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South Western Ambulance Service NHS Foundation Trust

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9 March 2022

During an inspection of Emergency and urgent care

South Western Ambulance Service NHS Foundation Trust works across the whole of the South West of England from Gloucestershire in the north to Cornwall and the Isles of Scilly in the south.

We carried out this short-notice announced inspection in March 2022. We had a focus on the urgent and emergency care pathway for patients across the integrated care system in Cornwall. As the ambulance trust serves the whole of the South West of England, not all information relates to Cornwall, but we have included specific data and evidence where we can. Some of the data also relates to the NHS trust in Plymouth as patients from the east of Cornwall are mostly conveyed to that hospital rather than the emergency department in Truro. Due to ongoing restrictions for safety during the pandemic, we did not accompany crews attending patients in the community, but met with them at Royal Cornwall Hospital, Treliske, Truro.

As this was a focused inspection, and we did not look at every question in our key lines of enquiry, we did not re-rate the service this time. Our reports published in March 2022 with a focus on Gloucestershire, but also the South Western Ambulance Service Emergency Operations Centres, can be found here: https://www.cqc.org.uk/provider/RYF

A summary of CQC findings on urgent and emergency care services in Cornwall

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

Cornwall

The health and care system in this area is under extreme pressure and struggling to meet people’s needs in a safe and timely way. We have identified a high level of risk to people’s health when trying to access urgent and emergency care in Cornwall. Provision of urgent and emergency care in Cornwall is supported by services, stakeholders, commissioners and the local authority and stakeholders were aware of the challenges across Cornwall; however, performance has remained poor, and people are unable to access the right urgent and emergency care, in the right place, at the right time.

We found significant delays to people’s treatment across primary care, urgent care, 999 and acute services which put people at risk of harm. Staff reported feeling very tired due to the on-going pressures which were exacerbated by high levels of staff sickness and staff leaving health and social care. All sectors were struggling to recruit to vacant posts. We found a particularly high level of staff absence across social care resulting in long delays for people waiting to leave hospital to receive social care either in their own home or in a care setting.

GP practices reported concerns about the availability of urgent and emergency responses, often resulting in significant delays in 999 responses for patients who were seriously unwell and GPs needing to provide emergency treatment or extended care whilst waiting for an ambulance. GPs also reported a lack of capacity in mental health services which resulted in people’s needs not being appropriately met, as well as a shortage of District Nurses in Cornwall.

A lack of dental and mental health support also presented significant challenges to the NHS111 service who were actively managing their own performance but needed additional resources available in the community to avoid signposting people to acute services. The NHS111 service in Cornwall worked to deliver timely access to people in this area, whilst performance was below national targets it was better than other areas in England.

Urgent care services were available in the community, including urgent treatment centres and minor illness and injury units and these services were promoted across Cornwall. These services adapted where possible to the change in pressures across Cornwall. When services experienced staffing issues, some units would be closed. When a decision was made to close a minor injury unit (MIU) the trust diverted patients to the nearest alternative MIU and updated the systems directory of services to reflect this. However, this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment. This had been highlighted on the trust’s risk register.

Due to the increased pressures in health and social care across Cornwall, we found some patients presented or were taken to urgent care services who were acutely unwell or who required dental or mental health care which wasn’t available elsewhere. Staff working in these services treated those patients to the best of their ability; however, patients were not always receiving the right care in the right place.

Delays in ambulance response times in Cornwall are extremely concerning and pose a high level of risk to patient safety. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, it also meant a significant reduction in the number of ambulances available to respond to 999 calls. These delays impacted on the safe care and treatment people received and posed a high risk to people awaiting a 999 response. At the time of our inspection, the ambulance service in Cornwall escalated safety concerns to NHS England and NHS Improvement.

Staff working in the ambulance service reported significant difficulties in accessing alternative pathways to Emergency Departments (ED). When trying to access acute assessment units, staff reported being bounced back and forth between services and resorting to ED as they were unable to get their patient accepted. Many other alternative pathways were only available in specific geographical areas and within specific times, making it challenging for front line ambulance crews to know what services they could access and when. In addition, ambulance staff were not always empowered to make referrals to alternative services. The complexity of these pathways often resulted in patients being conveyed to the ED.

Hospital wards were frequently being adapted to meet changes in demand and due to the impact of COVID-19. There was a significant number of people who were medically fit for discharge but remaining in the hospital impacting on the care delivered to other patients. The hospital had created additional space to accommodate patients who were fit for discharge but were awaiting care packages in the community; however, staff were stretched to care for these patients.

Delays in discharge from acute medical care impacted on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews, prolonged waits and overcrowding in the Emergency Department due to the lack of bed capacity. We found that care and treatment was not always provided in the ED in a timely way due to overcrowding, staffing issues and additional pressure on those working in the department. These delays in care and treatment put people at risk of harm.

In response to COVID-19, community assessment and treatment units (CATUs) had been established in Cornwall. These wards were designed to support patient flow, avoid admission into acute hospitals and provide timely diagnostic tests and assessments. However, these wards were full and unable to admit patients and experienced delayed discharges due to a lack of onward care provision in the community.

Community nursing teams had been recently established to support admissions avoidance and improved discharge. This work spanned across health and social care; however, at the time of our inspections it was in its infancy so we could not assess the impact.

The reasons for delayed discharge are complex and we found that discharge processes should be improved to prevent delays where possible. However, we recognise that patient flow across the Urgent and Emergency Care pathway in Cornwall is significantly impacted on by a shortage of staffed capacity in social care services. Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England. This staffing crisis is resulting in a shortage of domiciliary care packages and care home capacity meaning many people cannot be safely discharged from hospital. A care hotel has been established in Cornwall providing very short-term care for people with very low levels of care needs; this is working well for those who meet the criteria for staying in the hotel, however this is a relatively small number of people.

Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve. Whilst we have seen some pilots and community services adapted to meet changes in demand, additional focus on health promotion and preventative healthcare is needed to support people to manage their own health needs. People trying to access urgent and emergency care in Cornwall experience significant challenges and delays and do not always receive timely, appropriate care to meet their needs and people are at increased risk of harm.

Summary of South Western Ambulance Service NHS Foundation Trust

On this inspection centred on Cornwall, we reviewed emergency and urgent care services. For this core service we looked at elements of the safety, effectiveness, caring, responsiveness and leadership of the staff and teams responding to 999 calls, and those supporting the emergency departments on site.

This inspection was not rated. We continue to monitor all South Western Ambulance services and will inspect further in the course of our programme of inspections.

For emergency and urgent care, we found:

  • The service was under immense pressure from a lack of bed-capacity in the acute hospitals and the community with patients waiting in ambulances at emergency departments (which were also full). The service was staffed and resourced safely to meet people’s needs in most areas for commissioned and planned levels of demand. Staffing levels had been increased to deal with some of the predicted increase in demand for ambulances, but not to cope with the lack of bed capacity experienced. However, additional recruitment of staff continued across the service.
  • Delays in the handover of patients at emergency departments meant the service was unable to reach all patients who needed an ambulance in a timely way, in line with national targets. There was evidence to show the trust had taken internal action to manage the increasing demand on urgent and emergency care capacity. However, incidents of patients waiting long periods of time for an ambulance were increasing and occurred on most days. This was having a significant impact on the morale of staff across the service and on patients waiting.
  • There were risks for patients as a result of ambulance handover delays in emergency departments. There were known and unknown risks of harm to patients who were held in an ambulance or waiting in the community and an ambulance was not available or excessively delayed. This led to harm for some patients.
  • The NHS contractual response times for ambulances to attend patients were not being met and some were exceptionally long and increasing. This was because ambulances were waiting at emergency departments because of capacity pressures in hospitals and other parts of the health and social care system.

However:

  • Despite the pressure and challenges, staff were kind, compassionate and supportive to patients, some of whom had complex needs. One patient said of the staff: “they’ve been wonderful” and another said, “I just can’t fault them.”
  • There had been some excellent multidisciplinary working and mutual aid to and from the service. Volunteers and first responders continued to play a vital role.

How we carried out the inspection

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

For our emergency and urgent care inspection, we met with staff operating in the county of Cornwall. We spoke with trust’s county commander and the deputy county commander for Cornwall. We talked with paramedics, emergency care assistants and other members of staff on duty at the emergency department at Royal Cornwall Hospital, Truro. We spoke with 10 paramedics, emergency care assistants and other support personnel, and the hospital ambulance liaison officer (known as a HALO).

We spoke with six patients while on site at the emergency department. Some were still in ambulances and others had arrived by ambulance and been taken into the emergency department. Although we observed care delivered by ambulance staff for a number of patients, some of these were not well enough to talk with us. Due to rules of safety in the COVID-19 pandemic, and in light of the pressures of demand on the ambulance service, we did not ride out with crews or observe them on the scene with patients.

23 to 25 November 2021

During an inspection of Emergency and urgent care

South Western Ambulance Service NHS Foundation Trust works across the whole of the south west of England from Gloucestershire in the north to Cornwall and the Isles of Scilly in the south. This is an area of around 10,000 square miles and 20% of mainland England. The trust serves a population of around 5.6 million people. The south west also has in the region of 23 million tourist visitors each year.

The trust employs around 4,000 staff, runs 94 ambulance stations, six air ambulance bases and two hazardous area response teams. The team of staff includes paramedics, specialist practioners in urgent and emergency care, clinicians including doctors, advanced technicians, ambulance care assistants and nurse practitioners. The trust is also supported by GPs, the fire and rescue services (co-responders), community first responders, and volunteers.

We carried out this short-notice announced inspection in November 2021. We had an additional focus on the urgent and emergency care pathway for patients across the integrated care system in Gloucestershire. As the trust serves the whole of the South West of England, not all information relates to Gloucestershire, but we have included specific data and evidence where we can.

As this was a focused inspection, and we did not look at every question in our key lines of enquiry, we did not re-rate the service this time.

On this inspection we reviewed emergency and urgent care services (the ambulance crews responding to emergency 999 calls) and the emergency operations centres (known in the trust as the clinical hubs). For both services we looked at elements of the safety, effectiveness, caring, responsiveness and leadership of the staff and teams in the clinical hubs, responding to 999 calls, and those supporting the emergency departments on site.

At our previous inspection published in September 2018, we rated emergency and urgent care services at the trust as good overall, although the key question ‘Is the service Safe’ was rated as requires improvement. Caring was rated as outstanding and the other key questions as good. We rated the emergency operations centres as good overall.

