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.
- 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.