All inspections: South Central Ambulance Service NHS Foundation Trust

We carried out this announced inspection of South Central Ambulance Service NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services and because we had recent concerns about the quality of governance and training.

We also inspected the well-led key question for the trust leadership.

We inspected two core services, the Emergency Operations Centre and Urgent and Emergency Care.

The Emergency Operations Centre (EOC) receives and triages 999 calls from members of the public, as well as other emergency services. It provides advice and dispatches an ambulance to the scene as appropriate. The EOC also provides assessment and treatment advice to callers who do not need an ambulance response, a service known as “hear and treat”.

The EOC manages requests by healthcare professionals to convey people either from the community into hospital or between hospitals. It also receives and triages 999 calls relating to major incidents, and other major emergencies, and dispatches the appropriate response as a Category 1 provider under the Civil Contingencies Act 2004 (Part 1); this can include hazardous area response teams.

The Urgent and Emergency Care core service covers the assessment, treatment and care of patients at the scene by ambulance crews with transport to hospital, as well as the assessment, treatment and discharge from the care of the service.

It covers the provider’s major incident planning and response as a Category 1 provider under the Civil Contingencies Act 2004 (Part 1), as well as planning for and responses to other major emergencies.

It also includes preparedness for, and the support of, events and mass gatherings. Special operations such as serious sand protracted incidents use many of the resources and techniques used in major incidents such as hazardous area response teams and these are considered as part of this core service.

Emergency response from community first responder schemes involving members of the public is also included. High dependency and intensive care transport between hospitals or other care settings is included, as well as other specialist transport that requires an emergency ambulance. This might be from hospital for end-of-life care at home, or mental health patients requiring specialist care.

To understand how services were being delivered, we reviewed information that we hold on this provider and sought feedback from stakeholders including the clinical commissioning groups, Healthwatch and GP practices within the area served by the trust. We spoke with staff and people using the service, spoke with leaders at all levels and reviewed both national data and data that the trust supplied to us. We carried out an anonymous survey of staff.

We did not inspect the core service Patient Transport Services, nor the 111 service. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

It is recognised that the inspection took place at a time when the NHS was under pressure because of the effects of Coronavirus. Some of the shortcomings identified pre-date the pandemic but others have been exacerbated because of restrictions and the impact of Coronavirus.

Our rating of services went down. We rated them as inadequate because:

We rated effective and caring as good. We rated responsive as requires improvement. Safe and well-led were rated as inadequate

In rating the trust, we considered the current ratings of the resilience and patient transport services that were not inspected this time.

Safeguarding was not given enough priority. There was insufficient assurance that processes were protecting people, despite the Commission raising concerns with the trust in November 2021.
The identification, reporting, investigation and sharing of learning from serious incidents was not in accordance with the NHS Serious Incident Framework.
Trends in incidents, when identified, were not investigated or responded to in a way that mitigated future risks to patients.
Essential equipment was not always available and working, when needed.
The trust was not meeting the statutory Duty of Candour requirements
The trust leaders were dismissive of people raising concerns and did not adhere to its own policy for whistle blowers. Sometimes staff who raised concerns were treated badly.
Allegations against staff and leaders were not always followed up appropriately.
Medicines were not always managed safely or effectively.
The trust was not meeting key performance standards for call and response times.
Delays in reaching people who had requested emergency assistance were frequent and prolonged. This resulted in poor outcomes for some people.
Some of the calls were not handled in line with trust processes and this resulted in delays to people receiving help, sometimes leading to poor outcomes.
There were no formal appraisals and not all staff were completing mandatory training.
Emergency ambulances were not always staffed by crews with the skills to provide a full complement of emergency care to people with life threatening conditions.
Some people were not given the necessary pain relieving medicines.
There was insufficient attention to infection prevention and control measures.
Staffing and resources were not able to meet the demands put upon the service.
The governance and risk processes were not working to protect people and improve services.
At the time of the inspection, the provider was not meeting the requirements of the Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 because of a pigeon infestation that had not been resolved effectively.
There was poor understanding of the Mental Capacity Act (2005) and how this impacted on the work of frontline staff.

However

Frontline staff were working hard to deliver compassionate care to people with whom they had contact. They were proud of their work and how they had managed throughout the pandemic.
We saw and heard about examples where staff had been particularly kind and 'gone the extra mile to meet the needs of patients and their families.
There were numerous examples of innovative practice that supported people getting the right care, in the right place.

How we carried out the inspection

In order to understand the experience of patients and quality of service being provided, our comprehensive inspection consisted of;

Visits to nine sites managed by the trust.
Observation at one of the Emergency Operations Centers.
Discussions with staff of all grades, including middle managers, administrative staff, call handlers, clinicians, volunteers, make ready staff and staff working in specialist roles such as the Hospital Ambulance Liaison Officers.
Visited four acute hospital emergency departments to observe care, handovers and to speak with emergency department staff about the interface between the acute hospital and the ambulance trust.
Conducted an anonymous survey of trust staff.
Invited feedback from 20 GP practices across the region serviced by the trust.
Spoke with representatives from the clinical commissioning groups, the local authority and invited comments from Healthwatch.
Spoke with nineteen patients who had been brought to the acute hospitals by ambulance and six relatives of people who were unable to tell us about their experience
Spoke with staff from the emergency departments in the acute hospitals including three consultants, two emergency nurse practitioners, four registered nurses and a senior nurse manager.
Observed care of patients in waiting ambulances, whilst being moved into the emergency department and during handovers.
Reviewed information held about the trust and provided by the trust.
Reviewed board papers and interviewed board members and senior leaders.
A pharmacy inspector reviewed the medicines management.

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

What people who use the service said

Most patients were positive about the care and support they received from the service. Some felt the crews were indifferent and said they “just did their job and no more” whilst others fed back about individual crews who had gone beyond expectations. There were two instances where relatives felt that patients had not had appropriate analgesia, although this was accepted by the patient as “one of those things”.

However, we also heard concerns about the excessive waiting times for calls to be answered, for an ambulance to arrive and then for admission to the emergency department when the ambulance arrived at the hospital. Most felt it was not the fault of the ambulance crews but were very unhappy about the consequences of delays.

In addition to our discussion with key trust staff, we received a commentary about the management of resources from NHSIE.

The trust was managing resources well with the commentary saying that;

The audit committee had clear terms of reference.
Roles and responsibilities were delegated via the standing financial instructions (issued April 2021) which are available to all staff.
Finance partners worked with operational teams to ensure that they receive the required financial management support and guidance.
There were established, regular processes for finance staff to review financial performance.
Responsibilities for budget holders were clearly laid out in the trust’s standing financial instructions.
The audit committee (which has delegated authority from the board) received the Board Assurance Framework and strategic risk register at each meeting, with the purpose of seeking assurance that effective risk management was in place.
The executive team received and reviewed updates from all directorates relating to risk management in addition to the Board Assurance Framework and strategic risk register. The Executive Director of Finance had responsibility for financial risk management.
The trust had also established a risk assurance and compliance committee which comprised the executive directors and the company secretary. This carried out a deep-dive review of the trust’s biggest risks and ensured that appropriate mechanisms were in place to provide assurance over the management of those risks.
The board considered risks faced by the trust on a regular basis. For example, it received the Board Assurance Framework at each public board meeting.
The trust’s financial position was reviewed at the executive team and the board. The trust’s position was included within the Hampshire & Isle of Wight ICS finance report which was reviewed by the Integrated care System’s finance director group.
The financial information received by the board included a balance of board and divisional level and covered both actual and future-looking projections.
Financial performance was reviewed and challenged at the executive team and board
Investment business cases included costs and considered financial and non-financial returns on investment.
The trust maintained a corporate risk register which was reviewed through the risk, assurance and compliance committee and audit committee.
The finance function engaged with operational management at all levels within the organisation.
The trust had an anti-fraud and bribery policy which was issued in December 2021 (to be reviewed December 2025). This was led by the nominated Local Counter Fraud Specialist (LCFS).
The trust communicated its financial plan and position throughout the organisation.
Staff were encouraged to be open and honest through key trust policies and procedures, notably the anti-fraud and bribery policy, standards of business conduct and conflict of interest policy and anti-bribery policy. These were covered as part of the staff induction process.
All cost improvement programmes (CIPs) went through a quality impact assessment process including sign off by executive clinicians.
The trust used benchmarking data to identify potential efficiencies. The trust also benchmarked sickness and recruitment and retention rates with other providers.
The finance function had a clear plan for improving financial management processes.
The executive director of finance participated in the ambulance sector Finance Directors Network, which discussed emerging issues and shared best practice.

South Central Ambulance Service NHS Foundation Trust (SCAS) provides a range of emergency, urgent care and non-emergency healthcare services, along with commercial logistics services. The trust delivers most of these services to the populations of the South-Central region – Berkshire, Buckinghamshire, Milton Keynes, Hampshire and Oxfordshire. In addition, they provide a non-emergency patient transport services (PTS) in Surrey and Sussex.