As this was a focused inspection around system pathways focused on Gloucestershire, we did not inspect Resilience (previously rated in 2016 as outstanding) or Urgent and Emergency Care (for which the trust runs an urgent treatment centre in Tiverton – previously rated in 2016 as good). We continue to monitor these services and will inspect them in the course of our programme of inspections.

A summary of CQC findings on urgent and emergency care services in Gloucestershire

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. On this occasion we did not inspect any GPs as part of this approach. However, we recognise the pressures faced by general practice during the COVID-19 pandemic and the impact on urgent and emergency care. We have summarised our findings for Gloucestershire below:

Provision of urgent and emergency care in Gloucestershire was supported by health and social care services, stakeholders, commissioners and the local authority. Leaders we spoke with across a range of services told us of their commitment and determination to improve access and care for patients and to reduce pressure on staff. However, Gloucestershire had a significant number of patients unable to leave hospital which meant the hospitals were full and new patients had long delays waiting to be admitted.

The 111 service was generally performing well but performance had been impacted by high call volumes causing longer delays in giving clinical advice than were seen before the pandemic. Health and social care leaders had recently invested in a 24 hour a day, seven day a week Clinical Assessment Service (CAS). This was supported by GPs, advanced nurse practitioners, pharmacists and paramedics to ensure patients were appropriately signposted to the services across Gloucestershire.

At times, patients experienced long delays in a response from 999 services as well as delays in handover from the ambulance crew at hospital due to a lack of beds available and further, prolonged waits in emergency departments. Patients were also remaining in hospital for longer than they required acute medical care due to delays in their discharge home or to community care. These delays exposed people to the risk of harm especially at times of high demand. The reasons for these delays were complex and involved many different sectors and providers of health and social care.

Health and social care services had responded to the challenges across urgent and emergency care by implementing a range of same day emergency care services. While some were alleviating the pressure on the emergency department, the system had become complicated. Staff and patients were not always able to articulate and understand urgent and emergency care pathways.

The local directory of services used by staff in urgent and emergency care to direct patients to appropriate treatment and support was found to have inaccuracies and out of date information. This resulted in some patients being inappropriately referred to services or additional triage processes being implemented which delayed access to services. For example, the local directory of services had not been updated to ensure children were signposted to an emergency department with a paediatric service and an additional triage process had been implemented for patients accessing the minor illness and injury units to avoid inappropriate referrals. Staff from services across Gloucestershire were working to review how the directory of services was updated and continuing to strengthen how this would be used in the future.

We found urgent and emergency care pathways could be simplified to ensure the public and staff could better understand the services available and ensure people access the appropriate care. Health and social care leaders also welcomed this as an opportunity for improvement. We also identified opportunities to improve patient flow through community services in Gloucestershire. These were well run and could be developed further to increase the community provision of urgent care and prevent inappropriate attendance in the emergency departments.

There was also capacity reported in care homes across Gloucestershire which could also be used to support patients to leave hospital in a timely way. The local authority should be closely involved with all decision-making due to its extensive experience in admission avoidance and community-based pathways.

Summary of South Western Ambulance Service NHS Foundation Trust

For emergency and urgent care we found:

  • The service was under immense and unrelenting pressure from demand with ambulances being held at emergency departments (which were also full). The service was staffed and resourced safely to meet people’s needs in most areas for commissioned and planned levels of demand. However, the recent significant rise in numbers of callers to 999, and the inability to release ambulances from emergency departments meant the service was unable to reach all patients who needed an ambulance safely and effectively much of the time. There was evidence that the trust had done almost everything it was able to do to manage the increasing demand on urgent and emergency care capacity. Incidents of exceptional demand were increasing to occur most days, and this was becoming unsustainable for staff across the service. Staffing levels had been increased to deal with some of the anticipated rise in demand the service had predicted, but not to cope with the pressures and capacity shortages now experienced. However, additional recruitment was underway with some having already happened.
  • There was evidence of staff under such pressure that it was having a detrimental effect on both their mental and physical wellbeing. This included staff feeling pressure from dealing with anxious, upset and abusive members of the public, patients and sometimes other stressed healthcare professionals. Most of the staff described feeling exhausted, demoralised and stressed at times by the job with the current pressures. This was entirely recognised and acknowledged by the senior management and the executive team at the trust. Some staff remained as positive as they could and we saw and heard how this helped in their response to patients. The organisation was offering a package of support measures for staff, which staff acknowledged they were aware of and had used at times. However, some staff told us they struggled to find the time to prioritise their own wellbeing over that of the workload.
  • There were additional risks for patients from handover delays for ambulance crews at emergency departments which were unable to take patients due to their lack of capacity. There were also known and unknown risks of harm, some serious, to patients who were in the community and an ambulance was not available to send or was excessively delayed. Although many patients had an effective outcome, not all patients did due to delays in the transfer of their care to the emergency department or from the crew being able to reach them on time.
  • The NHS contractual response times for ambulances to attend patients were no longer being met and some were significantly delayed. This was to an extent not previously experienced at any time since these standards were implemented in 2017. It was due almost entirely to ambulances being held at overwhelmed emergency departments because of serious capacity pressures in hospitals and other parts of the urgent and emergency care system.

However:

  • Despite the immense pressure faced every day, staff were kind, compassionate and supportive to patients, some of whom were complex and challenging for staff. One of the patients we met said of the staff who had looked after them: “they are truly wonderful.”
  • There were good standards of cleanliness and infection prevention and control. Arrangements, equipment and guidance helped staff and patients stay safe.
  • There had been some excellent multidisciplinary working and mutual aid to and from the service. The support from the fire and rescue service was highlighted as being exceptional. Volunteers and first responders continued to play a vital role.

How we carried out the inspection

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

For our emergency and urgent care inspection, we met with staff from across the whole organisation. We spoke with operational managers, and the trust’s deputy county commander for Gloucestershire. We talked with paramedics, emergency care assistants and other members of staff at NHS emergency departments and in two ambulance stations in the county of Gloucestershire. This was to learn more of the multidisciplinary approach to urgent and emergency care and how the system supports all parts of this pathway. We spoke with 30 paramedics, emergency care assistants and other support personnel, a hospital ambulance liaison officer (known as a HALO) and two senior doctors working for the ambulance service. We spoke with 16 of the trust’s senior operational managers and executives. We were also contacted by over 30 staff after our inspection on site following our usual offer for staff who we had not been able to speak with to get in touch – or staff we had met who wanted to share more with us.

We talked with seven patients while on site at the emergency departments. Some were still in ambulances and others had arrived by ambulance and taken into the emergency departments. Although we observed care delivered by ambulance staff for a number of other patients, many of these were not well enough to talk with us. Due to rules of safety in the COVID-19 pandemic, and in light of the pressures of demand on the ambulance service, we did not ride out with crews or observe them on the scene with patients.

23 to 25 November 2021

During an inspection of Emergency operations centre (EOC)

South Western Ambulance Service NHS Foundation Trust works across the whole of the south west of England from Gloucestershire in the north to Cornwall and the Isles of Scilly in the south. This is an area of around 10,000 square miles and 20% of mainland England. The trust serves a population of around 5.6 million people. The south west also has in the region of 23 million tourist visitors each year.

The trust employs around 4,000 staff, runs 94 ambulance stations, six air ambulance bases and two hazardous area response teams. The team of staff includes paramedics, specialist practioners in urgent and emergency care, clinicians including doctors, advanced technicians, ambulance care assistants and nurse practitioners. The trust is also supported by GPs, the fire and rescue services (co-responders), community first responders, and volunteers.

We carried out this short-notice announced inspection in November 2021. We had an additional focus on the urgent and emergency care pathway for patients across the integrated care system in Gloucestershire. As the trust serves the whole of the South West of England, not all information relates to Gloucestershire, but we have included specific data and evidence where we can.

As this was a focused inspection, and we did not look at every question in our key lines of enquiry, we did not re-rate the service this time.

On this inspection we reviewed emergency and urgent care services (the ambulance crews responding to emergency 999 calls) and the emergency operations centres (known in the trust as the clinical hubs). For both services we looked at elements of the safety, effectiveness, caring, responsiveness and leadership of the staff and teams in the clinical hubs, responding to 999 calls, and those supporting the emergency departments on site.

At our previous inspection published in September 2018, we rated emergency and urgent care services at the trust as good overall, although the key question ‘Is the service Safe’ was rated as requires improvement. Caring was rated as outstanding and the other key questions as good. We rated the emergency operations centres as good overall.

As this was a focused inspection around system pathways focused on Gloucestershire, we did not inspect Resilience (previously rated in 2016 as outstanding) or Urgent and Emergency Care (for which the trust runs an urgent treatment centre in Tiverton – previously rated in 2016 as good). We continue to monitor these services and will inspect them in the course of our programme of inspections.

A summary of CQC findings on urgent and emergency care services in Gloucestershire

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. On this occasion we did not inspect any GPs as part of this approach. However, we recognise the pressures faced by general practice during the COVID-19 pandemic and the impact on urgent and emergency care. We have summarised our findings for Gloucestershire below:

Provision of urgent and emergency care in Gloucestershire was supported by health and social care services, stakeholders, commissioners and the local authority. Leaders we spoke with across a range of services told us of their commitment and determination to improve access and care for patients and to reduce pressure on staff. However, Gloucestershire had a significant number of patients unable to leave hospital which meant the hospitals were full and new patients had long delays waiting to be admitted.

The 111 service was generally performing well but performance had been impacted by high call volumes causing longer delays in giving clinical advice than were seen before the pandemic. Health and social care leaders had recently invested in a 24 hour a day, seven day a week Clinical Assessment Service (CAS). This was supported by GPs, advanced nurse practitioners, pharmacists and paramedics to ensure patients were appropriately signposted to the services across Gloucestershire.

At times, patients experienced long delays in a response from 999 services as well as delays in handover from the ambulance crew at hospital due to a lack of beds available and further, prolonged waits in emergency departments. Patients were also remaining in hospital for longer than they required acute medical care due to delays in their discharge home or to community care. These delays exposed people to the risk of harm especially at times of high demand. The reasons for these delays were complex and involved many different sectors and providers of health and social care.

Health and social care services had responded to the challenges across urgent and emergency care by implementing a range of same day emergency care services. While some were alleviating the pressure on the emergency department, the system had become complicated. Staff and patients were not always able to articulate and understand urgent and emergency care pathways.

The local directory of services used by staff in urgent and emergency care to direct patients to appropriate treatment and support was found to have inaccuracies and out of date information. This resulted in some patients being inappropriately referred to services or additional triage processes being implemented which delayed access to services. For example, the local directory of services had not been updated to ensure children were signposted to an emergency department with a paediatric service and an additional triage process had been implemented for patients accessing the minor illness and injury units to avoid inappropriate referrals. Staff from services across Gloucestershire were working to review how the directory of services was updated and continuing to strengthen how this would be used in the future.

