from 6.2% in June 2017, compared to the England average of 6.4%, to 13.9% in November 2017 compared to the England average of 10.7% was shown. This could mean patients receiving initial telephone advice were either unhappy with the advice given or their symptoms or complaint had worsened.
  • Mental Capacity Act training compliance was reported as 81.4%, which was less than the trust target of 95%. However, we found staff were aware of the processes to ensure people with mental health issues were well supported. Call takers followed NHS pathways and clinicians to assess for mental health needs or risk behaviours. Clinicians completed capacity assessments and ambulances were sent to patients assessed as lacking capacity.
  • People could not always access the service when needed. A surge management policy was used within the EOC when demand for the service outweighed available resource capacity. This meant patients who were not classed as a category one or two were not sent ambulance assistance (no-send) but directed to other services or placed within the clinical stack for a clinician review.
  • Clinicians felt that the computer aided dispatch system did not provide enough information to be able to determine patients’ priority or risk severity. This contributed to the long delays we observed in patients receiving a clinical review. Since our inspection a free text field had been added allowing clinicians to record additional clinical details and priority indicators.
  • Staff lacked insight into when ‘no-send’ calls should be reviewed when the surge management policy was activated. Staff were unable to determine if a patient’s condition had deteriorated and escalated to category one or two. However, following our inspection the trust had amended the surge management policy to include defined clinical review timeframes.
  • During the inspection we identified nine out of 73 patients received the required number of welfare calls in line with trust policy. EOC data showed us that during that time the patient should have received 10 welfare calls. We found no welfare calls were made despite the patients recorded risk score of eight. Data showed the longest wait for a response was six hours and eight minutes.
  • EOC received 593 complaints in 2017/2018 and were worse than the previous year where 432 complaints were recorded. The most common complaint related to ambulance response times. The trust received 415 complaints received this year, compared to 204 the previous year.
  • We found a lack of insight from senior leaders into the quality of the 999 call voice recordings. Senior managers were unclear as to whether recorded calls could be quickly retrieved should there be an urgent need to get details from the call recording quickly. However, following the inspection we found the trust had been monitoring call recordings far greater than five other ambulance trusts. The trust told us there had been no incidence of recorded calls where information could not be immediately retrievable. There was clear executive oversight with call recordings being listed on the standard agenda on the executive management board.
  • Our last inspection identified concerns with a culture of bullying and harassment. At this inspection staff told us that this had mostly improved because there was better support to raise concerns about poor behaviour. However, some staff told us there were still members of the team whom made it difficult for others. They told us about concerns about individuals moving to other parts of the organisation which did not deal directly with poor behaviour.
  • Call takers and dispatchers felt well supported and spoke highly of the senior team leaders. However, we observed different cultures between the two EOC sites. Staff based at Coxheath felt less valued than their colleagues at Crawley.

However:

  • Data showed 98% of registered healthcare professionals had completed safeguarding level three adult and children training. This was a significant improvement on our previous inspection findings.
  • A joint working project was in place between the trust and Kent police. Staff reported this was working well and hoped would continue. The project was in operation on Friday and Saturday nights and was to jointly respond to any incidences which involved alcohol related injuries, domestic disputes and mental health incidents
  • A mental health ‘street triage’ service was starting to be trialled within Coxheath EOC during our last inspection. Recent data showed a reduction in the proportion of patients attending accident and emergency departments for a mental health condition from an average of 53% to 7%.
  • Patients were treated with dignity and compassion. We observed staff give reassurance to callers and stayed calm during difficult and distressing situations. During cardiac arrests we observed call takers staying on the telephone line to offer support until an ambulance crew arrived.
  • Staff provided emotional support to patients to minimise their distress. We listened to call takers providing callers and patients with reassurance, speaking calmly and clearly to emotionally distressed patients.
  • The trust had not completed a patient survey over the last 12 months, however the trust website had a ‘contact us’ tab and a ‘we’d like to know what you think’ leaflet. Notice boards were seen in both EOC sites with patient feedback and positive comments displayed. Positive comments such as ‘we are sincerely grateful to you all’ and ‘they were very thorough and their passion and dedication really shone through’
  • The trust amended the surge management policy immediately after the inspection. The update included the introduction of formal timeframes for reviewing the ‘no send’ calls. To gain further insight into ‘no send’ calls the trust will complete an audit each month to be reviewed by the surge management review group.
  • ‘Hear and treat’ patients had increased from 64,000 to 69,000 each month. The ‘hear and treat’ service did not require ambulance transportation to accident and emergency.
  • Dementia training was provided to all staff. Any patients identified as living with dementia had an ambulance automatically dispatched to allow crews to carry out a full, face-to-face assessment and respond to the patient’s individual needs.
  • Most staff told us they felt valued, listened to and respected and there had been a significant change in leadership style since our previous inspections. We saw positive examples of leadership from the EOC managers at both EOC locations. Staff told us team leaders would support them during difficult or concerning calls and arrange support from the clinician if necessary.
  • There was a trust vision and strategy that was developed collaboratively with staff. New values were developed to support and drive a change in organisation culture.
  • The systems and processes to report, investigate and learn from incidents had significantly improved. Staff felt actively encouraged to be open, candid and learn from incidents. Reporting of near misses and no harm had increased by 40% since our previous inspection, identifying that staff were compliant in reporting incidents. However, we identified concerns for patients who experienced excessive delays, as this was not reported formally as an incident.