There is also Resilience and Specialist Operations offering medical care in hostile environments such as industrial accidents and natural disasters. This team is known as Hazardous Area Response Team (HART) based in Hampshire.

SCAS is the main provider of 999 emergency ambulance services within the South Central region (as are all English ambulance trusts in their defined geographical areas); all other services the trust delivers are tendered for on a competitive basis.

Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are remotely dispatched if needed. There is a PTS contact centre at each EOC. The trust also works with air ambulance partners; Thames Valley and Chiltern Air Ambulance (TVAA) and Hampshire and Isle of Wight Air Ambulance (HIOWAA). The trust serves a population of over seven million people across the six counties. They employ approximately 3,300 staff who, together with over 1,000 volunteers, operate 24 hours a day, seven days a week.

We carried out this short noticed focused inspection because we received information of concern about the safety and quality of the service.

Concerns raised related to the safeguarding arrangements at South Central Ambulance Service NHS Foundation Trust. The focused inspection only considered how well the trust was delivering their safeguarding responsibilities.

Post inspection we raised concerns with the trust about issues we had found. The trust took immediate action and provided assurance all concerns raised would be addressed which included a given timeframe.

How we carried out the inspection

We spoke with staff and looked at a wide range of documents including policies and procedures, audit reports, meeting minutes and trust board papers. We spoke with other agencies concerned with the safeguarding of people who used the trust services.

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.

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. 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 assessed patients’ food and drink requirements. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care.
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.

However,

The service did not consistently control infection risk well. Equipment and control measures were not always used to protect patients, themselves and others from infection. Equipment, vehicles and premises were not always visibly clean and this was not consistently monitored throughout the service.
The service did not always assess the environmental risks of PTS stations. Some premises did not keep vehicles and people safe. Safety measure had not been identified to mitigate the risk to vehicles and staff.
The service did not always meet agreed response times.

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

We rated safe, effective, caring, responsive and well led as good. We took into account the current ratings of services not inspected this time.

Staff understood their roles and responsibilities in relation to safeguarding adults and children. Staff knew how to report incidents and the trust carried out detailed investigations; there was feedback to staff, patients, and families. Staff kept records of patient’s care and treatment. Records were completed electronically and stored securely. Infection control risk were generally well managed although in some areas premises were not clean. There was an established medicines management system for the ordering and receipt of medicines will clear records of administration. However, expired medicines were not always disposed of in a timely and safe way and the temperatures of all medicine storage areas were not all monitored. The storage of medical gases was not always appropriate at some site. Staffing was generally well managed under difficult circumstances with recruitment challenges in all services.
Care and treatment was based on national guidance such as the Joint Royal Colleges Ambulance Liaison Committee and the National Institute for Health and Care Excellence. Highly trained ambulance personnel, staff with specialised skills and expertise including; maternity, mental health and safeguarding were also available to advise and support staff. Patients pain was managed effectively. Improvements were evident within the emergency and urgent care service with regards to staff being competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Consent was obtained and recorded in line with legislation and guidance. Staff recorded best interest decisions when patients did not have capacity to consent to their care and treatment. The national mean for call answering time was 13 seconds for July 2018 for this trust the mean was 12 seconds. The HART team did not have a dedicated trainer to plan and coordinate the training for HART paramedics. Although staff had training on mental health awareness and related topics, there was notable variation in staff knowledge, ability and confidence when dealing with people in mental health crisis.
Staff cared for patients with a great deal of compassion, treating them with dignity and respect. They provided emotional support to all patients and their families to minimise their distress.
People could access the service when they needed it. The trust was proactively using hospital ambulance liaison officers when delays occurred at emergency departments. The services took account of patients’ individual needs. Information sharing had improved with the roll-out of the electronic patient record, and the trust shared care summaries in real time with other healthcare providers. The trust monitored progress and performance against the Ambulance Response Programme standards daily through trust-wide operational calls. The response rates to 999 calls had improved and the trust were achieving results above the England’s average. The service treated concerns and complaints seriously, investigated them and learned lessons from the results. Managers at all levels had the right skills and abilities to run the service and provide high quality sustainable care. There was a vision relating to what services wanted to achieve and they were actively working towards achieving this. The trust’s strategy, vision and values underpinned a culture which was patient centred. There was a systemic approach to continually improve the quality of services and safeguard high standards of care. Effective systems for identifying risks, planning to eliminate or reduce them and coping with both the expected and unexpected were in place. All services engaged well with staff and partner organisations to plan and manage services. In general staff felt respected, supported and valued. However, the trust had not appointed a freedom to speak up guardian. The trust was committed to improving the service by learning from when things went well and when they went wrong, promoting training, research and innovation.
Staff felt equality and diversity were promoted in their day to day work and when looking at opportunities for career progression. The trust had structures, systems and processes in place to support the delivery of its strategy. Although The quality and safety committee did not have a formalised work plan. The trust had processes for monitoring risk and performance, however the role of the board assurance framework (BAF) was less clear.

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

We noted positive changes since our last inspection in 2016.
Staff understood their roles and responsibilities in relation to safeguarding adults and children. The trust had up to date safeguarding policies and procedures that reflected current best practice guidance and staff reported concerns appropriately.
There was openness and transparency about safety, and the trust encouraged continual learning. The trust supported staff to report incidents, including near misses.
Staff were aware of when and how to report incidents and there was an effective investigation and feedback process to share learning. Risks were fed into the risk management structure for possible inclusion on the trust wide risk register.
Staff planned and delivered care in line with evidence-based guidance, standards and best practice and met the individual needs of patients through careful care planning. Staff followed care pathways on electronic, multidisciplinary patient records to support practice.
Staff received annual appraisals and the trust supported new staff to complete their competency assessments, and helped to maintain and further develop their skills and experience.
Patients and relatives gave positive feedback about the care and kindness received from staff. All patients and relatives we spoke with were happy with the care and support provided by staff. We observed staff treated patients with compassion, kindness, dignity and respect. Staff worked in partnership with patients and their relatives in their care.
The trust introduced the new ambulance response performance (ARP) measures in November 2017. The mean response times for category 1 met the seven-minute target national standard twice in April and May 2018, and consistently performed better than the England average for all months in the period of November 2017 to May 2018
The trust set quality performance targets, and reviewed these regularly against internal and external targets.
The trust had governance, risk management, and quality measures to improve patient care, safety, and outcomes.

However:

Infection control was not always effective, we saw three vehicles including rapid response vehicles and ambulances that were dirty and dusty and two grab bags which had ingrained dirt.
Three resource centres within the trust were in poor repair for example we noted trip hazards for staff and toilet and changing facilities were in poor condition.
The trust did not consistently store medicines safely. Staff did not monitor the storage temperatures of medicines in ambulance stations which could affect their effectiveness. We raised this with the trust who took immediate action to address this.
Guidance on how to make a complaint was not readily available on ambulances while this information was available on the trust’s website not all patients and their families may have internet access and therefore would not have access to this information.
Staff experienced excessive hand-over times at some acute hospitals, which impacted on the trust’s resources and reduced the ability to meet service demand. However, the trust was actively working with other providers and stakeholder to find a solution to patient flow issues.
Staff reported there were still gaps in their training regarding patients living with mental health conditions, some expressed they did not feel adequately prepared to support patients experiencing mental ill health.

Staff provided care and treatment based on national guidance and evidence. Staff cared for patients with compassion, involved patients and those close to them in decisions about their care and treatment, and provided emotional support.
There were appropriate methods and processes to respond and manage risks to patients. Staff understood their roles and responsibilities in relation to safeguarding vulnerable adults and children.
Staff knew how to report incidents and the trust carried out detailed investigations; there was some feedback to staff, patients and families.
The trust EOC had risk management and quality measures to improve patient care, safety, and their outcomes.
There was local leadership at each emergency operations centre. There was generally an inclusive and constructive working culture within EOC services.
Senior managers had identified risks to the retention of call taking and dispatch staff.
Services were planned to meet local needs, and managers monitored the effectiveness of care and treatment through local and national audits.
The trust took complaints seriously and once concluded staff had opportunities to learn from when things went wrong.
Staff spoke positively of the one to one meetings and appraisals to support them.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

However:

The EOC had periods where they were not able to meet the required number of forecast hours of emergency call takers. There had been a turnover of staff including clinicians and call takers. At times call answering times were below the national average.
Three out of six mandatory training compliance rates did not meet the trust targets. Although information provided by the trust post inspection showed this had improved by July 2018 with all subjects being compliant.
The environment at Southern House EOC was not visibly clean or well-maintained. Staff’s views of the layout and noise level was that it was not conducive to a good working environment. The trust’s plan to improve the environment had met the approval of the staff who were looking forward to the changes.
The trust risk register acknowledged a lack of dedicated EOC clinical governance lead in March 2018.

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

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

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

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

The leadership of the service promoted a positive culture in the resilience service. Innovation was encouraged and staff were encouraged to join national improvement groups to influence changes in protocols, processes, equipment and training. There were examples of innovation, that was being incorporated into national practices.