We found urgent and emergency care pathways could be simplified to ensure the public and staff could better understand the services available and ensure people access the appropriate care. Health and social care leaders also welcomed this as an opportunity for improvement. We also identified opportunities to improve patient flow through community services in Gloucestershire. These were well run and could be developed further to increase the community provision of urgent care and prevent inappropriate attendance in the emergency departments.

There was also capacity reported in care homes across Gloucestershire which could also be used to support patients to leave hospital in a timely way. The local authority should be closely involved with all decision-making due to its extensive experience in admission avoidance and community-based pathways.

Summary of South Western Ambulance Service NHS Foundation Trust

For the emergency operations centres (clinical hubs) we found:

  • The service was under immense and unrelenting pressure from demand with ambulances being held at emergency departments (which were also full). The service was staffed and resourced safely to meet people’s needs in most areas for commissioned and planned levels of demand. However, the recent significant rise in numbers of callers to 999, and the inability to release ambulances from emergency departments meant the service was unable to reach all patients who needed an ambulance safely and effectively much of the time. There was evidence that the trust had done almost everything it was able to do to manage the increasing demand on urgent and emergency care capacity. Incidents of exceptional demand were increasing to occur most days, and this was becoming unsustainable for staff across the service. Staffing levels had been increased to deal with some of the anticipated rise in demand the service had predicted, but not to cope with the pressures and capacity shortages now experienced. However, additional recruitment was underway with some having already happened.
  • There was evidence of staff under such pressure that it was having a detrimental effect on both their mental and physical wellbeing. This included staff feeling pressure from dealing with anxious, upset and abusive members of the public, patients and sometimes other stressed healthcare professionals. Most of the staff described feeling exhausted, demoralised and stressed at times by the job with the current pressures. This was entirely recognised and acknowledged by the senior management and the executive team at the trust. Some staff remained as positive as they could and we saw and heard how this helped in their response to callers. The organisation was offering a package of support measures for staff, which staff in the clinical hubs acknowledged they were aware of and had used at times. However, some staff told us they struggled to find the time to prioritise their own wellbeing over that of the workload.
  • The expected time for emergency 999 calls to be answered (under 20 seconds for the 90th centile) was no longer being met and since autumn 2021, were now much above (worse than) the England average. This situation was not previously experienced at any time over the previous few years. Although the number of clinical incidents were not significantly higher in number, the call volume had risen with people making additional calls asking, usually, for an update on the ambulance arriving. This delay was due almost entirely to ambulances being held at emergency departments with serious capacity pressures in that and other parts of the urgent and emergency care system. As a result, they were not readily available to swiftly turn around and be back in the community to help other patients. This resulted in people calling more often for an update or if a situation had changed.

However:

  • Despite the immense pressure faced every day, staff were kind, compassionate and supportive to patients, some of whom had complex needs and may be challenging for staff. They knew how to remain calm and respectful when dealing with distressed or abusive callers.
  • In order to keep staff safe in the clinical hubs, there were good provisions to minimise the risk of the spread of infection and the trust and staff adhered to national guidance.

How we carried out the inspection

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

For our emergency operations centres inspection, we met with staff from across the whole organisation. We talked with 14 emergency medical dispatchers (the staff trained to take the 999 calls) and six dispatchers (staff who managed the dispatch of ambulances and other resources). We met and talked with four trained clinicians who assess and give advice to the emergency medical dispatchers, patients and carers. These included doctors, nurses and paramedics. We listened to 28 calls coming into the service from the public and other healthcare professionals and heard how these were handled by the emergency medical dispatchers and clinical teams. We met and talked with 16 of the trust’s senior operational managers and executives. We were also contacted by over 30 staff after our inspection on site following our usual offer for staff who we had not been able to speak with to get in touch – or staff we had met who wanted to share more concerns.

We visited both clinical hubs in Exeter (within the trust’s headquarters) and in Bristol.

26 June 2018

During a routine inspection

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

Caring was rated as outstanding. Effective, responsive and well-led were rated as good. Both effective and well-led improved from requires improvement at our 2016 inspection with responsive remaining as good. Well-led at trust level was rated as good. However, safe remained as requires improvement.

  • We rated well-led at the trust as good. There was effective, experienced and skilled leadership, a strong vision for the organisation, and embedded values. Leadership had strengthened, and the new structure in frontline services would being local leadership closer to staff, patients and stakeholders. Patient care was a top priority for the trust. There was mostly effective governance around performance, but this had not resolved some previous issues and led to the emergence of others in frontline services. The culture within the staff was enormously variable, although those we met were committed and highly professional. Nevertheless, some felt unsupported in certain aspects of wellbeing, communication and change. There was good and detailed management information available, and strong financial governance and audit. There was commitment to engagement with stakeholders, although the trust needed to move away from public relations to the public supporting service delivery, improvement and change. There was a strong and deep commitment to learning, development and innovation.
  • Emergency and urgent care remained rated as requires improvement overall. The questions of safety, effectiveness and well-led remained requires improvement, with responsive remaining good, and caring remaining outstanding. These ratings have not changed since our previous inspection, and although we saw several key improvements since then, there were some problems unresolved, and others emerging. Concerns included the trust failing to meet the standard response times to reach patients, although this was improving recently for the most urgent category. Vehicles and premises were not always secured in accordance with trust policies and procedures. Some consumables and medicines were not in date or secured, and not always disposed of correctly. Not all patient records were always protected. Again, storage of some confidential medicine records failed to meet trust policy and legal requirements. Some improvements were needed in outcomes for patients, particularly those being treated for a stroke. The governance of these issues had not recognised or addressed them. However, there was outstanding care to patients and those who were with them, or involved in an incident. The service was designed to meet people’s needs and care for those who needed more individual support. We recognised the leadership and structure in frontline services was relatively new and needed time to embed.
  • Emergency operations centres remained rated as good overall. The questions of safety, responsive and well-led remained good. Effective improved from requires improvement to good. Caring remained as outstanding. We found improvements in several areas since our last inspection, although some of these had recently dipped for operational reasons, and needed to be restored. There was a safe service, with systems and process protecting people from harm. This included improved and good levels of staff. There was good multidisciplinary teamworking, and adherence to national guidance and evidence-based practice. There was outstanding caring for people, often in difficult circumstances for both the caller and the staff talking with them. The managers had the experience and skills to lead the service and ensure it was giving safe and quality care. The poor number of regular staff performance reviews were a significant concern at our previous inspection. These had significantly improved, although there was still some progress to be completed to meet targets. Clinical and non-clinical call audits were again not meeting the targets, but were back on track to improve.
  • On this inspection we did not inspect Out of hours services, Resilience, or Urgent and emergency care (the Tiverton urgent care centre). The trust no longer provides Patient transport services. The ratings we gave to these services on the previous inspections in October 2016 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

26 June 2018

During an inspection of Emergency operations centre (EOC)

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

  • The trust provided a safe service to patients and made sure they were protected from abuse. There were safe levels of staff who were trained to provide safe care, and records maintained, infection control practices, the systems used, and how staff recognised and managed patients risks assured us of a safe service.
  • Staff were competent to carry out their role and there was good multidisciplinary working within the clinical hubs.
  • Callers were consistently treated compassionately and staff made sure patients understood what was going to happen and supported them emotionally.
  • Services met the needs of the local population and the prioritisation system ensured patients received the most appropriate response. Complaints were also investigated thoroughly.
  • Risk was understood and managed and there was a proactive approach to reviewing and improving quality and safety. Morale had improved and there was a strong commitment to improving the quality of the service both locally and nationally.

However

  • Not all staff demonstrated an understanding of learning taken from incidents. The trust needed to make improvements to call audits to make sure care was effective for patients and good outcomes.
  • The needs of frequent callers were not always met.
  • Improvements were required to ensure a consistent and timely response to complaints.

7- 10 June, 17, 20 and 22 June

During a routine inspection

South Western Ambulance Service NHS Foundation Trust is one of 10 ambulance trusts in England. On March 1, 2011 the trust became the first ambulance service in the country to become a Foundation Trust, and acquired Great Western Ambulance Service in February 2013. It provides services in the following geographical area:

• Cornwall

• Isles of Scilly (IOS)

• Devon

• Dorset

• Somerset

• Wiltshire

• Gloucestershire

• The former Avon area (Bristol, Bath, North and North East Somerset and South

• Gloucestershire)

The area is made up of approximately 5.3 million people with an additional 17.5 million visitors per year and covers 10,000 square miles (around 20% of mainland England). It spans 13 Clinical Commissioning Groups and serves 18 acute trusts.

The trust employs over 4,000 mainly clinical and operational staff, including Paramedics (1,788), Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners) plus GPs and around 2,785 volunteers (including community first responders, BASICS doctors, fire co-responders and volunteer PTS drivers).

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of three emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. In addition, the trust also provides patient transport services, hazardous area response teams, NHS 111 services for the people of Cornwall, Devon and Dorset, urgent and emergency care at one minor injuries unit in Devon and out of hours GP services in Gloucestershire and Dorset. The service also provides clinical teams for six air ambulances.

In 2014/15 the trust responded to 867,505 emergency and urgent incidents, received 918,227 NHS 111 calls, helped 155,965 patients calling their out of hours service and completed 99,907 patient transport journeys.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We undertook our announced inspection between 6-10 June 2016 and conducted unannounced inspections on 17, 20 and 22 June 2016 and inspected the following core services:

Emergency Operations Centres

Urgent and Emergency Care

Patient Transport Services

Resilience

Emergency and Urgent Care

Out of Hours

We undertook a comprehensive inspection of the trusts 111 service in March 2016. Details of that inspection have been published separately.

Overall, the trust was rated as requires improvement. We rated caring as outstanding and rated responsiveness as good.

Our key findings were as follows:

Safe

  • Not all staff were reporting incidents, particularly when they were verbally abused by callers and in some areas staff did not routinely report incidents related to patient safety. Some staff felt that due to the demands on the service they did not have time to report all incidents. However, the trust had taken steps to make the reporting process more straightforward by providing a link within the electronic patient record. This allowed staff to complete incident forms without having to return to the ambulance station. 
  • Feedback to staff following incident reporting did not always take place. Whilst not in all areas, some groups of staff were unable to identify learning from incidents that had occurred during the twelve months preceding our inspection.
  • Some incidents were logged and resolved but not reported on the trust wide incident reporting system. This meant that managerial oversight of the themes occurring from all incidents was not comprehensive.
  • Some areas of the service was significantly below the trust’s target for updating mandatory training. Within these services, the levels of staffing were not sufficient to provide relief at all times when staff were training, on holiday, off sick, or taking special leave.
  • Medicines systems used by staff were not always safe and trusts policies, procedures and protocols were not always followed. Within the minor injuries unit, prescription pads were not monitored in order to prevent misuse. 
  • Ambulances and rapid response cars were not always secured when staff were escorting patients into emergency departments at hospitals or tending to patients at other locations. This meant that unauthorised people could access the ambulances.
  • Cleanliness and control of infection was not being managed effectively. Clinical waste was not always disposed of as required. The trust was not meeting its targets for cleaning of vehicles or stations. Infection control training for staff was not meeting the trusts targets for the number of staff who had completed this.
  • Within patient transport services, there were several vehicles with ripped seat covers and one with a hole in the internal wall. These defects meant that the vehicle could not be cleaned adequately to prevent the spread of infection.
  • In patient transport services, not all staff were completing vehicle daily inspection checklists. Checklists were not reviewed effectively to enable the safety of vehicles to be assured. Only 21.3%of vehicles had been consistently deep cleaned every eight weeks or less during the twelve months preceding our inspection.
  • There was insufficient space in the minor injuries unit waiting area for the number of people attending the centre.
  • Safeguarding arrangements for vulnerable adults were not sufficiently robust within the minor injuries unit.
  • Patient confidential information was not always stored securely.
  • Some staff within patient transport services provided treatment for patients but no records of these interventions were completed. These treatments included administering Entenox (nitrous oxide and oxygen gas mixture) and adjusting oxygen.
  • At the time of our inspection, emergency preparedness drills had not been completed on the patient transport boat on the Isles of Scilly.However, the emergency preparedness drills are part of the Domestic Safety Management Plan for the Star of Life that went live in June 2016. The first drill is scheduled for September 2016.
  • Within the minor injuries unit, the environment and use of facilities was not designed to ensure the safety of children. Initial clinical assessment of patients was undertaken by experienced healthcare assistants. However, they did not use an assessment framework to do this and there was no competency assessment to ensure their practice was safe. Computer errors in patient records could not be corrected. This sometimes led to an incorrect diagnosis or medicines dose remaining on patient records.
  • Within the out of hours service procedures for the management of the safety and secure management of controlled drugs were not always followed

However:

  • There was a good system in place for reporting incidents, carrying out investigations, providing feedback to staff, learning and making improvements. In places the culture for incident reporting was very positive.
  • Within the majority of services there were reliable practices for safeguarding people from abuse.
  • Patients’ records were held securely on electronic systems and special notes were available to help support and protect patients and staff.
  • When calling, the risks to patients were assessed with approved triage systems. Decisions were monitored and revised by clinicians when appropriate, or risks changed.
  • There had been a good implementation of the pilot for the ambulance response programme. This triage system was being trialled by the service to assess the safety, effectiveness, and responsiveness of the service should it move away from time-target based responses to sending the right response, first time.
  • The service was able to respond to major incidents and change priorities in times of extreme pressure. There were protocols for staff to follow in high-risk situations to keep staff and the public safe.
  • The service had recognised the growth in call volumes and was responding by increasing staffing levels above establishment levels in the emergency operation centres.
  • There was a good skill-mix among the staff within emergency operations centres, and there were plans to broaden the experience in future.
  • Staff training met the national requirements set out by the National Ambulance Resilience Unit (NARU).
  • Within emergency and urgent care we saw that staff regularly cleaned their hands and we observed staff cleaning their vehicles at the end of shifts. The vehicles we checked were visibly clean and equipment and vehicles were serviced in line with manufacturer’s instructions to make sure they were fit for purpose.

Effective

  • Within the emergency operation centres, staff were not being assessed for their competency and performance and the service was significantly below the trust’s target for completing these appraisals each year. Some senior staff had not had appraisals for a number of years, but the organisation was not aware of this, and not addressing it. This issue had been on the trust’s risk register for over nine years.
  • The rate of annual performance appraisals within emergency and urgent care was variable ranging from 38.4% for specialist paramedics to 87.7% for paramedics. This was below the trust target of 90%. The quality of the appraisals was also variable.
  • Staff in patient transport services did not participate in the learning development review process and compliance with appraisals was low
  • Due to other training priorities, there had been a reduction in the number of calls audited for their quality and safety. The emergency operation centres had not been able, therefore, to determine if the handling of incoming calls was effective at all times. However, we recognised this was being addressed, and improving.
  • The service was struggling with rising call volumes and this had resulted in more calls being abandoned.
  • Response times for most categories were consistently below the England average. The proportion of Red 2 calls responded to within 8 minutes was worse than the England average from April 2015 to January 2016. The trust had not met the national target of 75% since October 2014. From May 2015 the data provided showed a steady decline in performance.
  • From February 2015 to January 2016 the proportion of A19 calls responded to within 19 minutes was mainly worse than the England average. The national standard of 95% was not met for 10 of these 12 months.
  • From April to October 2015 the average proportion of patients who received angioplasty (unblocking of a coronary artery) following ST segment elevation myocardial infarction within 150 minutes was worse than the national average.
  • The average proportion of patients assessed face to face who received an appropriate stroke or transient ischaemic attack care bundle in April to October 2015 was worse than the national average.
  • Not all staff were competent in providing treatment and care to patients with mental health issues.
  • Within patient transport services, competencies of intermediate care assistants to administer Entenox (nitrous oxide and oxygen gas mixture) and perform cardiac monitoring had not been refreshed. Standard operating procedures were not accessible to staff when they were out and about transporting patients. Staff were not informed when patients were diabetic and this meant that staff did not have access to important information that may be needed by emergency crews attending to assist. The process of gaining consent was not recorded.
  • It was not always clear for people on how to raise a complaint.

However:

  • There were evidence-based systems to provide assessment and advice for patients. The emergency operations centre teams were using national guidelines and following best practice protocols to assess people’s needs and provide the right service.
  • Staff had the skills and knowledge to deliver effective advice and guidance. There were internal and external development opportunities and training available for staff.
  • There was multidisciplinary work between teams and other local stakeholders. Hazardous area response teams, critical care and the air operations teams worked more closely together as ‘special operations’ to enhance the care patients received. The EPRR teams worked well and had good co-ordination with a range of other agencies including NHS Providers, other emergency services, local authorities, commercial operators, voluntary organisations and the different departments internally.
  • There was good access to information with special notes being used to provide effective outcomes for people where there were known risks or other issues.
  • The service was performing within its target for ‘hear and treat’ calls, although this was above (not as good as) the England average.
  • The proportion of Red 1 calls responded to within 8 minutes was better than the England average for 16 out of 19 months between July 2014 and January 2016.
  • From April to October 2015 the average proportion of patients with ST elevation myocardial infarction who received an appropriate care bundle was better than the national average.
  • The service provided evidence based care and treatment in line with national guidelines such as the Joint Royal Colleges Ambulance Liaison Committee and the National Institute for Health and Care Excellence.
  • The trust had developed an initiative to reduce the number of patient transfers to hospitals. There were pathways to prevent hospital transfers and staff had received additional training to enable them to treat patients at home. This had reduced the number of hospital transfers.
  • The patient transport service was achieving the targets identified in key performance indicators for commissioner satisfaction and patient satisfaction and the service was working well with local acute hospitals to provide useful information that enabled wards to plan better for patient arrivals and departures
  • Business continuity plans were developed in line with International Standardisation Organisation (ISO) standards.
  • The special operations team were supported by six air ambulances provided by five charities providing cover for the whole of the geographical area covered by SWAST.
  • Within the minor injuries unit (urgent and emergency care), pain relief was administered quickly and effectively. X-ray results were reviewed by a specialist radiology doctor within 24 hours and there was a low rate of unplanned re-attendances.
  • Clinical audits took place within the minor injuries unit and the information gained was used to improve care and treatment. The learning needs of staff were identified at six-weekly clinical supervision sessions and at annual appraisals.

Caring

  • Staff in all areas consistently demonstrated a high level of compassion, kindness and respect towards people, whether callers, patients or relatives/ carers. At all times, patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.
  • Feedback from patients and those close to them was consistently very positive. We accompanied crews on emergency and urgent calls and spoke with patients and relatives in emergency departments. Without exception, patients, relatives and other healthcare professionals told us that ambulance staff acted with care and compassion.
  • Staff were passionate about their patients’ care and wellbeing. We saw numerous examples where staff ‘went the extra mile’ to ensure their patients’ comfort and wellbeing. 
  • Staff recognised when patients required further information and support and this was provided at all times.
  • Staff made sure people had understood the information given back to them by telephone advisors. Staff asked questions in a calm approach but with empathy and clarity. Staff recognised it was hard for people calling the service to interact over a telephone line, but staff got the best information and gave the best responses they could when they were otherwise not able to see the patient. Distressed and overwhelmed callers were very well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.
  • There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP
  • Staff took time to interact with patients and were supportive to them and to their relatives/carers and treated patients with dignity and respected their privacy at all times.
  • Staff showed understanding of the challenges faced by patients and their carers.
  • Communication with children and young people was age appropriate and effective.

Responsive

  • The emergency operations service was operating a responsive ‘hear and treat’ service to ensure the best use of limited resources. Resources were used where they were most needed.
  • The trust had been commended for its service to reduce and respond to frequent callers and to reduce unnecessary admissions to emergency departments.
  • There was service planning to meet the immediate urgent and emergency care needs of local people. There was flexibility, choice and continuity of care which was reflected in the types of services we saw. Most patients had timely access to initial assessment, diagnosis or urgent treatment.
  • The ambulance response project or ARP started 19 April 2016. The expected outcome of ARP was to ensure that the most appropriate response vehicle was sent to each patient’s correct location rather than just meeting a time target by sending the nearest vehicle. Call centre staff would provide additional time to triage patients on the phone when it was clinically safe and appropriate to do so, and this helped them to decide on the best vehicle to send. The full impact of the ARP project was not known during the inspection period, as it was still in pilot phase.
  • The trust used a network of volunteer community first responders, responders such as fire co responders, doctors and others including trust staff that could supplement core ambulance resources
  • Reasonable adjustments were in place for some patients. Action was taken to remove barriers to patients with physical disability, those with reduced mobility or those who had bariatric needs who found it physically hard to use or access services. The trust also ran blue light days where people with a learning disability could familiarise themselves with ambulance vehicles, equipment and staff to understand the service better. This also enabled staff to better understand the needs of people with learning disabilities.
  • Two new Patient Transport Service bases had been opened at Weston Super Mare and Soundwell ambulance stations to meet local need. There was a ‘24/7’service which consisted of one vehicle and a crew available between 6p.m.and 6a.m. Escorts were encouraged to accompany patients living with dementia or learning disability or for patients whose first language was not English. This enabled staff to meet the patient’s individual needs
  • The resilience facilities were purpose built and located to cover the majority of the trusts operational area.
  • The trust was supported by five air ambulance charities with six aircraft providing good air ambulance coverage.
  • There was a dedicated events team who took the lead for assessing, planning and resourcing public events to minimise the effect on the trust’s normal business.
  • 99.8% of patients attending the minor injuries unit were treated, discharged or transferred within four hours in the year ending March 2016. The average time to treatment was 49 minutes. Waiting times were constantly monitored in real-time by clinical staff.
  • Complaints were handled with sensitivity and time was taken to provide a considered response within most core services. There was learning and improvements made when people complained about the service they received, though not all complaints were being responded to in the time required.