South Central Ambulance Service covers the counties of Berkshire, Buckinghamshire, Hampshire and Oxfordshire. There are also NHS 111 services in Luton and Bedfordshire. This area covers approximately 3,554 square miles with a residential population of over four million.

South Central Ambulance Service NHS FoundationTrust (SCAS) is part of the National Health Service (NHS). They were established on the 1 July 2006 following the merger of four ambulance trusts. On 1 March 2012, the trust became a foundation trust.The emergency operations centres handle around 500,000 emergency and urgent calls each year.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and logistics and commercial services. The trust also provides Resilience and Specialist Operations offering medical care in hostile environments such as industrial accidents and natural disasters including a Hazardous Area Response Team (HART) based in Hampshire.

Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There is a PTS contact centre at each EOC. The trust also works with air ambulance partners; Thames Valley and Chiltern Air Ambulance (TVAA) and Hampshire and Isle of Wight Air Ambulance (HIOWAA).

The trust also offers the following services: First Aid Training to organisations and the public, a commercial logistics collection and delivery service for our partners in the NHS, and Community First Responders (volunteers trained by SCAS to provide life-saving treatment).

We inspected this location as part of our planned, comprehensive inspection programme . Our inspection took place on 3 to 6 May 2016 with unannounced visits on13 and 16 May 2016. We looked at three core services: access via emergency operations centres, patient transport services and emergency and urgent care including Resilience and Specialist Operations. The 111 service provided by the trust was inspected separately. The logistical and commercial training services were not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC). During the inspection we visited both ambulance premises as well as hospital locations in order to speak to patients and staff about the ambulance service.

Overall, we rated this location as requires improvement. We rated, emergency operations centre (EOC ) as good and emergency and urgent care and patient transport services as requires improvement.

Overall, we rated the trust as being good for caring and responsive services and requires improvement for safe, effective and well led services.

Our key findings were as follows:

Are services safe?

Staff were clear about their responsibilities to report incidents and there was a culture of learning from incidents that was promoted in the trust. However, not all staff received feedback from incidents or had the time to report incidents when they happened, particularly in patient transport services (PTS).
Processes to protect people from harm, such as infection control, the cleanliness of vehicles, the safe handling of medicines and equipment and vehicle safety checks were being followed, although this was inconsistent in some areas.
Patients were appropriately assessed and appropriate action was taken in response to risk.
Patient records were accurately kept and special notes were kept for patients with specific conditions. Records were stored securely.
Staff were aware of safeguarding and how to recognise and report abuse or neglect. The trust however, did not have formal systems to ensure safeguarding alerts were sent in a timely way out of hours or at the weekend. If issues were urgent, then the police would be informed.
Overall, levels of compliance for statutory and mandatory training did not meet trust targets. This was mainly due to operational pressure, although in some areas time allocated to training had not been broadened to include this essential training. The trust was affected by the national shortage of paramedics and had staffing vacancies across all services, in the operations centres and in patient transport services. Action was being taken on recruitment and bank, agency and independent providers were being used to fill staffing gaps. However, many staff were working long hours, some without breaks and they were working under pressure to meet performance targets. Staffing rotas had been changed to meet peaks in demand, but this was affecting staff work /life balance. The trust was working to introduce new rotas to improve the work life balance of staff, whilst continuing to meet the challenge of rising demand.
The ambulance service was classified as a Category 1 responder under the Civil Contingencies Act 2004. Category1 responders are the organizations at the core of an major emergency response. The trust understood their duties under the Civil Contingencies Act 2004 and staff were of their responsibilities. The trust worked with partners to improve the ways in which police, fire and ambulance services worked together at major and complex incidents. Pre-identified high-risk sites in the region were identified so there could be an effective coordinated response in a local area, there were joint training events with other services, such as the police and fire services, and the trust participated in emergency plans and rehearsals to be able to respond to chemical, biological, radiological, nuclear or explosive incident scenarios.

Are services effective?

Care and treatment for patients was planned taking account of current evidence based guidance, standards and best practice. Clinical and medical protocols were used to ensure standards met national practice guidelines.
The trust monitored national ambulance quality indicators in emergency and urgent care services. There was less evidence of the routine use of clinical audit to monitor standards of care.
The average time to respond to emergency calls was worse than the England average and the trust had some of the longest call waiting times. The trust was taking action on this. The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
The trust was performing above the England average for emergency calls resolved by telephone advice and support only (“hear and treat”).
The trust performed above the England average for the number of patients managed without need for transport to hospital, referred to as ‘see and treat’. The re-contact rate for patients, that is, for patients who called the services within 24 hours of their first call, was similar to the England average.
Response targets for 999 emergency services for patients with life threatening or urgent conditions were not being met. The trust had an improvement plan in place.
Following a cardiac arrest, the Return of Spontaneous Circulation (ROSC) (for example, signs of breathing, coughing, or movement and a palpable pulse or a measurable blood pressure) is a main objective for all out-of-hospital cardiac arrests, and can be achieved through immediate and effective treatment at the scene. Percentage of patients with ROSC at time of arrival at hospital was better than England average. However, using the Utstein Comparator Group (a more comparable and specific measure of the management of cardiac arrest) the percentage of patients with ROSC at time of arrival at hospital was worse than England average.
A response targets for the transport of mental health patients in crises who needed a place of safety (section 136) within 30 minutes was being met for 74% of patients. The trust was above the England average of 62% (range 31% to 90%).
Most patients who had suffered a stroke received an appropriate care bundles. However, patients who had suffered a heart attack did not always receive an appropriate care bundle. The trust was implementing a recovery action plan to improve this.
The trust was above national targets for using care bundles for hypoglycaemia, limb fractures, and febrile convulsion. The trust had not met the target for asthma care.
New contracts had extended the operating hours of the patient transport service (PTS), to support the development of a seven-day service. However, key performance indicator data for 2015/16 showed PTS target times had not consistently been met for the arrival and collection of patients following hospital outpatient appointments or discharge. Transport times for renal patients in general met national standard times and had significantly improved from the previous financial year.

There was effective coordination of services with other providers and good multidisciplinary working to support seamless care, admission avoidance and alternative care pathways. For example, hospital ambulance liaison officers and hospital liaison officers were viewed by positively by hospital staff to coordinate emergency ambulance services and patient transport services respectively.
Staff had good induction procedures and access to training. The trust was supporting staff to enhance their roles, for example, specialist paramedics. However, many paramedic staff identified difficulties with accessing training and qualification opportunities.
Many staff did not receive regular supervision although, most staff had an appropriate annual appraisal. Some staff in PTS services had not received a recent appraisal
Staff followed consent procedures. Many staff did not have a clear understanding of the Mental Health Act, although this had improved for staff working in emergency 999 services and there was support for staff from mental health practitioners.

Are services caring?

Staff across all services were caring, compassionate and treated patients with dignity and respect. Patients were positive about the service they received and the way they were treated.
Staff supported patients to cope emotionally with their care and treatment. They were also supportive and reassuring when dealing with patients who were distressed.

Call handlers took time to ensure callers understood the advice and to explain treatment or expectations to callers in a way the callers could understand.
Ambulance crews explained treatment and care options in a way that patients understood and involved them and their relatives in decisions about whether it was appropriate to take them to hospital or not.
Care was outstanding in patient transport services were patients reported well developed supportive and caring and trusted relationships particularly regular users, such as renal or mental health patients. Patients appreciated this personal approach and the respect shown by staff for their social and emotional needs.

Patients could receive advice from clinicians to manage their own health. Clinicians would also provide information to patients about managing conditions if symptoms worsened and would signpost patients to alternative services non-emergency services such as their GP or local urgent care centres.
There were only a few examples where patients had highlighted being treated inappropriately and without care.

Are services responsive?

The trust had developed services in order to meet the needs of the local population and respond to the increasing demand for emergency and patient transport services. Many services were being introduced to manage demands on the service, avoid hospital admissions and refer patient to alternative non-urgent pathways of care.

The emergency operations centres had clinical specialists, for example, in mental health, and support staff. More community first responders (CFR) and co-responders were being used to respond to emergency calls.