However:

  • It wasn’t easy for patients or people close to them to know how to complain or raise a concern. Staff gave a variety of responses of how patients could make a complaint describing that patients could telephone or submit their concerns online on the trust website. Not all vehicles had complaints forms or information for patients to read or take away with them.
  • There were no communication aids or hearing loops within patient transport vehicles. Staff did not use interpretation facilities when patients did not speak English as their first language. Instead they relied upon patients bringing an escort for the journey. However, staff could access the language line for translation services whilst at the ambulance base
  • The triage systems used within the emergency operations centres did not prompt staff to ask whether a person was vulnerable, such as living with dementia or a learning disability.
  • The HART teams were able to respond quickly to emergencies within their area, except within Cornwall due to the distance from Exeter.
  • Within the minor injuries unit, X-ray services were not always available when patients needed them. The x-ray department closed at 5pm during the week and was only open for four hours a day at weekends. Although patients told us they did not mind returning the next day, there was a possibility of delayed treatment.
  • Within the out of hours service, people reported finding it easy to make appointments.

Well led

  • Quality, in terms of patient outcomes and experience, did not feature highly at operations meetings, although a quarterly quality report had recently been introduced.
  • Within most areas, risks to quality and safety were well understood at a local level but were not locally recorded and accountability for managing these risks was not defined. Risk registers maintained at directorate and corporate levels did not align with the risks and worries described to us by staff and managers. We saw little evidence that the risk register was regularly discussed at service line or division or actions to mitigate risks reviewed. There were some risks on the risk register that had remained there too long without resolution. This included the poor performance in staff appraisals which had been added in 2007 and staff turnover added in 2013.
  • We were concerned about a lack of local oversight in respect of infection control. This highlighted a disconnection between different reporting lines.
  • Whilst the trust had made significant efforts to support staff wellbeing, their efforts were somewhat overshadowed by the intensity of work, due to relentless and increasing demand on the service and the pressures this placed on staff. Staff morale and motivation was mixed. Some worrying messages had emerged from the 2015 staff survey in relation to frontline ambulance staff. Staff dissatisfaction was reflected by results which showed that a significant proportion of staff felt unwell due to work related stress, felt pressurised to work despite not feeling well enough to perform duties, and had experienced musculoskeletal problems as a result of work activities. The survey also highlighted that a significant proportion of staff suffered physical violence and/or harassment, bullying or abuse from patients, their relatives or other members of the public. Local action plans had recently been developed but this was work in progress. The leadership was not aware of when the levels of professional support given to staff were failing.
  • There was a culture in which there was an unspoken expectation that staff would work longer hours than they were contracted to work. Staff told us they regularly finished their shifts late, missed their meal breaks, arrived early for work to undertake vehicle checks and undertook activities such as reading email updates and bulletins and undertaking training in their own time.
  • The intensity of work undoubtedly contributed to staff absenteeism and high levels of staff turnover. There was a variable degree of and formality in one-to-one support for staff.
  • There was a limited approach to obtaining the views of patients and staff were not engaged in this process.
  • The 2013/2014 integrated business plan included was some evidence of forward planning for service improvement in the patient transport services. However at a local level, leaders appeared demotivated to effect improvement. Staff did not feel valued by their employers or by the managers of their service where the culture was described as insensitive to the needs of staff.
  • Some aspects of governance related to safety issues were not adequately monitored within patient transport services, for example, infection control. Risk registers did not capture all known risks, including clinical risks and the governance processes did not identify a lack of incident report. Identified training needs were not acted upon.
  • There was very limited oversight of quality in the Patient Transport Service other than performance against key performance indicators. Some aspects of governance related to safety issues were unclear and were not monitored effectively.

However:

  • There was a clear vision and credible strategy for the emergency operations service. The leadership reflected the values of the service and were open, approachable and supportive. The service was innovative and looking for ways to improve and sustain.
  • There was a clear vision in place for the EPRR teams, especially special operations and where they wanted to take the service over the coming five years.
  • The governance framework had clear responsibilities. 
  • The trust had introduced the 'Staying Well' service in December 2015 in response to a year-long staff consultation and staff requests for a coordinated support system, with an emphasis on mental health. There was a peer support network introduced in April 2016 and the trust had 38 trained peer supporters. Staff could also access 'fast track' physiotherapy treatment, which was funded by the trust.
  • There was a well-publicised mission statement and a set of core values within emergency and urgent care. Whilst not all staff could articulate these, they consistently demonstrated their commitment to delivering high quality care to patients.
  • Leaders of the patient transport service had ensured that all staff were fully informed about the outcome of the tendering process. Performance of the service against the key performance indicators was monitored effectively.
  • Staff within the EPRR teams attended/chaired a wide variety of national groups and committees to lead and share best practice.
  • The trust conducted traumatic risk monitoring and the ‘staying well service’ were available to staff should they need it.
  • A dedicated events team had taken responsibility for planning, resourcing and managing SWAST attendance at public events.
  • A computer application ‘SWAST Commander’ had been developed for iPad and Android platforms to be used by operational commanders during major incidents

We saw several areas of outstanding practice including:

  • The trust was influencing service improvements at a national level, for example the ambulance response programme.
  • The Aspire programme, developed by the trust, was providing excellent opportunities for personal and career development to all staff.
  • There was, at times, outstanding professionalism and grace under pressure among the emergency medical advisors in the Bristol and Exeter emergency operation centre (clinical hub) teams. We heard staff being criticised, shouted at, called abusive names and threatened. All of this was disruptive to staff and unsettling. The staff remained calm, and handled the callers with courtesy and patience.
  • Staff in the emergency operations centres showed outstanding compassion and understanding to people in difficult and stressful situations. Staff made a genuine connection with patients and others who were scared or anxious and developed an, albeit temporary bond, with the person trying to help them. Staff would, appropriately, say “take care” and “all the best” to people, and this was often repeated back to staff by people who had appreciated their friendliness and warmth.
  • Although the emergency operation centres’ call-quality audit programme was not completed as often as required because of other priorities, and staff shortages, it had been previously commended and recognised for its quality. There was, nevertheless, an outstanding quality to the audits when they were being undertaken. This included the feedback, which was delivered with thoughtfulness, professionalism and the intention for staff to do well. There had been changes based on staff being asked how they found the process to make it more empathetic for those being examined.
  • There was an outstanding and commended programme to manage frequent callers to the service. This was helping to release the organisation’s limited resources to more appropriate situations. There was strong multidisciplinary working to support frequent callers with the service promoting the issue among the wider community and partner organisations.
  • At the time of our inspection the service had just embarked on a trial, known as the Ambulance Response Programme. This 12-week pilot aimed to improve response times to critically ill patients, making sure the best response was sent to each incident first time and with the appropriate degree of urgency. The trust was one of two ambulance services nationally participating in this trial.
  • The introduction of Right Care had resulted in 56.8% of patients, who called for an ambulance, being treated at the scene or referred to other services, rather than being conveyed to hospital emergency department.
  • Operational staff took time to interact with patients and were supportive to them and to their relatives/carers. Staff treated patients with compassion and dignity and respected their privacy at all times.
  • The range of staff support schemes provided showed a commitment to improving staff wellbeing and we received positive feedback from staff who had used these services. The introduction of a fast track physiotherapy service had resulted in a reduction in sickness absence due to musculoskeletal injury.
  • The trust had a dedicated events team to manage the assessment, planning and resourcing for public events.
  • The trust produced a newsletter called “twentyfourseven” published for members of the public with news, long-service awards for staff, notable events taken place or coming up in the trust’s area, and success stories. These newsletters were available on the trust’s website. The high-quality publication provided the public with good information about the service and its achievements.

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

Importantly, the trust must:

  • Ensure mandatory training for all staff, including safeguarding for vulnerable people, is updated and maintained in accordance with the trust’s target.
  • Ensure staff appraisals are completed each year to meet the trust’s target. The organisation must also ensure it is aware of those staff who have not had an appraisal for many years, and offer support and recognition where warranted.
  • Ensure risk registers are aligned with operational risks and that risk registered are reviewed regularly to monitor and mitigate risks
  • Ensure work intensity and fatigue is monitored and actions put in place to mitigate risks to staff
  • Ensure governance meetings at local levels contain a strong focus upon quality and safety. This will include performance reports on training, appraisals, patient outcomes, complaints and incidents relevant to the local level. Actions from addressing any shortcomings or changes must be recognised and completed. Leaders of the Patient Transport Services must ensure that staff are encouraged to report incidents and that feedback and learning from incidents is shared with the team. Incidents should be an integral part of the governance process and viewed as a positive opportunity for learning.
  • Ensure patient transport service engage in a regular programme of audit including infection control, safety of vehicles. These audits should be recorded and an agreed action plan documented and progress monitored through the governance processes.
  • Ensure accurate, contemporaneous and complete record of all treatment undertaken by Patient Transport Services staff and that across all services records are stored securely at all times to prevent unauthorised access.
  • Ensure adequate guidelines and protocols are in place to guide patient transport staff in their clinical decisions regarding adjustment of oxygen therapy.
  • Ensure a system is put into place which informs patient transport service crews of any important clinical information relating to the patients they convey, such as when a patient has diabetes.
  • Ensure that healthcare assistants who undertake initial clinical assessment of patients are assessed as competent before working independently
  • Ensure that all staff are familiar with their responsibilities in regard to the safeguarding of vulnerable adults and that robust reporting arrangements are in place.
  • Ensure partly administered controlled medicines no longer required are disposed of in accordance with the service standard operating procedures and that medicines are stored securely in the back of ambulances and cars when the crew is not present.
  • Review the management of clinical waste in ambulance stations to avoid risks to staff.
  • Ensure infection control issues identified in this report are addressed.
  • Ensure complaints are handled effectively. Information and guidance about how to complain must be available and accessible to everyone who uses the service in a language and format to meet the needs of the people using the service, for example those who were hearing or sight impaired.
  • Take action to meet locally agreed thresholds in respect of Ambulance Clinical Quality Outcomes.

In addition the trust should:

  • Ensure all staff have the time and resources to directly report incidents, and all staff recognise and respond to their duty to report them in a timely way following trust policy.
  • Make improvements to the delays in investigating and reporting on serious incidents within the period granted.
  • Be clear as to how the feedback from serious incidents is disseminated to staff in future.
  • Extend the infection control policy in the emergency operations centres so the procedures for staff around the use of hand gels were clear and consistent for all members of the teams.
  • Consider implementing occasional test or practice runs for IT system failures in the emergency operations centres when most convenient and safe to do so.
  • Continue with the work to provide commonality among the systems used within the emergency operations centres.
  • Ensure all emergency operations centres staff are aware of the need to have clinical input into the decision to stand down an ambulance from a scene.
  • Consider possible solutions for emergency operations centres staff from having outdated special notes linked to an address where the notes were no longer relevant.
  • Undertaken a staff review within the emergency operations centres to review the percentage of relief cover modelled against the increasing call volumes. Ensure staff can be released for training, holidays, special leave, and sickness, for example, without this affecting the quality of the service and pressure on remaining staff.
  • Remodel the staffing rotas to take account of the known or predictable changes in seasonal demand.
  • Ensure the major incident room in Exeter is not being used for other things preventing it being established for its purpose at immediate notice.
  • Re-focus upon the emergency operations centres call-quality audit programme to provide staff with good feedback, encourage improvement, and reward excellence.
  • Provide some relevant and useful mental-health training to all emergency operations centres staff.
  • Improve the response to stroke patients so at least 57% of patients reach a hyper acute stroke centre within 60 minutes of their call to the service.
  • Look for methods for emergency operations centres staff to spread out their continuing despatch education throughout the year and not just prior to their recertification being due.
  • Consider training or guidance for emergency operations centres staff for communicating with young children.
  • Ensure there is a formal handover period factored into the working pattern of the emergency medical dispatchers in the emergency operations centres.
  • Establish one-to-one sessions for staff and line managers to take place within the emergency operations centres on a regular basis. Ensure these are taking place and add value to the staff concerned and the organisation.
  • Ensure all staff who do not have direct access to emails or the trust’s intranet are kept up-to-date and well informed of new or updated information at all times.
  • Review how a patient’s mental health status is determined. Triage protocols do not proactively determine if the person is living with dementia or might have a learning disability.
  • Develop and nurture valuable connections between staff in the emergency operations centres in Bristol and Exeter.
  • Review security for all staff working in the emergency operations centres, when the surrounding area was largely unoccupied by other people, were able to leave the offices safely.
  • Work to develop a more positive culture within patient transport services. This includes taking action to listen to all groups of staff in a forum that is perceived to be safe and confidential, and addressing the development needs of staff in leadership positions.
  • Ensure exit interviews are conducted and take action to address concerns identified by staff within these exit interviews.
  • Ensure regular staff meetings occur within patient transport services and these are recorded for the benefit of those staff unable to attend.
  • Ensure the environment in the urgent care centre is safe for children.
  • Ensure that there is sufficient space in the waiting area and that waiting patients can be viewed by staff at all times.
  • Ensure the handheld electronic patient care record devices are fit for purpose in all areas.
  • Review the lighting for vehicles reversing onto the quay in St Agnes to ensure safety of staff and patients when reversing onto the quay to meet the boat.
  • Review the audit of the services provided on the Isles of Scilly undertaken in June 2015, to ensure actions identified have been implemented.
  • Review the provision, availability and contact ability of community first responders on the Isles of Scilly.
  • Ensure that patient transport services monitor compliance with The National Institute for Health and Care Excellence (NICE) Quality Standard QS72 Renal Replacement Therapy services for Adults.

Professor Sir Mike Richards

Chief Inspector of Hospitals

7-10, 17, 20, 22 June 2016

During a routine inspection

South Western Ambulance Service NHS Foundation Trust is one of 10 ambulance trusts in England. On March 1, 2011 the trust became the first ambulance service in the country to become a Foundation Trust, and acquired Great Western Ambulance Service in February 2013. It provides services in the following geographical area:

• Cornwall

• Isles of Scilly (IOS)

• Devon

• Dorset

• Somerset

• Wiltshire

• Gloucestershire

• The former Avon area (Bristol, Bath, North and North East Somerset and South

• Gloucestershire)

The area is made up of approximately 5.3 million people with an additional 17.5 million visitors per year and covers 10,000 square miles (around 20% of mainland England). It spans 13 Clinical Commissioning Groups and serves 18 acute trusts.

The trust employs over 4,000 mainly clinical and operational staff, including Paramedics (1,788), Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners), plus GPs and around 2,785 volunteers (including community first responders, BASICS doctors, fire co-responders and volunteer PTS drivers).

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of three emergency operation centres (EOC), where clinical advice is provided and emergency vehicles are dispatched if required. In addition, the trust also provides patient transport services, hazardous area response teams, NHS 111 services for the people of Cornwall, Devon and Dorset, urgent and emergency care at one minor injuries unit in Devon and out of hours GP services in Gloucestershire and Dorset. The service also provides clinical teams for six air ambulances.

In 2014/15 the trust responded to 867,505 emergency and urgent incidents, received 918,227 NHS 111 calls, helped 155,965 patients calling their out of hours service and completed 99,907 patient transport journeys.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We undertook our announced inspection between 6-10 June 2016 and conducted unannounced inspections on 17, 20 and 22 June 2016 and inspected the following core services:

Emergency Operations Centres

Urgent and Emergency Care

Patient Transport Services

Resilience

Emergency and Urgent Care

Out of Hours

Overall, the trust was rated as requires improvement. We rated caring as outstanding and rated responsiveness as good. Safety, effectiveness and well led was rated as requires improvement.

Our key findings were as follows:

 

Safe

  • Not all staff were reporting incidents, particularly when they were verbally abused by callers and in some areas staff did not routinely report incidents related to patient safety. Some staff felt that due to the demands on the service they did not have time to report all incidents.However, the trust had taken steps to make the reporting process more straightforward by providing a link within the electronic patient record. This allowed staff to complete incident forms without having to return to the ambulance station.
  • Feedback to staff following incident reporting did not always take place. Whilst not in all areas, some groups of staff were unable to identify learning from incidents that had occurred during the twelve months preceding our inspection.
  • Some incidents were logged and resolved but not reported on the trust wide incident reporting system. This meant that managerial oversight of the themes occurring from all incidents was not comprehensive.
  • Some areas of the service was significantly below the trust’s target for updating mandatory training. Within these services, the levels of staffing were not sufficient to provide relief at all times when staff were training, on holiday, off sick, or taking special leave.
  • Medicines systems used by staff were not always safe and trusts policies, procedures and protocols were not always followed. Within the urgent care centre, prescription pads were not monitored sufficiently in order to prevent misuse.
  • Ambulances and rapid response cars were not always secured when staff were escorting patients into emergency departments at hospitals or tending to patients at other locations. This meant that unauthorised people could access the ambulances
  • Cleanliness and control of infection was not being managed effectively. Clinical waste was not always disposed of as required. The trust was not meeting its targets for cleaning of vehicles or stations. Infection control training for staff was not meeting the trusts targets for the number of staff who had completed this.
  • Within patient transport services, there were several vehicles with ripped seat covers and one with a hole in the internal wall. These defects meant that the vehicle could not be cleaned adequately to prevent the spread of infection.
  • In patient transport services, not all staff were completing vehicle daily inspection checklists. Checklists were not reviewed effectively to enable the safety of vehicles to be assured. Only 21.3%of vehicles had been consistently deep cleaned every eight weeks or less during the twelve months preceding our inspection.
  • There was insufficient space in the urgent care centre waiting area for the number of people attending the centre.
  • Safeguarding arrangements for vulnerable adults were not sufficiently robust within the minor injuries unit.
  • Patient confidential information was not always stored securely.
  • Some staff within patient transport services provided treatment for patients but no records of these interventions were completed. These treatments included administering Entenox (nitrous oxide and oxygen gas mixture) and adjusting oxygen.
  • At the time of our inspection, emergency preparedness drills had not been completed on the patient transport boat on the Isles of Scilly. However, the emergency preparedness drills are part of the Domestic Safety Management Plan for the Star of Life that went live in June 2016. The first drill is scheduled for September 2016.
  • Within the minor injuries unit, the environment and use of facilities was not designed to ensure the safety of children. Initial clinical assessment of patients was undertaken by experienced healthcare assistants. However, they did not use an assessment framework to do this and there was no competency assessment to ensure their practice was safe. Computer errors in patient records could not be corrected. This sometimes led to an incorrect diagnosis or medicines dose remaining on patient records.

However:

  • There was a good system in place for reporting incidents, carrying out investigations, providing feedback to staff, learning and making improvements. In places the culture for incident reporting was very positive.
  • Within the majority of services there were reliable practices for safeguarding people from abuse.
  • Patients’ records were held securely on electronic systems and special notes were available to help support and protect patients and staff.
  • When calling, the risks to patients were assessed with approved triage systems. Decisions were monitored and revised by clinicians when appropriate, or risks changed.
  • There had been a good implementation of the pilot for the ambulance response programme. This triage system was being trialled by the service to assess the safety, effectiveness, and responsiveness of the service should it move away from time-target based responses to sending the right response, first time.
  • The service was able to respond to major incidents and change priorities in times of extreme pressure. There were protocols for staff to follow in high-risk situations to keep staff and the public safe.
  • The service had recognised the growth in call volumes and was responding by increasing staffing levels above establishment levels in the emergency operation centres.
  • There was a good skill-mix among the staff within emergency operations centres, and there were plans to broaden the experience in future.
  • Staff training met the national requirements set out by the National Ambulance Resilience Unit (NARU).
  • Within emergency and urgent care saw that staff regularly cleaned their hands and we observed staff cleaning their vehicles at the end of shifts. The vehicles we checked were visibly clean and equipment and vehicles were serviced in line with manufacturer’s instructions to make sure they were fit for purpose.