Prolonged delays at some acute hospital’s emergency departments had reduced the capacity of front line staff to respond to patient’s needs. The number of long waits for an ambulance had steadily increased.
Action was being taken to address the increasing demand for emergency ambulance services. There were demand practitioners in post to manage frequent calls and provide patients with individual care plans. Services were being developed to ensure waiting times for an ambulance arrival met national targets, for example, more resources were being identified to support GPs calling for an ambulance calls. More specialist paramedics had been employed who could treat patients at the scene or at home in order to avoid hospital admission.
The air ambulance services could respond to calls within their region within 15 minutes. In addition, night flying had commenced (until 2am) to meet the demand of the service.
Patient transport services (PTS) had been extended to operate over seven days. The service was accessible to all eligible patients irrespective of any additional needs. Staff could identify patients who needed prompt transport, for example, if they had significant pain, a chronic illness or were to receive a home care package from the detailed notes. However, the electronic systems did not flag patients as a priority for collection to ensure this happened in a systematic way.
Patients and staff experienced delays when calling the contact centres to identify when transport would be available. Call response times were not met. A new on line PTS booking system had been introduced to try to reduce delays. The online ‘book ready’ system was also introduced to prevent vehicles being sent when a patient was not ready for collection. The system also allowed hospital staff to see the estimated time of arrival. Patients could access this information through the ‘my booking’ section of the trust website.
There was support for vulnerable patients, for example, people with a mental health condition, a learning disability and those living with dementia. Staff told us they had more awareness of meeting the needs of vulnerable patients.
There was provision to provide ambulance transport for bariatric patients.
Staff had access to translation and interpreter services for people whose First language was not English. Callers also had access to services that supported patients with hearing and speech impairments
There was a clear process for the management of complaints, staff were aware of their responsibilities, and complaints were investigated at local level. However, information and learning from complaints was not always shared effectively in PTS services. The trust was not routinely responding to complaints in a timely manner.

Are services well-led?

Services had a clear vision and strategies were being developed or revised to take account of increasing numbers of emergency admissions and changes to patient transport services.
Staff were engaged with the trusts vison and strategy and displayed the trusts values in their own work.
Many staff were positive about their local leadership and felt supported within their teams. Team leaders were given support and training to do their roles
Staff were proud to work for the organisation, although staffing pressures were affecting staff moral and wellbeing. Staff in all areas were working long hours and under pressure with late or missed meal breaks. Many staffing cited disruptions to their work/ life balance. The trust was recruiting to all roles including overseas recruitment for paramedics. They were also supporting staff development and training some emergency medical technicians to paramedic level.
Governance arrangements to monitor the quality and safety of services were in place. The level of staff involvement and understanding, the feedback and sharing of information and the monitoring of services through audit varied. Staff in frontline emergency 999 services had an awareness of risk but sometimes lacked knowledge on the progress being made and the action being taken to manage locally identified risks.
The trust could demonstrate some improvements to the service following the last inspection in September 2014.
Not all staff groups were given the opportunity to attend team meetings and some did not have time to attend team meetings. This did limit opportunities for some staff to raise concerns, share in learning or contribute to service development.
There was a focus on improving the health and wellbeing of staff and the trust had recognition and reward schemes for staff.
Services could demonstrate innovative practices.

We saw several areas of outstanding practice including:

A smartphone triage app had been produced in conjunction with the Wessex Trauma Network. This meant clinicians could use the triage tool to identify if their patient needed to bypass a local hospital and be conveyed directly to a major trauma centre, and which one was the closest.
The trust had introduced demand practitioners and emergency care practitioners (specialist paramedics) to support patients to manage their own health conditions at home and to treat patients without the need for hospital admission.
The trust uses a mobile simulation vehicle which offers an innovative approach to training for staff.
Mental Health practitioners are in control contact centres at weekend peak times. They are piloting direct referrals to Samaritans and local mental health teams. This has improved timely patient access to mental health services.
The Berkshire Hub connects services together as a single point of access location. The Hub includes out of hours, community, minor injury and illnesses and mental health services. There are shared records and special patient notes for patients. The Hub has increased access to NHS, GP, dental, pharmacy, mental health and labour line services.

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

Importantly, the trust must ensure:

Staff in urgent and emergency care are supported with their development through supervision
Response times for emergency and urgent care services are met.
Governance arrangements in emergency and urgent care services must ensure that staff are aware of risks and safe practices are consistently applied.

In addition the trust should ensure:

Staffing levels across all services meets planned levels identified by the trust.
Review compliance with appraisals and mandatory and statutory training, including safeguarding training, to ensure that staff are supported to complete the required training in a timely.
Ambulance response bags are appropriate for use and are replaced when necessary.
Noise levels in Northern House are reviewed to minimise the risk of missing, miss-hearing or delays in recording patient information.
Escalation procedures for the immediate handover of emergency patients are developed and agreed with all hospital trusts.
The process for making safeguarding referrals to local authorities is reviewed and referrals happen in a timely manner to ensure safety of vulnerable patients outside of normal working hours.
All medicines must be safely managed at all times, particular attention must be given to the safe management of controlled drugs.
All staff should have adequate training in mental health and dementia awareness, which is updated at regular intervals to ensure that mental health knowledge is current.
All complaints should be investigated and responded to in a timely manner in line with the trust policy.
The structure of team meetings should be in place for all staff groups to ensure staff are given the opportunity to attend, share information and raise issues or concerns.
The processes for sharing the learning from incidents, safeguarding and complaints with staff is reviewed to ensure staff are using this information to improve the quality of care provided to patients.
Health and safety risk assessments are completed at resource centres.
Rest breaks for all ambulance staff should be planned into their schedule, compliance monitored and action taken to ensure staff well-being.
Staff comply with hand hygiene and infection control polices with regular infection control audits to check compliance across the PTS.
The risks associated with lack of connectivity for PTS staff working in rural areas is reviewed and ensure staff, particularly lone workers, are able to summon help through their PDAs in an emergency, and the reliability of this system is monitored.
There is clarity in the standard operating procedure and policy for the administration of oxygen to patients by frontline PTS and this process is clearly understood by staff.
Current systems for PTS are reviewed so patients with the greatest need are more easily identified as priorities for patient transport.
There is a standard approach to record minutes for meetings across the PTS. These should be in sufficient depth and recognised as being a formal document, with the content written in a style to reflect this.
Improve the recording of the authority to administer or supply a medicines under a PGD
Medicine modules are managed correctly, and tamper evident tags are consistently recorded.
All patient records are kept securely and disposed of in line with trust policy.
Staff are given the time and opportunity to report incidents in emergency and urgent care services and they have appropriate feedback.
The time allocated for staff to complete vehicle checks at the start of each shift is reviewed and actioned appropriately so that staff have sufficient time to complete the task.
The current recruitment drive continues, while monitoring and taking action on the health and wellbeing of the current work force, including the impact of shift rostering and any changes implemented.
Continues to work with commissioners and other providers to improve response times and their ability to meet their key performance indicators and national targets..
The reasons for staff turnover and low morale across all services is continually addressed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

South Central Ambulance Service NHS Foundation Trust (SCAS) was formed on 1 July 2006, after the merger of the Royal Berkshire Ambulance Service NHS Trust, the Hampshire Ambulance Service NHS Trust, the Oxfordshire Ambulance Service NHS Trust and part of the Two Shires Ambulance Service NHS Trust. The trust provides NHS ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire in the South Central region. This area covers approximately 3,554 square miles with a residential population of approximately 4.6 million. On 1 March 2012, the trust achieved foundation trust status.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS). There is also Resilience and Specialist Operations offering medical care in hostile environments such as industrial accidents and natural disasters. This team is known as Hazardous Area Response Team (HART) based in Hampshire.

The trust also offers the following services: First Aid Training to organisations and the public, a commercial logistics collection and delivery service for our partners in the NHS, and Community First Responders (volunteers trained by SCAS to provide life-saving treatment).

Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There was a PTS contact centre at each EOC. The trust also works with air ambulance partners; Thames Valley and Chiltern Air Ambulance (TVAA) and Hampshire and Isle of Wight Air Ambulance (HIOWAA).

Our inspection took place on 3 to 6 May 2016 with unannounced visits on 13 and 16 May 2016. We inspected the trust as part comprehensive inspection of ambulance service. We looked at four core services: access via emergency operations centres, emergency and urgent care services including Resilience and Specialist Operations, patient transport services and the NHS 111 service provided by the trust. The logistical and commercial training services were also not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC).

Overall, we rated the trust as ‘good’. We rated, the emergency operations centre (EOC) patient transport services and NHS 111 services as ‘good’ and emergency and urgent care as ‘requires improvement’.

Overall, we rated the trust’s services as being ‘good’ for providing safe, caring, responsive and well led services and ‘requires improvement’ for effective services. The trust was rated as ‘good’ for well-led overall.

Is the trust well-led?

The trust had a five year vision and clinical strategy to provide excellent, sustainable services, and to coordinate mobile responsive healthcare services so that people received the right care at the right time in the right place (including care that could be closer to home). This strategy was being revised as the trust operational, financial and performance position had change and assumptions about the level of demand and acuity of patients had been underestimated.
Governance arrangements in the trust had been evaluated and the trust had a level of assurance around this framework. The arrangements had been reviewed to reflect the trust current challenges. There was a comprehensive and detailed integrated performance report, and risk and quality issues were being appropriately escalated to the board though the divisional structures. Although some risks and mitigating actions, and the assurances around these, were not always clearly identified.
The leadership team showed commitment and enthusiasm to develop and continuouslyimprove services. There had been good pace and progress to modernise the service and to identify and take action on further service developments. The board had identified the need to steady the organisation and focus on improving performance.
Overall, the trust had a positive, open and transparent relationship with its stakeholders and partners.
The leadership of the service had improved across all service areas. Many staff reported the excellence and support of team leaders and the support and care of colleagues. Staff engagement and communication had improved. The trust was similar to other trust for staff engagement in the NHS Staff survey.
Staff were positive about working for the trust and recognised the value of their service. However, morale was low across many areas, particularly for frontline emergency 999 staff. The main issues were around shift patterns and rotas. Staff could clearly understand the need to direct resources to meet demand, but this was taking its toll on staff wellbeing. Staff reported being frustrated and tired. The trust had recently started to review arrangements.
The trust had evaluated its equality delivery system (EDS) uniquely using community groups to do so. The EDS aims to improve patient outcomes and patient access to services and to have a representative and supportive workforce and inclusive leadership. The majority of indicators were achieved. The trust was taking further action to reduce discrimination and recruitment bias (also identified in the staff survey) in the trust and ensure patient safety.
Public engagement took place through a variety of means, such as campaign work, liaison work, use of social media and surveys. There were a high number of volunteers and community first responders.
The trust had a highly innovative culture and staff were encouraged to suggest new ‘bright ideas’ to improve service delivery. Innovation was managed and evaluated through a programme office and there were many examples of service innovation and improvements developed by the trust and its staff.
In previous years, the trust had been in a position of financial surplus but was currently working in an environment where there were constraints, and a predicted deficit. The trust had a financial recovery plan but had yet to agree financial targets with the local clinical commissioning groups.

Are services safe?

Staff were clear about their responsibilities to report incidents and there was a culture of learning from incidents that was promoted in the trust. However, not all staff received feedback from incidents or had the time to report incidents when they happened, particularly in patient transport services (PTS).
Processes to protect people from harm, such as infection control, the cleanliness of vehicles, the safe handling of medicines and equipment and vehicle safety checks were being followed, although this was inconsistent in some areas.
Patients were appropriately assessed and appropriate action was taken in response to risk.
Patient records were accurately kept and special notes were kept for patients with specific conditions. Records were stored securely.
Staff were aware of safeguarding and how to recognise and report abuse or neglect. The trust however, did not have formal systems to ensure safeguarding alerts were sent in a timely way out of hours or at the weekend. If issues were urgent, then the police would be informed.
Overall, levels of compliance for statutory and mandatory training did not meet trust targets. This was mainly due to operational pressure, although in some areas time allocated to training had not been broadened to include this essential training. The trust was affected by the national shortage of paramedics and had staffing vacancies across all services, in the operations centres and in patient transport services. Action was being taken on recruitment and bank, agency and independent providers were being used to fill staffing gaps. However, many staff were working long hours, some without breaks and they were working under pressure to meet performance targets. Staffing rotas had been changed to meet peaks in demand, but this was affecting staff work /life balance. The trust was working to introduce new rotas to improve the work life balance of staff, whilst continuing to meet the challenge of rising demand.
The ambulance service was classified as a Category 1 responder under the Civil Contingencies Act 2004.Category 1 responders are the organizations at the core of an major emergency response. The trust understood their duties under the Civil Contingencies Act 2004 and staff were of their responsibilities. The trust worked with partners to improve the ways in which police, fire and ambulance services worked together at major and complex incidents. Pre-identified high-risk sites in the region were identified so there could be an effective coordinated response in a local area, there were joint training events with other services, such as the police and fire services, and the trust participated in emergency plans and rehearsals to be able to respond to chemical, biological, radiological, nuclear or explosive incident scenarios.

Are services effective?

Care and treatment for patients was planned taking account of current evidence based guidance, standards and best practice. Clinical and medical protocols were used to ensure standards met national practice guidelines.
The trust monitored national ambulance quality indicators in emergency and urgent care services. There was less evidence of the routine use of clinical audit to monitor standards of care and outcomes.
The average time to respond to emergency calls was worse than the England average and the trust had some of the longest call waiting times. The trust was taking action on this. The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
The proportion of the calls abandoned before being answered had decreased and was now better than the England average.
The trust was performing above the England average for emergency calls resolved by telephone advice and support only (“hear and treat”).
The trust performed above the England average for the number of patients managed without need for transport to hospital, referred to as ‘see and treat’. The re-contact rate for patients, that is, for patients who called the services within 24 hours of their first call, was similar to the England average.
Response targets for 999 emergency services for patients with life threatening or urgent conditions were not being met. The trust had an improvement plan in place.
Following a cardiac arrest, the Return of Spontaneous Circulation (ROSC) (for example, signs of breathing, coughing, or movement and a palpable pulse or a measurable blood pressure) is a main objective for all out-of-hospital cardiac arrests, and can be achieved through immediate and effective treatment at the scene. Percentage of patients with ROSC at time of arrival at hospital was better than England average. However, using the Utstein Comparator Group (a more comparable and specific measure of the management of cardiac arrest) the percentage of patients with ROSC at time of arrival at hospital was worse than England average.
A response targets for the transport of mental health patients in crises who needed a place of safety (section 136) within 30 minutes was being met for 74% of patients. The trust was above the England average of 62% (range 31% to 90%).
Most patients who had suffered a stroke received an appropriate care bundles. However, patients who had suffered a heart attack did not always receive an appropriate care bundle. The trust was implementing a recovery action plan to improve this.
The trust was above national targets for using care bundles for hypoglycaemia, limb fractures, and febrile convulsion. The trust had not met the target for asthma care.
New contracts had extended the operating hours of the patient transport service (PTS), to support the development of a seven-day service. However, key performance indicator data for 2015/16 showed PTS target times had not consistently been met for the arrival and collection of patients following hospital outpatient appointments or discharge. Transport times for renal patients in general met national standard times and had significantly improved from the previous financial year.

There was effective coordination of services with other providers and good multidisciplinary working to support seamless care, admission avoidance and alternative care pathways. For example, hospital ambulance liaison officers and hospital liaison officers were viewed by positively by hospital staff to coordinate emergency ambulance services and patient transport services respectively.
Staff had good induction procedures and access to training. The trust was supporting staff to enhance their roles, for example, specialist paramedics. However, many paramedic staff identified difficulties with accessing training and qualification opportunities.
Many staff did not receive regular supervision although, most staff had an appropriate annual appraisal. Some staff in PTS services had not received a recent appraisal
Staff followed consent procedures. Many staff did not have a clear understanding of the Mental Health Act, although this had improved for staff working in emergency 999 services and there was support for staff from mental health practitioners.

Are services caring?

Staff across all services were caring, compassionate and treated patients with dignity and respect. Patients were positive about the service they received and the way they were treated.
Staff supported patients to cope emotionally with their care and treatment. They were also supportive and reassuring when dealing with patients who were distressed.

Call handlers took time to ensure callers understood the advice and to explain treatment or expectations to callers in a way the callers could understand.
Ambulance crews explained treatment and care options in a way that patients understood and involved them and their relatives in decisions about whether it was appropriate to take them to hospital or not.
Care was outstanding in patient transport services were patients reported well developed supportive and caring and trusted relationships particularly regular users, such as renal or mental health patients. Patients appreciated this personal approach and the respect shown by staff for their social and emotional needs.

Patients could receive advice from clinicians to manage their own health. Clinicians would also provide information to patients about managing conditions if symptoms worsened and would signpost patients to alternative services non-emergency services such as their GP or local urgent care centres.
There were only a few examples where patients had highlighted being treated inappropriately and without care.

Are services responsive?

The trust had developed services in order to meet the needs of the local population and respond to the increasing demand for emergency and patient transport services. Many services were being introduced to manage demands on the service, avoid hospital admissions and refer patient to alternative non-urgent pathways of care.

The emergency operations centres had clinical specialists, for example, in mental health, and support staff. More community first responders (CFR) and co-responders were being used to respond to emergency calls.

Prolonged delays at some acute hospital’s emergency departments had reduced the capacity of front line staff to respond to patient’s needs. The number of long waits for an ambulance had steadily increased.
Action was being taken to address the increasing demand for emergency ambulance services. There were demand practitioners in post to manage frequent calls and provide patients with individual care plans. Services were being developed to ensure waiting times for an ambulance arrival met national targets, for example, more resources were being identified to support GPs calling for an ambulance calls. More specialist paramedics had been employed who could treat patients at the scene or at home in order to avoid hospital admission.
The air ambulance services could respond to calls within their region within 15 minutes. In addition, night flying had commenced (until 2am) to meet the demand of the service.
Patient transport services (PTS) had been extended to operate over seven days. The service was accessible to all eligible patients irrespective of any additional needs. Staff could identify patients who needed prompt transport, for example, if they had significant pain, a chronic illness or were to receive a home care package from the detailed notes. However, the electronic systems did not flag patients as a priority for collection to ensure this happened in a systematic way.
Patients and staff experienced delays when calling the contact centres to identify when transport would be available. Call response times were not met. A new on line PTS booking system had been introduced to try to reduce delays. The online ‘book ready’ system was also introduced to prevent vehicles being sent when a patient was not ready for collection. The system also allowed hospital staff to see the estimated time of arrival. Patients could access this information through the ‘my booking’ section of the trust website.
There was support for vulnerable patients, for example, people with a mental health condition, a learning disability and those living with dementia. Staff told us they had more awareness of meeting the needs of vulnerable patients.
There was provision to provide ambulance transport for bariatric patients.
Staff had access to translation and interpreter services for people whose First language was not English. Callers also had access to services that supported patients with hearing and speech impairments
There was a clear process for the management of complaints, staff were aware of their responsibilities, and complaints were investigated at local level. However, information and learning from complaints was not always shared effectively in PTS services. The trust was not routinely responding to complaints in a timely manner.

Are services well-led?

Services had a clear vision and strategies were being developed or revised to take account of increasing numbers of emergency admissions and changes to patient transport services.
Staff were engaged with the trusts vison and strategy and displayed the trusts values in their own work.
Many staff were positive about their local leadership and felt supported within their teams. Team leaders were given support and training to do their roles
Staff were proud to work for the organisation, although staffing pressures were affecting staff moral and wellbeing. Staff in all areas were working long hours and under pressure with late or missed meal breaks. Many staffing cited disruptions to their work/ life balance. The trust was recruiting to all roles including overseas recruitment for paramedics. They were also supporting staff development and training some emergency medical technicians to paramedic level.
Governance arrangements to monitor the quality and safety of services were in place. The level of staff involvement and understanding, the feedback and sharing of information and the monitoring of services through audit varied. Staff in frontline emergency 999 services had an awareness of risk but sometimes lacked knowledge on the progress being made and the action being taken to manage locally identified risks.
The trust could demonstrate some improvements to the service following the last inspection in September 2014.
Not all staff groups were given the opportunity to attend team meetings and some did not have time to attend team meetings. This did limit opportunities for some staff to raise concerns, share in learning or contribute to service development.
There was a focus on improving the health and wellbeing of staff and the trust had recognition and reward schemes for staff.
Services could demonstrate innovative practices.

We saw several areas of outstanding practice including:

The trust was implementing an accelerated clinical transformation programme to work with partners accelerate changes in care delivery, improve patient outcomes and improve efficiency. Current activities include, for example, the use of smartphone technology for remote clinical assessment, end of life care to support patients in their own home, and increased referral and access to pharmacists
A smartphone triage app had been produced in conjunction with the Wessex Trauma Network. This meant clinicians could use the triage tool to identify if their patient needed to bypass a local hospital and be conveyed directly to a major trauma centre, and which one was the closest.
The trust had introduced demand practitioners and emergency care practitioners (specialist paramedics) to support patients to manage their own health conditions at home and to treat patients without the need for hospital admission.
The trust uses a mobile simulation vehicle which offers an innovative approach to training for staff.
Mental Health practitioners are in control contact centres at weekend peak times. They are piloting direct referrals to Samaritans and local mental health teams. This has improved timely patient access to mental health services.
The Berkshire Hub connects services together as a single point of access location. The Hub includes out of hours, community, minor injury and illnesses and mental health services. There are shared records and special patient notes for patients. The Hub has increased access to NHS, GP, dental, pharmacy, mental health and labour line services.
The NHS 111 provider had worked collaboratively with Age UK to develop a “Sense of Ageing” course for all staff in order to raise awareness of the needs of older patients. This course was being shared nationally as an example of good practice
The trust was working in partnership with a university in Poland to support the recruitment of paramedics. The university taught students in English to aid employment in the UK and the trust had also supported the integration of Polish staff into the community.
The trust had worked with community groups to undertake the assessment of its equality delivery system.
The trust had worked with community groups to evaluate its equality delivery system.

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

Importantly, the trust must ensure:

Staff in urgent and emergency care are supported with their development through supervision
Response times for emergency and urgent care services are met.
Governance arrangements in emergency and urgent care services must ensure that staff are aware of risks and safe practices are consistently applied.

In addition the trust, as a provider, should ensure:

Serious incidents investigations identify underlying causes, themes and human factors so that appropriate trust actions are identified.
The governance process need to improve to ensure complaints are appropriately monitored and timely action is taken to improve how complaints and handled and the quality and tone of complaint responses.
Update processes in terms of the Fit and Proper Persons Test and include information about professional registration and from non-clinical professional regulators.
The trust continues to review rotas and shift patterns for all staff to effectively support managing workload, work/life balance and staff retention.
For specific information about services and action the services ‘should’ take, please refer to the reports for South Central Ambulance Service and South Central Ambulance Service NHS 111 service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

South Central Ambulance Service NHS Foundation Trust (SCAS) was formed on 1 July 2006, after the merger of the Royal Berkshire Ambulance Service NHS Trust, the Hampshire Ambulance Service NHS Trust, the Oxfordshire Ambulance Service NHS Trust and part of the Two Shires Ambulance Service NHS Trust. It provides NHS ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire in the South Central region. This area covers approximately 3,554 square miles with a residential population of over 4 million. On 1 March 2012, the trust achieved foundation trust status.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and logistics and commercial services. There is also a Hazardous Area Response Team (HART) based in Hampshire. Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There was a PTS contact centre at each EOC.

Our inspection took place on 10 and 11 September 2014 with unannounced visits on 30 September and 1 October. We inspected the trust as part of our first wave of comprehensive ambulance inspections. We looked at three core services: access via emergency operations centres, patient transport services and emergency and urgent care. The 111 service provided by the trust was not inspected on this occasion. The logistical and commercial training services were also not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC).

The team of 48 included CQC inspectors and inspection managers, an analyst and inspection planners and a variety of specialists: The team of specialist was comprised of a consultant physician in intensive care, two nurses working in accident and emergency departments, four paramedic staff, one emergency care practitioner, a paramedic clinical supervisor and development manager, three managers with an operations role, a head of governance, a director of service delivery, two chief executives, a pharmacist, a safe guarding lead, two people with a role in an operations centres and three experts by experience.

We did not provide ratings for this trust because this inspection was part of our first wave of ambulance inspections to apply our methodology and develop our understanding of inspecting in this sector.

Key findings

Is the trust well led?

The trust had a vision and clinical strategy to provide excellent, sustainable services, and to coordinate mobile responsive healthcare services so that people received the right care at the right time in the right place (including care that could be closer to home).
Governance arrangements were clear and there was an integrated performance report to benchmark quality, operational and financial information. The trust had also identified its quality priorities and could demonstrate progress against these. However, much of the data on risk and quality was at a high level and some risk issues, such as safeguarding and significant delays in patient transport services (PTS), needed a better focus.
Many areas had team meetings and monthly operational performance meetings to review quality and operational issues. These reported to the trust’s Level 2 meetings (operational leadership level) and then senior management meetings. This structure needed to be replicated in all areas to consistently identify the action taken in response to risks and performance issues.
The leadership team showed commitment, enthusiasm and passion to develop and continuously improve services. Most staff reported that the trust culture reflected an effective and responsive service rather than a target-driven organisation. Leadership at team level varied in terms of effectiveness and the trust needed to improve in this area to develop its strategic priorities.
Public engagement took place through a variety of means, such as liaison work, use of social media and through its membership. Patient feedback through surveys, interviews and liaison work, was being used to improve the service.
Staff were positive about working for the trust. They said it was a friendly and positive place to work but not without its challenges; namely, managing tight resources against an increasing demand for services. The NHS staff survey 2013 demonstrated that the trust was better than average for staff engagement when compared to other ambulance trust. Staff engagement was well developed, although staff indicated the need for more ongoing dialogue around service changes.
The trust had a highly innovative culture and staff were encouraged to suggest new ideas to improve service delivery. This was seen as important against a background of tightening resources, but also essential to develop services in response to the needs of patients. There were many examples of service improvements developed by the trust and its staff.
The trust demonstrated proactive and effective financial management to invest in new technology and service developments, and to ensure that services were sustainable. Cost improvement programmes were demonstrating savings and were monitored. Mitigating actions were identified to reduce the potential impact although the action taken in some of these areas needed to improve.

Key findings across the core services:

Staff were caring and compassionate, and treated patients with dignity and respect.
Staff were positive about the quality of care they provided for patients and were proud to work for the trust. There was low morale in places and the pressures faced by the trust were recognised. Staff however “lived” the values of the organisation: “Towards excellence – Saving lives and enabling you to get the care you need”.
Patients told us their experiences of care and treatment was good. They were positive about emergency ambulance response times but there were concerns about the punctuality of patient transport services.
Incident reporting was increasing on the newly introduced reporting system. The trust was taking action following incidents, but there needed to be earlier and quicker investigation for some incidents. Learning was shared via clinical bulletins, the trust intranet, noticeboards and email. The trust had introduced SCAScade to improve organisational learning from when things go wrong. This included anonymous cases and reflective tools for staff to use on the trust intranet. However, staff in the EOC and PTS needed to be encouraged to use and take responsibility for reporting incidents and also required feedback and shared learning in their areas.
Staff in the emergency and urgent care service had good knowledge of the Mental Capacity Act 2005, but staff in EOC and PTS needed to have better knowledge to ensure the best interest of patients.
Safeguarded procedures were being used but needed to improve and the safeguarding lead had a limited capacity to deliver the safeguarding agenda across the organisation. Safeguarding champions in geographical areas were to be developed but this needed to be prioritised.
Staff had good training opportunities and specialist training on dementia care, learning disabilities and mental health was being improved. Staff were supported with funding for further qualifications and professional development, However, some staff did not always have access to computer facilities to undertake training or the dedicated time to complete it, and attendance at mandatory and statutory training was low.
Most complaints were responded to within the trust’s target time of 25 days and action was being taken to improve services as a result. Complaints were analysed to identify themes and the trust aimed to share learning, for example, through teams and noticeboards. There was evidence of actions taken as a result of complaints in all services. However, staff told us they did not always get feedback on complaints or concerns raised.
The trust understood its duties under the Civil Contingencies Act 2004 and all staff were aware of what to do in the event of a major incident. Staff had appropriate training, there was joint working with partner organisations (such as the fire service, police and military), and rehearsals were undertaken as part of preparation and planning exercises.
The trust had worked with partner organisations including fire and rescue, police, and the environmental agency during the floods in the Thames Valley area in early 2013. The Hazardous Area Response Team (HART) had worked throughout the region and specifically in Wraysbury, Berkshire, 24 hours a day over 4 days, to assist with the rescue and support operation.

Emergency Operation centres (EOC)

Emergency 999 calls were triaged through NHS Pathways (which is a software system of clinical assessment for triaging telephone calls from the public based on the symptoms they report when they call). There was good compliance to prioritise and categorise calls for ambulance dispatch according to the clinical needs of patients. However, staff knowledge of appropriate dispatch times for mental health patients in crises under a Mental Health Act Section 136 and needing a place of safety, needed to improve.
There were dedicated triage lines for GPs and healthcare professionals, and for patients who were critically unwell and needed the air ambulance (the Helicopter Emergency Medical Services, [HEMS]) or other specialist services, such as the Hazardous Area Response Team (HART).
Safety procedures were followed but some needed to improve, such as incident reporting and raising safeguarding concerns, and some staff needed a better understanding of the Mental Capacity Act 2005.
Staffing levels were a concern and staff worked long hours, sometimes without breaks. Action was being taken to manage peaks in demand but staff were not meeting target times to answer emergency calls.
Overall, the trust had referral rates of 8% from NHS 111 to 999 services, and these were better than the service level agreement performance of 10% and one of the lowest in the country. Staff identified the need for further action on managing the demand created by the NHS 111 service, and the trust’s long-term planning against the rising increase in demand for services was ongoing.
The staff were supportive to patients who called in distress. They listened carefully, explained their actions and involved patients in their decisions.
Clinical advisors were available to help staff and to support patients to manage their own health when appropriate. The clinical adviser also undertook welfare checks over the phone to ensure a patient’s condition was not deteriorating while they were waiting for an ambulance. The trust was below the national average for ‘hear and treat’, which is the proportion of calls that are dealt with based on provision of telephone advice only. The re-contact rate within 24 hours of ‘hear and treat’ was higher than the national average in 2013-14 but had decreased this year and was below the national average in (April to July 2014).
Engagement between the trust and the public and patients was being developed further.
The trust had a clear strategy for the EOC to provide clinical coordination of care across a range of health and social care settings. However, most staff were not aware of this strategy in relation to their service. Governance arrangements needed to improve to support staff to share learning, raise concerns, manage risk and act on performance information. Staff worked well in their teams but some wanted better support from managers, particularly in the northern EOC.

Emergency and Urgent Care

Front-line 999 services provided an emergency response to people with life threatening emergency or urgent conditions. Overall, during 2013/14, the trust was meeting national emergency response targets for 75% of calls to be responded to within 8 minutes. The national categories are for Red 1 calls (for patients who have suffered cardiac arrest or stopped breathing) and for Red 2 calls ( for all other life threatening emergencies). Red 1 and Red 2 calls added together and are referred to as Category A calls. The category A target is to have a vehicle that could convey a patients to hospital arrive at the scene within 19 minutes for 95% of cases. This target was also met.
The trust had the highest percentage of ‘see and treat’ in the country (that is, managing patients at the scene without the need for ambulance transfer to hospital). The re-contact rate within 24 hours of this treatment was higher than the national average in 2013-14 but was decreasing.
The trust used a Resource Escalation Action Plan (REAP) as a way of forecasting performance and service delivery. There was moderate to high pressure on the service during our inspection and the trust was communicating effectively with hospitals to align conveyancing decisions against waiting times and the capacity to receive patients. This included having hospital ambulance liaison officers (HALOs) to support the timely handover and safety of patients in A&E departments, and to monitor and respond to situations particularly at times of increased demand for services. There was effective planning and preparation for major incidents and the trust had worked effectively with partner organisations.
The trust was monitoring long waiting times and had introduced measures to ensure that people were monitored while waiting and that high-priority calls took precedence. There was an impact however on people who may be in a healthcare setting but awaiting transfer to another hospital for acute care and for people at a distance from an ambulance station. The trust was taking action to reduce these waiting times and projects were planned in different areas.
The service followed safety procedures overall, but needed to improve infection control practice and the management of medicines. Staff had a good understanding of the Mental Capacity Act 2005 and of safeguarding procedures although the timeliness of reporting concerns and referrals needed to improve. The performance of the external contractor to ‘make ready’ ambulances (that is, to prepare ambulances, for example, in terms of cleanliness and appropriate equipment) was monitored but the quality of their work required better supervision and monitoring. Ambulance crews had allocated time to check vehicles but told us they spent more time rechecking vehicles to ensure they were ready for use.
The trust was affected by the national shortage of paramedics and there were a high number of vacancies. The allocation and skill mix of staff were appropriate but staff worked long hours and some reported stress and fatigue. There was a rising demand for services that was above predicted levels. The trust had introduced shift changes to help manage resources to meet demand in emergency services and new rotas were being introduced to further improve the work life balance of staff. The trust used private providers to ensure service cover and these providers were appropriately monitored.
National evidence-based guidelines were used to assess and treat patients. Patients experiencing a heart attack did receive pain relief although this was not always the pain relief that was nationally recommended. Patients experiencing a heart attack were transported quickly to hospital. Patients that had had a stroke had appropriate care but there could be delays in their transport to hospital. Some hospital staff identified the need for better pain relief for children in certain circumstances.
The coordination of emergency care with hospitals and GPs was good overall, but needed to improve for heart and stroke care in Buckinghamshire and for mental health patients in crisis across the four counties. The trust was working with its partners and had action plans to improve care in these areas.
The trust was ranked the best in the country for patients who had had a cardiac arrest and stopped breathing, who then after resuscitation, had a pulse/ heartbeat on arrival to hospital. This is called return of spontaneous circulation (ROSC). The trust had improved its effectiveness of action taken when staff witnessed a cardiac arrest and was fourth best in the country this year (April to August 2014) a change from eighth best in 2013-14.
The trust was ranked the best in the country for patients who had had a cardiac arrest and survived to be discharged from hospital.
Staff explained treatment options to patients in a way that they, or their relatives, could understand. Patients, and relatives or carers, received good emotional support if they were in distress. There was support for vulnerable patients, such as those with a learning disability, bariatric patients and people whose first language was not English.
Engagement between the trust and the public and patients was well developed through a variety of channels, such as social media, surveys, newsletters and liaison work.
The trust had a clear vision and strategy for the service to provide mobile healthcare and to coordinate care in hospital, the community and people’s homes. Staff were supportive of the strategy and worked well together in teams and with their managers. There were good governance arrangements to monitor performance and quality and to manage risks although more action was needed on ongoing risks.

Patient Transport Services

Patient transport services (PTS) provided non-emergency transport for patients who attend, for example, outpatient clinics or day hospitals, or were discharged from hospital. Commissioners had identified eligibility criteria for the service and the trust was working with 12 clinical commissioning groups to monitor performance and compliance.
Staff followed the eligibility criteria designed by commissioners and were also working to improve the signposting of people to other services if they did not meet the criteria.
Procedures to ensure the safety of services needed to improve, specifically around incident reporting, equipment checks and safeguarding procedures. Most vehicles were visibly clean. ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) orders were understood and used appropriately, but staff had limited awareness of the Mental Capacity Act 2005.
There were staffing vacancies and staff felt stretched, particularly in the dispatch team where this had an impact on the planning and scheduling of transport. The trust was using volunteers and private providers to cover driving shifts. There needed to be better governance arrangements for private providers and for driving and employment checks for volunteers.
The trust had made significant changes to the IT system in the PTS on the day of our inspection. Anticipated resource and capacity risks needed to be better managed, for example, problems with the new IT system had caused a serious disruption to transport arrangements for many patients during our inspection
Dispatch staff did not always have appropriate assessment information, from hospitals or patients or from their own records. Patients sometimes did not have an appropriate vehicle or equipment, and transport sometimes had to be reorganised. The system to plan journeys was manual and often reactive based on a lack of timely and coordinated information and this had caused delays to patient transport.
The trust was not meeting performance targets and this was having an impact on patients’ care and treatment. Patients were experiencing delayed and missed appointments for outpatient consultations and diagnostic scans, and renal dialysis, and some were choosing to curtail their treatment in order not to risk missing their transport home for fears of excessive delay. Some hospitals had reorganised clinics, for example, to finish early to accommodate the vagaries of the PTS. There were good examples of multi-disciplinary working with GPs and health professionals in hospitals. The trust had been working with other providers to improve the coordination of care and some progress had been made.
Patient surveys were regularly undertaken; these were positive about the service but identified delays. Patients we spoke with were positive about the care and compassion of staff. However, they were concerned that the service was not effective and that they were not given enough information about delays, missed appointments and the eligibility criteria.
Many patients told us they had been distressed and anxious waiting for transport, but did not know whom to contact within the service. Call handlers were overwhelmed with calls about service delays and only half of all calls were answered.
There was good support for vulnerable patients (for example, those with dementia or a learning disability), and carers and escorts could travel in the ambulances too. A policy for the transport of children needed to be developed.
The trust had a clear strategy for the development of PTS to support safe non-emergency travel between people’s homes and healthcare settings, but most staff were unaware of this strategy. Governance arrangements needed to improve in order to assess and manage risks. Although staff worked effectively in teams, many wanted the management and leadership of the service to improve and for the trust to prioritise PTS alongside the emergency 999 service.

We saw several areas of outstanding practice:

We observed many examples where staff demonstrated outstanding care and compassion to patients despite sometimes working in very difficult and pressured environments. Staff “lived” the values of the trust “Towards excellence – Saving lives and enabling you to get the care you need”.
Representatives of the trust attended local youth organisation meetings, village fetes and school assemblies. The trust had developed a child-friendly first-aid book printed specially for schools and the wider local community.
The trust provided an innovative learning resource to their frontline staff using the educational resource centre and film centre at Bracknell. The staff were involved in making films which supported learning around new guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).
The trust had introduced a lifesaving automatic external defibrillator (AED) locator mobile phone application. By using GPS, this app locates the nearest AED in the event of a cardiac arrest. In total, the app identified over 800 AEDs across four counties.
A new initiative was the introduction of a ‘Simbulance’: a large command vehicle fully equipped with simulation learning activities. It was an innovative virtual classroom facility in that it gave ambulance staff the opportunity to experience realistic medical situations inside an ambulance saloon.
Operation centres had direct access to electronic information held by community services, including GPs. This meant that the staff could access up-to-date information about patients (for example, details of their current medication).
Trauma risk management (TRiM) was in place to provide confidential support to staff who may have been affected by traumatic incidents or conditions. Staff were assessed 3 days after a traumatic event and again after 28 days. Thirty-two TRiM practitioners gave peer support and advice, and there was also an external counselling service. The early intervention had both reduced sickness absence and improved the welfare of staff.
The Helicopter Emergency Medical Services (HEMS) showed innovative practices and learning taken from combat zones. The team now had the equipment and skills to give blood transfusions and perform ultrasound and blood gas tests. In some circumstances, this bypassed or reduced the time a patient had to spend in the accident and emergency (A&E) department, and meant they could receive treatment immediately on arrival at the hospital. HEMS was also planning to introduce a night service, so it would operate 24 hours every day.
The introduction of a midwife to the clinical support desk (CSD) in the Southern House emergency operation centre had improved the outcomes for expectant mothers and their new babies. The 24-hour labour line started as a pilot in May 2014. It gave women in labour access to advice and support, whereas the ‘professional’s line’ enabled medical professionals to speak to a midwife 24/7 during a woman’s labour and birth. The service had over 1,600 calls in the first eight weeks.
The trust provided a service on Friday and Saturday nights in the city centres of Portsmouth (Safe Place) and Southampton (ICE Bus) to provide support, first aid and transfer to hospital if required for the public enjoying a night out. This had been set up in partnership with other organisations such as the Hampshire Police, the local council, volunteers and the local street pastors
The trust had a clinical lead in mental health and learning disability. This role was unique among ambulance trusts. The lead had established a national mental health group for ambulance trusts, and worked with partner agencies such as the Royal College of Psychiatrists and the College of Policing. The introduction of mental health practitioners into the EOC was supporting operational practice and care to mental health patients.
The trust had worked in partnership with Oxford Brookes University to provide staff with extra opportunities to develop their careers by becoming a paramedic, and to counter the national shortage of paramedics. A foundation degree course was to start in January 2015. The training covered an 18-month period and included in-hours training. The trust’s investment had been significant in terms of the time taken to negotiate the resources and facilities for the programme and the release of staff from work duties.

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

Importantly, the trust must ensure that:

Staff uptake of statutory and mandatory training meets trust targets
Staff in EOC and PTS understand the Mental Capacity Act 2005
All EOC and PTS staff receive safeguarding training to the required level so that they are able to recognise signs of abuse and ensure there are robust arrangement in place for staff to report concerns within the agreed timescale.
Emergency call takers answer calls, and the emergency medical dispatchers dispatch an ambulance within target times

In addition the trust should ensure that:

Procedures for incident reporting continue to improve and staff in EOC and PTS have appropriate training and are able to report incidents directly. There must be timely investigation of incidents, staff must receive feedback and learning must be shared.
The risks around IT vulnerability in the EOC and PTS are appropriately managed.
Infection control practices are followed and ambulance stations (resource centres) and vehicles are effectively cleaned and deep cleaned.
There are suitable arrangements to ensure that equipment is regularly checked and fit for purpose.
Staff are aware of the appropriate steps to take to reduce the risks to patients left unattended in PTS ambulances because of staff working alone.
Appropriate equipment is available in all areas for the transport of children in PTS and this continues to be rolled out for emergency transport.
Volunteer drivers in PTS have the appropriate safety and employment checks before working within the service.
The trust to continue to work with partners and ensure the planning and scheduling of PTS improve to prevent delays and missed appointments, and to reduce the impact on the clinical care, treatment and welfare of patients.
The governance and security arrangements for the management of controlled drugs need to be improved in Hampshire.
Recruitment of staff in all areas continues and there are specific staff retention plans in response to identified reasons as to why staff leave.
Staff in PTS receive appropriate training on dementia care, learning disabilities and all staff continue to received training in mental health conditions.
Anticipated resource and capacity risks in PTS continue to be appropriately identified, assessed and managed.
Pain relief continues to be appropriately administered for patients with ST segment elevation myocardial infarction (STEMI) and pain relief for children is effectively monitored.
Continue to work with acute trusts to review protocols for the non- critical transfer of hospital patients.
There is better coordination of care between providers, in particular for cardiac and stroke services in Buckinghamshire and mental health services.
Complaints are responded to within the trust’s target of 25 days. All staff in EOC and PTS receive feedback from complaints and learning is shared.
Operations staff in PTS are appropriately resourced to be able to answer telephone calls.
Patients (or people acting on their behalf) using the PTS are made of aware of how to complain or send compliments about the service.
Staff in PTS have regular supervision and the trust should raise awareness amongst staff about the professional and career development opportunities within the trust.
The formal structure of team meetings is in place for all staff groups and staff are given the opportunity to attend, share information and raise issues or concerns.
Staff have a better understanding of the trust’s vision and strategy as it applies to their service in EOC and PTS and staff communication continues around service changes and development.
Leadership in the northern EOC and PTS supports staff and action is taken to improve staff morale where this is low.
Staff in PTS receive feedback from the completed patient satisfaction surveys.
There are better governance arrangements within EOC and PTS to share information with staff, so that staff can raise concerns and risks are appropriately identified, assessed and managed.
There are better governance arrangements for private providers in PTS and make ready services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

These reports, under our old approach to inspection, involved us assessing a whole provider against the standards we expect.

South Central Ambulance Service NHS Foundation Trust

All Inspections

6/7 April 2022 10/11 May 2022

During a routine inspection

6/7 April 2022 10/11 May 2022

During an inspection of Emergency operations centre (EOC)

6/7 April 2022 10/11 May 2022

During an inspection of Emergency and urgent care

24th November 2021

During an inspection looking at part of the service

05 Feb to 11 Mar 2020

During a routine inspection

05 Feb to 11 Mar 2020

During an inspection of Patient transport services

24 July to 9 August 2018

During a routine inspection

24 July to 9 August 2018

During an inspection of Emergency and urgent care

24 July to 9 August 2018

During an inspection of Emergency operations centre (EOC)

24 July to 9 August 2018

During an inspection of Resilience

3-6 May 2016 and unannounced 13 and 16 May 2016

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals

3 - 6 May 2016 and unannounced 13 and 16 May 2016

During a routine inspection

Professor Sir Mike Richards

8–12, 30 September and 1 October 2014

During a routine inspection

Key findings

Professor Sir Mike Richards

Organisation review of compliance