Effective

  • Within the emergency operation centres, staff were not being assessed for their competency and performance and the service was significantly below the trust’s target for completing these appraisals each year. Some senior staff had not had appraisals for a number of years, but the organisation was not aware of this, and not addressing it. This issue had been on the trust’s risk register for over nine years.
  • The rate of annual performance appraisals within emergency and urgent care was variable ranging from 38.4% for specialist paramedics to 87.7% for paramedics. This was below the trust target of 90%. The quality of the appraisals was also variable.
  • Staff in patient transport services did not participate in the learning development review process and compliance with appraisals was low
  • Due to other training priorities, there had been a reduction in the number of calls audited for their quality and safety. The emergency operation centres had not been able, therefore, to determine if the handling of incoming calls was effective at all times. However, we recognised this was being addressed, and improving.
  • The service was struggling with rising call volumes and this had resulted in more calls being abandoned.
  • Response times for most categories were consistently below the England average. The proportion of Red 2 calls responded to within 8 minutes was worse than the England average from April 2015 to January 2016. The trust had not met the national target of 75% since October 2014. From May 2015 the data provided showed a steady decline in performance.
  • From February 2015 to January 2016 the proportion of A19 calls responded to within 19 minutes was mainly worse than the England average. The national standard of 95% was not met for 10 of these 12 months.
  • From April to October 2015 the average proportion of patients who received angioplasty (unblocking of a coronary artery) following ST segment elevation myocardial infarction within 150 minutes was worse than the national average.
  • The average proportion of patients assessed face to face who received an appropriate stroke or transient ischaemic attack care bundle in April to October 2015 was worse than the national average.
  • Not all staff were competent in providing treatment and care to patients with mental health issues.
  • Within patient transport services, competencies of intermediate care assistants to administer Entenox (nitrous oxide and oxygen gas mixture) and perform cardiac monitoring had not been refreshed. Standard operating procedures were not accessible to staff when they were out and about transporting patients. Staff were not informed when patients were diabetic and this meant that staff did not have access to important information that may be needed by emergency crews attending to assist. The process of gaining consent was not recorded.

However:

  • There were evidence-based systems to provide assessment and advice for patients. The emergency operations centre teams were using national guidelines and following best practice protocols to assess people’s needs and provide the right service.
  • Staff had the skills and knowledge to deliver effective advice and guidance. There were internal and external development opportunities and training available for staff.
  • There was multidisciplinary work between teams and other local stakeholders. Hazardous area response teams, critical care and the air operations teams worked more closely together as ‘special operations’ to enhance the care patients received. The EPRR teams worked well and had good co-ordination with a range of other agencies including NHS Providers, other emergency services, local authorities, commercial operators, voluntary organisations and the different departments internally.
  • There was good access to information with special notes being used to provide effective outcomes for people where there were known risks or other issues.
  • The service was performing within its target for ‘hear and treat’ calls, although this was above (not as good as) the England average.
  • The proportion of Red 1 calls responded to within 8 minutes was better than the England average for 16 out of 19 months between July 2014 and January 2016.
  • From April to October 2015 the average proportion of patients with ST elevation myocardial infarction who received an appropriate care bundle was better than the national average.
  • The service provided evidence based care and treatment in line with national guidelines such as the Joint Royal Colleges Ambulance Liaison Committee and the National Institute for Health and Care Excellence.
  • The trust had developed an initiative to reduce the number of patient transfers to hospitals. There were pathways to prevent hospital transfers and staff had received additional training to enable them to treat patients at home. This had reduced the number of hospital transfers.
  • The patient transport service was achieving the targets identified in key performance indicators for commissioner satisfaction and patient satisfaction and the service was working well with local acute hospitals to provide useful information that enabled wards to plan better for patient arrivals and departures
  • Business continuity plans were developed in line with International Standardisation Organisation (ISO) standards.
  • The special operations team were supported by six air ambulances provided by five charities providing cover for the whole of the geographical area covered by SWAST.
  • Within the minor injuries unit (urgent and emergency care), pain relief was administered quickly and effectively. X-ray results were reviewed by a specialist radiology doctor within 24 hours and there was a low rate of unplanned re-attendances.
  • Clinical audits took place within the minor injuries unit and the information gained was used to improve care and treatment. The learning needs of staff were identified at six-weekly clinical supervision sessions and at annual appraisals.

Caring

  • Staff in all areas consistently demonstrated a high level of compassion, kindness and respect towards people, whether callers, patients or relatives/ carers. At all times patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.
  • Feedback from patients and those close to them was consistently very positive. We accompanied crews on emergency and urgent calls and spoke with patients and relatives in emergency departments. Without exception, patients, relatives and other healthcare professionals told us that ambulance staff acted with care and compassion.
  • Staff were passionate about their patients’ care and wellbeing. We saw numerous examples where staff ‘went the extra mile’ to ensure their patients’ comfort and wellbeing.
  • Staff recognised when patients required further information and support and this was provided at all times.
  • Staff made sure people had understood the information given back to them by telephone advisors. Staff asked questions in a calm approach but with empathy and clarity. Staff recognised it was hard for people calling the service to interact over a telephone line, but staff got the best information and gave the best responses they could when they were otherwise not able to see the patient. Distressed and overwhelmed callers were well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.
  • There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP
  • Staff took time to interact with patients and were supportive to them and to their relatives/carers and treated patients with dignity and respected their privacy at all times.
  • Staff showed understanding of the challenges faced by patients and their carers
  • Communication with children and young people was age appropriate and effective.

 

Responsive

  • The emergency operations service was operating a responsive ‘hear and treat’ service to ensure the best use of limited resources. Resources were used where they were most needed.
  • The trust had been commended for its service to reduce and respond to frequent callers and to reduce unnecessary admissions to emergency departments
  • There was service planning to meet the immediate urgent and emergency care needs of local people. There was flexibility, choice and continuity of care which was reflected in the types of services we saw. Most patients had timely access to initial assessment, diagnosis or urgent treatment.
  • The ambulance response project or ARP started 19 April 2016. The expected outcome of ARP was to ensure that the most appropriate response vehicle was sent to each patient’s correct location rather than just meeting a time target by sending the nearest vehicle. Call centre staff would provide additional time to triage patients on the phone when it was clinically safe and appropriate to do so, and this helped them to decide on the best vehicle to send. The full impact of the ARP project was not known during the inspection period, as it was still in pilot phase.
  • The trust used a network of volunteer community first responders, responders such as fire co responders, doctors and others including trust staff that could supplement core ambulance resources
  • Reasonable adjustments were in place for some patients. Action was taken to remove barriers to patients with physical disability, those with reduced mobility or those who had bariatric needs who found it physically hard to use or access services. The trust also ran blue light days where people with a learning disability could familiarise themselves with ambulance vehicles, equipment and staff to understand the service better. This also enabled staff to better understand the needs of people with learning disabilities.
  • Two new Patient Transport Service bases had been opened at Weston Super Mare and Soundwell ambulance stations to meet local need. There was a ‘24/7’service which consisted of one vehicle and a crew available between 6p.m.and 6a.m. Escorts were encouraged to accompany patients living with dementia or learning disability or for patients whose first language was not English. This enabled staff to meet the patient’s individual needs
  • The resilience facilities were purpose built and located to cover the majority of the SWAST operational area.
  • SWAST was supported by five air ambulance charities with six aircraft providing good air ambulance coverage.
  • The events team took the lead for assessing, planning and resourcing public events to minimise the effect on the trust’s normal business.
  • 99.8% of patients attending the minor injuries unit were treated, discharged or transferred within four hours in the year ending March 2016. The average time to treatment was 49 minutes. Waiting times were constantly monitored in real-time by clinical staff.
  • Complaints were handled with sensitivity and time was taken to provide a considered response within most core services. There was learning and improvements made when people complained about the service they received, though not all complaints were being responded to in the time required.

However:

  • It wasn’t easy for patients or people close to them to know how to complain or raise a concern. Staff gave a variety of responses of how patients could make a complaint describing that patients could telephone or submit their concerns online on the trust website. Not all vehicles had complaints forms or information for patients to read or take away with them.
  • There were no communication aids or hearing loops within patient transport vehicles. Staff did not use interpretation facilities when patients did not speak English as their first language. Instead they relied upon patients bringing an escort for the journey. However, staff could access the language line for translation services whilst at the ambulance base.
  • The triage systems used within the emergency operations centres did not prompt staff to ask whether a person was vulnerable, such as living with dementia or a learning disability.
  • The HART teams were able to respond quickly to emergencies within their area, except within Cornwall due to the distance from Exeter.
  • Within the minor injuries unit, X-ray services were not always available when patients needed them. The x-ray department closed at 5pm during the week and was only open for four hours a day at weekends. Although patients told us they did not mind returning the next day, there was a possibility of delayed treatment.

 

Well led

  • Quality, in terms of patient outcomes and experience, did not feature highly at operations meetings, although a quarterly quality report had recently been introduced.
  • Within most areas, risks to quality and safety were well understood at a local level but were not locally recorded and accountability for managing these risks was not defined. Risk registers maintained at directorate and corporate levels did not align with the risks and worries described to us by staff and managers. We saw little evidence that the risk register was regularly discussed at service line or division or actions to mitigate risks reviewed. There were some risks on the risk register that had remained there too long without resolution. This included the poor performance in staff appraisals which had been added in 2007 and staff turnover added in 2013.
  • We were concerned about a lack of local oversight in respect of infection control. This highlighted a disconnection between different reporting lines.
  • Whilst the trust had made significant efforts to support staff wellbeing, their efforts were somewhat overshadowed by the intensity of work, due to relentless and increasing demand on the service and the pressures this placed on staff. Staff morale and motivation was mixed. Some worrying messages had emerged from the 2015 staff survey in relation to frontline ambulance staff. Staff dissatisfaction was reflected by results which showed that a significant proportion of staff felt unwell due to work related stress, felt pressurised to work despite not feeling well enough to perform duties, and had experienced musculoskeletal problems as a result of work activities. The survey also highlighted that a significant proportion of staff suffered physical violence and/or harassment, bullying or abuse from patients, their relatives or other members of the public. Local action plans had recently been developed but this was work in progress. The leadership was not aware of when the levels of professional support given to staff were failing.
  • There was a culture in which there was an unspoken expectation that staff would work longer hours than they were contracted to work. Staff told us they regularly finished their shifts late, missed their meal breaks, arrived early for work to undertake vehicle checks and undertook activities such as reading email updates and bulletins and undertaking training in their own time.
  • The intensity of work undoubtedly contributed to staff absenteeism and high levels of staff turnover. There was a variable degree of and formality in one-to-one support for staff.
  • There was a limited approach to obtaining the views of patients and staff were not engaged in this process.
  • The 2013/2014 integrated business plan included was some evidence of forward planning for service improvement in the patient transport service. However at a local level, leaders appeared demotivated to effect improvement.. As a result there was no forward vision of service improvement at a local level. Staff did not feel valued by their employers or by the managers of their service where the culture was described as insensitive to the needs of staff.
  • Some aspects of governance related to safety issues were not adequately monitored within patient transport services, for example, infection control. Risk registers did not capture all known risks, including clinical risks and the governance processes did not identify a lack of incident report. Identified training needs were not acted upon.
  • There was very limited oversight of quality in the Patient Transport Service other than performance against key performance indicators. Some aspects of governance related to safety issues were unclear and were not monitored effectively.

However:

  • There was a clear vision and credible strategy for the emergency operations service. The leadership reflected the values of the service and were open, approachable and supportive. The service was innovative and looking for ways to improve and sustain.
  • There was a clear vision in place for the EPRR teams, especially special operations and where they wanted to take the service over the coming five years.
  • The governance framework had clear responsibilities.
  • The trust had introduced the 'Staying Well' service in December 2015 in response to a year-long staff consultation and staff requests for a coordinated support system, with an emphasis on mental health. There was a peer support network introduced in April 2016 and the trust had 38 trained peer supporters. Staff could also access 'fast track' physiotherapy treatment, which was funded by the trust.
  • There was a well-publicised mission statement and a set of core values within emergency and urgent care. Whilst not all staff could articulate these, they consistently demonstrated their commitment to delivering high quality care to patients.
  • Leaders of the patient transport service had ensured that all staff were fully informed about the outcome of the tendering process. Performance of the service against the key performance indicators was monitored effectively.
  • Staff within the EPRR teams attended/chaired a wide variety of national groups and committees to lead and share best practice.
  • The trust conducted traumatic risk monitoring and the ‘staying well service’ were available to staff should they need it.
  • A dedicated events team had taken responsibility for planning, resourcing and managing SWAST attendance at public events.
  • A computer application ‘SWAST Commander’ had been developed for iPad and Android platforms to be used by operational commanders during major incidents

 

We saw several areas of outstanding practice including:

  • The trust was influencing service improvements at a national level, for example the ambulance response programme.
  • The Aspire programme, developed by the trust, was providing excellent opportunities for personal and career development to all staff.
  • At times, outstanding professionalism and grace under pressure among the emergency medical advisors in the Bristol and Exeter emergency operation centre (clinical hub) teams. We heard staff being criticised, shouted at, called abusive names and threatened. All of this was disruptive to staff and unsettling. The staff remained calm, and handled the callers with courtesy and patience.
  • Staff in the emergency operations centres showed outstanding compassion and understanding to people in difficult and stressful situations. Staff made a genuine connection with patients and others who were scared or anxious and developed an, albeit temporary bond, with the person trying to help them. Staff would, appropriately, say “take care” and “all the best” to people, and this was often repeated back to staff by people who had appreciated their friendliness and warmth.
  • Although the emergency operation centres’ call-quality audit programme was not completed as often as required because of other priorities, and staff shortages, it had been previously commended and recognised for its quality. There was, nevertheless, an outstanding quality to the audits when they were being undertaken. This included the feedback, which was delivered with thoughtfulness, professionalism and the intention for staff to do well. There had been changes based on staff being asked how they found the process to make it more empathetic for those being examined.
  • There was an outstanding and commended programme to manage frequent callers to the service. This was helping to release the organisation’s limited resources to more appropriate situations. There was strong multidisciplinary working to support frequent callers with the service promoting the issue among the wider community and partner organisations.
  • At the time of our inspection the service had just embarked on a trial, known as the Ambulance Response Programme. This 12-week pilot aimed to improve response times to critically ill patients, making sure the best response was sent to each incident first time and with the appropriate degree of urgency. The trust was one of two ambulance services nationally participating in this trial.
  • The introduction of Right Care had resulted in 56.8% of patients, who called for an ambulance, being treated at the scene or referred to other services, rather than being conveyed to hospital emergency department.
  • Operational staff took time to interact with patients and were supportive to them and to their relatives/carers. Staff treated patients with compassion and dignity and respected their privacy at all times.
  • The range of staff support schemes provided showed a commitment to improving staff wellbeing and we received positive feedback from staff who had used these services. The introduction of a fast track physiotherapy service had resulted in a reduction in sickness absence due to musculoskeletal injury.  
  • The trust had a dedicated events team to manage the assessment, planning and resourcing for public events.
  • The trust produced a newsletter called “twentyfourseven” published for members of the public with news, long-service awards for staff, notable events taken place or coming up in the trust’s area, and success stories. These newsletters were available on the trust’s website. The high-quality publication provided the public with good information about the service and its achievements. 

 

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

Importantly, the trust must:

  • Ensure mandatory training for all staff, including safeguarding for vulnerable people, is updated and maintained in accordance with the trust’s target.
  • Ensure staff appraisals are completed each year to meet the trust’s target. The organisation must also ensure it is aware of those staff who have not had an appraisal for many years, and offer support and recognition where warranted.
  • Ensure risk registers are aligned with operational risks and that risk registered are reviewed regularly to monitor and mitigate risks
  • Ensure work intensity and fatigue is monitored and actions put in place to mitigate risks to staff
  • Ensure governance meetings at local levels contain a strong focus upon quality and safety. This will include performance reports on training, appraisals, patient outcomes, complaints and incidents relevant to the local level. Actions from addressing any shortcomings or changes must be recognised and completed. Leaders of the Patient Transport Services must ensure that staff are encouraged to report incidents and that feedback and learning from incidents is shared with the team. Incidents should be an integral part of the governance process and viewed as a positive opportunity for learning.
  • Ensure patient transport service engage in a regular programme of audit including infection control, safety of vehicles. These audits should be recorded and an agreed action plan documented and progress monitored through the governance processes.
  • Ensure accurate, contemporaneous and complete record of all treatment undertaken by Patient Transport Services staff and that across all services records are stored securely at all times to prevent unauthorised access.
  • Ensure adequate guidelines and protocols are in place to guide staff in their clinical decisions regarding adjustment of oxygen therapy.
  • Ensure a system is put into place which informs patient transport service crews of any important clinical information relating to the patients they convey, such as when a patient has diabetes.
  • Ensure that healthcare assistants who undertake initial clinical assessment of patients are assessed as competent before working independently
  • Ensure that all staff are familiar with their responsibilities in regard to the safeguarding of vulnerable adults and that robust reporting arrangements are in place.
  • Ensure partly administered controlled medicines no longer required are disposed of in accordance with the service standard operating procedures and that medicines are stored securely in the back of ambulances and cars when the crew is not present.
  • Review the management of clinical waste in ambulance stations to avoid risks to staff.
  • Ensure infection control issues identified in this report are addressed.
  • Ensure complaints are handled effectively. Information and guidance about how to complain must be available and accessible to everyone who uses the service in a language and format to meet the needs of the people using the service, for example those who were hearing or sight impaired.
  • Take action to meet locally agreed thresholds in respect of Ambulance Clinical Quality Outcomes.

 

In addition the trust should:

  • Ensure all staff have the time and resources to directly report incidents, and all staff recognise and respond to their duty to report them in a timely way following trust policy.
  • Make improvements to the delays in investigating and reporting on serious incidents within the period granted.
  • Be clear as to how the feedback from serious incidents is disseminated to staff in future.
  • Extend the infection control policy in the emergency operations centres so the procedures for staff around the use of hand gels were clear and consistent for all members of the teams.
  • Consider implementing occasional test or practice runs for IT system failures in the emergency operations centres when most convenient and safe to do so.
  • Continue with the work to provide commonality among the systems used within the emergency operations centres.
  • Ensure all emergency operations centres staff are aware of the need to have clinical input into the decision to stand down an ambulance from a scene.
  • Consider possible solutions for emergency operations centres staff from having outdated special notes linked to an address where the notes were no longer relevant.
  • Undertaken a staff review within the emergency operations centres to review the percentage of relief cover modelled against the increasing call volumes. Ensure staff can be released for training, holidays, special leave, and sickness, for example, without this affecting the quality of the service and pressure on remaining staff.
  • Remodel the staffing rotas to take account of the known or predictable changes in seasonal demand.
  • Ensure the major incident room in Exeter is not being used for other things preventing it being established for its purpose at immediate notice.
  • Re-focus upon the emergency operations centres call-quality audit programme to provide staff with good feedback, encourage improvement, and reward excellence.
  • Provide some relevant and useful mental-health training to all emergency operations centres staff.
  • Improve the response to stroke patients so at least 57% of patients reach a hyper acute stroke centre within 60 minutes of their call to the service.
  • Look for methods for emergency operations centres staff to spread out their continuing despatch education throughout the year and not just prior to their recertification being due.
  • Consider specific training or guidance for emergency operations centres staff for communicating with young children.
  • Ensure there is a formal handover period factored into the working pattern of the emergency medical dispatchers in the emergency operations centres.
  • Establish one-to-one sessions for staff and line managers to take place within the emergency operations centres on a regular basis. Ensure these are taking place and add value to the staff concerned and the organisation.
  • Ensure all staff who do not have direct access to emails or the trust’s intranet are kept up-to-date and well informed of new or updated information at all times.
  • Review how a patient’s mental health status is determined. Triage protocols do not proactively determine if the person is living with dementia or might have a learning disability.
  • Develop and nurture valuable connections between staff in the emergency operations centres in Bristol and Exeter.
  • Review security for all staff working in the emergency operations centres, when the surrounding area was largely unoccupied by other people, were able to leave the offices safely.
  • Work to develop a more positive culture within patient transport services. This includes taking action to listen to all groups of staff in a forum that is perceived to be safe and confidential, and addressing the development needs of staff in leadership positions.
  • Ensure exit interviews are conducted and take action to address concerns identified by staff within these exit interviews.
  • Ensure regular staff meetings occur within patient transport services and these are recorded for the benefit of those staff unable to attend.
  • Ensure the environment in the urgent care centre is safe for children.
  • Ensure that there is sufficient space in the waiting area and that waiting patients can be viewed by staff at all times.
  • Review the lighting for vehicles reversing onto the quay in St Agnes to ensure safety of staff and patients when reversing onto the quay to meet the boat.
  • Review the audit of the services provided on the Isles of Scilly undertaken in June 2015, to ensure actions identified have been implemented.
  • Review the provision, availability and contact ability of community first responders on the Isles of Scilly.
  • Ensure that patient transport services monitor compliance with The National Institute for Health and Care Excellence (NICE) Quality Standard QS72 Renal Replacement Therapy services for Adults.
  • Ensure the handheld electronic patient care record devices are fit for purpose in all areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals