g4s health services (uk) limited g4spatienttransport ... · g4s health services (uk) limited...

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, other information known to CQC and information given to us from patients, the public andother organisations.

Ratings

Overall rating for thisambulance location Requires improvement –––

Patient transport services (PTS) Requires improvement –––

G4S Health Services (UK) Limited

G4SG4S PPatientatient TTrransportansportSerServicviceses -- KentKent && MedwMedwayayQuality Report

Brown Europe HouseGleaming Wood DriveChathamKent ME5 8RZTel: 07720 490 996Website: www.g4s.com

Date of inspection visit: 24 April 2019Date of publication: 02/07/2019

1 G4S Patient Transport Services - Kent & Medway Quality Report 02/07/2019

Letter from the Chief Inspector of Hospitals

NHS non-emergency patient transport services help people access healthcare in England. They are free at the point ofuse for patients who meet certain medical criteria and are unable to use public or other means of transport.

In Kent the patient transport service is managed by a lead clinical commissioning group. To help meet demand fortransport requests, the group subcontracts to independent providers such as G4S.

G4S Patient Transport Services - Kent & Medway was operated by G4S Health Services (UK) Limited.

We inspected this service using our comprehensive inspection methodology. We carried out an unannouncedinspection on 24 April 2019, along with staff telephone interviews on 25 April 2019.

This was the service’s first inspection since registration.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

We rated it as Requires improvement overall because:

• Some staff did not understand when they could raise a safeguarding concern without the consent of the individual.

• At Gillingham depot the premises needed cleaning. The vehicle park, vehicle “make-ready” area and bulk storagefacilities were insufficient for an operation of this size and complexity. Some aspects were not fit for purpose.

• We observed the unsafe use of an electrical cable by a contractor in the vehicle park. However, this was correctedby managers as soon as we raised our concern.

• Appraisal rates for some staff groups did not meet their target of 85%. However, managers and ambulance careassistants were meeting this target.

• We found that staff followed the service’s procedure for staff to report incidents relating to abuse of risk of abusebut that five incidents that should have been reported to CQC were not. Also, the services procedure did not helpstaff identify when incidents should be reported to CQC.

• Some staff did not feel supported by their managers and felt they could not speak about their complaints.

However,

• The service had high compliance rates for staff mandatory training and had met most of their targets.

• The service had clear processes and systems to help keep vehicles and equipment ready for use. This includedyearly MOTs, regular servicing and maintenance.

• Vehicle interiors were visibly clean, and we saw they were deep-cleaned every eight weeks or sooner if needed.

• Staff demonstrated clear understanding of their daily duties about cleanliness and infection prevention and controlin line with the provider’s infection prevention and control policy. The service was piloting a portable computersystem which significantly improved the way in which vehicle preparation checks and post-use cleaning wasmonitored. This system provided an excellent level of assurance and was due to be cascaded to all depots.

• Staff demonstrated a willingness to report incidents and raise concerns. Staff received feedback and any relevantextra training to ensure the service learned from incidents to improve patient safety.

Summary of findings


• All staff had undertaken in-house induction and mandatory training in key areas to provide them with theknowledge and skills they needed to do their jobs safely.

• The service had up to date policies and guidance to support staff.

• Staff treated patients with compassion. One patient told us crews went above and beyond to ensure their safetyand wellbeing.

• The service acted to meet patients’ individual needs. This included patients for whom English was not a firstlanguage.

• The service met the needs of children that travelled with them. Staff ensured that children had their favourite toyfor comfort before they started on their journey.

• The service had company wide and local risk registers that assessed, reviewed, and mitigated risks.

• The leadership looked for innovation and improvements.

• Most managers supported their staff.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (South East), on behalf of the Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Patienttransportservices(PTS)

Requires improvement ––– We rated this core service as Requiresimprovement overall because:

• Some staff did not understand when they couldraise a safeguarding concern without theconsent of the individual.

• At Gillingham depot the premises neededcleaning. The vehicle park, vehicle“make-ready” area and bulk storage facilitieswere insufficient for an operation of this sizeand complexity. Some aspects were not fit forpurpose.

• We observed the unsafe use of an electricalcable by a contractor in the vehicle park.However, this was corrected by managers assoon as we raised our concern.

• Appraisal rates for some staff groups did notmeet their target of 85%. However, managersand ambulance care assistants were meetingthis target.

• We found that staff followed the service’sprocedure for staff to report incidents relatingto abuse of risk of abuse but that five incidentsthat should have been reported to CQC werenot. Also, the services procedure did not helpstaff identify when incidents should be reportedto CQC.

• Some staff did not feel supported by theirmanagers and felt they could not speak abouttheir complaints.

However, we also found the following areas of goodpractice:

• The service had high compliance rates for staffmandatory training and had met most of theirtargets.

• The service had clear processes and systems tohelp keep vehicles and equipment ready foruse. This included yearly MOTs, regular servicingand maintenance.

Summaryoffindings

Summary of findings


• Vehicle interiors were visibly clean, and we sawthey were deep-cleaned every eight weeks orsooner if needed.

• Staff demonstrated clear understanding of theirdaily duties about cleanliness and infectionprevention and control in line with theprovider’s infection prevention and controlpolicy. The service was piloting a portablecomputer system which significantly improvedthe way in which vehicle preparation checksand post-use cleaning was monitored. Thissystem provided an excellent level of assuranceand was due to be cascaded to all depots.

• Staff demonstrated a willingness to reportincidents and raise concerns. Staff receivedfeedback and any relevant extra training toensure the service learned from incidents toimprove patient safety.

• All staff had undertaken in-house induction andmandatory training in key areas to provide themwith the knowledge and skills they needed to dotheir jobs safely.

• The service had up to date policies andguidance to support staff.

• Staff treated patients with compassion. Onepatient told us crews went above and beyond toensure their safety and wellbeing.

• The service acted to meet patients’ individualneeds. This included patients for whom Englishwas not a first language.

• The service met the needs of children thattravelled with them. Staff ensured that childrenhad their favourite toy for comfort before theystarted on their journey.

• The service had company wide and local riskregisters that assessed, reviewed, and mitigatedrisks.

• The leadership looked for innovation andimprovements.


Summaryoffindings

Summary of findings


G4SG4S PPatientatient TTrransportansportSerServicviceses -- KentKent && MedwMedwayay

Detailed findings

Services we looked atPatient transport services (PTS)


Contents

PageDetailed findings from this inspectionBackground to G4S Patient Transport Services - Kent & Medway 7

Our inspection team 7

How we carried out this inspection 7

Facts and data about G4S Patient Transport Services - Kent & Medway 8

Our ratings for this service 8

Action we have told the provider to take 31

Background to G4S Patient Transport Services - Kent & Medway

G4S Patient Transport Services - Kent & Medway wasoperated by G4S Health Services (UK) Limited. Theservice opened in 2018 and was an independentambulance service based in Chatham, Kent.

This service was contracted by the clinical commissioninggroups of Kent, Medway, Bexley and Bromley to helppeople access healthcare in their respective areas. Theprovider employed 453 staff and had 200 vehiclesoperating from seven depots in; Tonbridge, Margate,Maidstone, Gillingham, Dartford, Canterbury, and

Ashford. They offered transport services for peopleattending outpatient appointments and renal dialysisclinics as well as admissions or discharges from hospitalsand inter-hospital transfers. The service transportedadults and children of any age as long as they did notneed an incubator to travel.

The service has had a registered manager in post since2018.

We had not inspected this service before.

Our inspection team

The team that inspected the service comprised a CQClead inspector; three CQC inspectors, one assistantinspector and two specialist advisors with experience inpatient transport services.

The inspection team was overseen by CatherineCampbell, Head of Hospital Inspection (South East).

How we carried out this inspection

During the inspection we visited three sites andaccompanied three crews on duty. We observedhandovers and care provided, checked vehicles andequipment and spoke with patients and relatives. Eightvehicles of differing makes’ and models were inspected.We looked at six patients records.

We spoke with 30 staff in various roles including seniormanagers, depot managers and ambulance care

assistants along with administrative and cleaning staff.We looked at policies and procedures, staff training andappraisal records along with meeting notes, auditreports, the environment and equipment used.

We also received feedback from four staff fromstakeholder hospitals and clinics. We spoke to ninepatients that had travelled with the service.

Detailed findings


Facts and data about G4S Patient Transport Services - Kent & Medway

The service was registered with the CQC to provide theregulated activity of transport services, triage andmedical advice provided remotely.

The service had 200 vehicles at the time of thisinspection; this was a mix of cars and ambulances thatwere either adapted for patient transport or designed forthis purpose.

The service was organised locally from an office locationin Chatham, Kent. They also had a head office in Londonthat organised companywide issues. The service had acall centre in Wath upon Dearne. They also had a callcentre in Chelmsford that handled calls at busy periods.Also based at their Chelmsford site was their head ofoperations, safeguarding line, incident management,business intelligence, and complaints management. Theservice had logistics specialists in their Chelmsford officethat organised out of area journeys.

There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection.

Activity

• In the reporting period from March 2018 to February2019 there were 331,670 patient transport journeysundertaken.

• 409 ambulance care assistants were employed by theservice, which also had a bank of temporary staff thatit could use.

• The service did not use controlled drugs.

Track record on safety

• No never events in the reporting period from March2018 to February 2019

• 103 incident reports in the past year, of which 10 wererated as severe incidents, 33 moderate incidents and51 mild incidents.

• Three serious injuries were reported, and six incidentsrelated to deaths occurring during transport. Thesedeaths were related to either patients that had died intheir homes which were found when the crew arrivedor patients receiving end of life care.

• The service had received 892 complaints in the past 12months.

Our ratings for this service

Our ratings for this service are:

Safe Effective Caring Responsive Well-led Overall

Patient transportservices

Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Overall Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Detailed findings


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceThe only service provided by this ambulance service waspatient transport services.

The service was registered with the CQC to provide theregulated activity of transport services, triage and medicaladvice provided remotely.

The service had 200 vehicles at the time of this inspectionthis was a mix of cars and ambulances that were eitheradapted for patient transport or designed for this purpose.

In the reporting period from March 2018 to February 2019there were 331,670 patient transport journeys undertaken.There were 409 ambulance care assistants employed bythe service. There was also a bank of temporary staff thatwere used.

The service was organised locally from an office location inChatham, Kent. They also had a head office in London thatorganises companywide issues. The service had a callcentre in Wath upon Dearne. They also had a call centre inChelmsford that handled calls at busy periods. Also basedat their Chelmsford site was their head of operations,safeguarding line, incident management, businessintelligence, and complaints management. The service hadlogistics specialists in their Chelmsford office thatorganised out of area journeys.

Summary of findingsWe found the following areas of good practice:

• The service had high compliance rates for staffmandatory training and had met most of theirtargets.

• Staff showed a willingness to report incidents andraise concerns. Staff received feedback and anyrelevant extra training to ensure the service learnedfrom incidents to improve patient safety.

• Crews had identified and provided detailed reportsof safeguarding concerns.

• Vehicle interiors were visibly clean, and we saw theywere deep-cleaned every eight weeks or sooner ifneeded.

• Staff demonstrated clear understanding of their dailyduties about cleanliness and infection preventionand control in line with the provider’s infectionprevention and control policy. The service waspiloting a portable computer system whichsignificantly improved the way in which vehiclepreparation checks and post use cleaning wasmonitored. This system provided an excellent level ofassurance and was due to be cascaded to all depots.

• The service had clear processes and systems to helpkeep vehicles and equipment ready for use. Thisincluded yearly MOTs, regular servicing andmaintenance.

Patienttransportservices

Patient transport services (PTS)


• All staff had undertaken in-house induction andmandatory training in key areas to provide them withthe knowledge and skills they needed to do their jobssafely.

• The service had up to date policies and guidance tosupport staff.

• Staff treated patients with compassion. One patienttold us “crews went above and beyond to ensuretheir safety and wellbeing.”

• The service acted to meet patients’ individual needs.This included patients for whom English was not afirst language.

• The service met the needs of children that travelledwith them. Staff ensured that children had theirfavourite toy for comfort before they started on theirjourney.

• The service had company wide and local riskregisters that were used to assess, review, andmitigate risks.

• The leadership looked for innovation andimprovements.


However, we found the following issues that the serviceprovider needs to improve:

• At Gillingham depot the premises were dirty. Thevehicle park, vehicle “make-ready” area and bulkstorage facilities were insufficient for an operation ofthis size and complexity. Some aspects were not fitfor purpose.

• We observed the unsafe use of an electrical cable bya contractor in the vehicle park. However, this wasdealt with by managers as soon as we raised ourconcern.

• Some staff did not understand when they could raisea safeguarding concern without the consent of anindividual.

• Appraisal rates for some staff groups did not meettheir target of 85%. However, managers andambulance care assistants were meeting this target.

• We found that staff followed the service’s procedurefor staff to report incidents relating to abuse of risk ofabuse but that five incidents that should have beenreported to CQC were not. Also, the servicesprocedure did not help staff identify when incidentsshould be reported to CQC.




Are patient transport services safe?

Requires improvement –––

We had not inspected this service before and therefore hasnot been rated before. We rated it as requiresimprovement because we found that staff did not allunderstand when they could raise a safeguarding concernwithout consent. Also, there were not suitable areas tomake vehicles ready at the Gillingham site. However, theservice met 15 out of 20 of their targets for mandatorytraining rates.

Incidents

• The service managed patient safety incidents well.Staff recognised incidents and reported them.Managers investigated incidents and sharedlessons learned with the whole team and the widerservice. When things went wrong, staff apologisedand gave patients honest information and suitablesupport.

• The service recorded incidents in four categories whichwere; death, severe, moderate and mild. Incidentsreported in the past 12 months included; six deathincidents, 10 severe incidents, 33 moderate incidentsand 51 mild incidents. Serious incidents are adverseevents, where the consequences to patients, familiesand carers, staff or organisations are so significant or thepotential for learning is so great, that a heightened levelof response is justified

• The service reported no never events. Never events areserious patient safety incidents that should not happenif healthcare providers follow national guidance on howto prevent them. Never events relevant to patienttransport services include chest or neck entrapment introlley (or bedside) rails.

• We reviewed the service’s guidance for reporting andinvestigating incidents. This was clear on what wouldqualify for each of the above categories with examplesto help staff categorise incidents correctly.

• Staff knew how to report safety incidents. We spoke with11 staff that all knew how to report incidents. Some staff

were using an intranet tool to report incidents andothers used paper forms that were then transferred tothe intranet system. This then triggered the incidentinvestigation process.

• The service had systems to investigate incidents thatkept people safe. We reviewed the route cause analysisfor five different incidents. These contained an incidentoverview, timeline of events, interviews with staff orstatements from staff, immediate actions taken, followup actions, consideration for duty of candour,involvement of the patient and/or relatives, and actionplans. These also showed that there had beenconsideration of what investigation methodology wasused for the incident.

• Staff were involved in the investigation of incidents. Wesaw interview records in investigations performed togain understanding from staff that were involved inincidents. These records clearly showed that staff werereassured that the purpose of the investigation was toimprove the service and not to blame staff.

• The service shared lessons learnt from incidents. Wereviewed four lessons learnt leaflets that were thendisplayed in depots for staff to view. These included anoverview of the incident, any learning outcomes, andextracts from related policies to serve as a reminder tostaff.

• The service had systems to feedback learning fromincidents to staff although this may not always havebeen effective. We saw posters in the depots thatidentified learning from incidents. Managers told us thatthe incident reporter would also receive feedback aboutlearning from the incident. Three staff we spoke withtold us that they had seen the lessons learnt posters.However, four staff we spoke with about incidentreporting said that they had not received feedback.

• The service investigated incidents and applied duty ofcandour in line with their policy. The service had an upto date policy about duty of candour. We reviewed threeduty of candour incidents which were handled in linewith their policy. The service provided e-learning for allstaff on duty of candour with a compliance of 97%. Theduty of candour is a regulatory duty that relates toopenness and transparency and requires providers of




health and social care services to notify patients (orother relevant persons) of certain notifiable safetyincidents and provide reasonable support to thatperson.

Mandatory training

• The service provided mandatory training in keyskills to all staff and made sure most staffcompleted it.

• The service offered a range of mandatory training bothface to face and via e-learning. The service hadconsidered the frequency needed for these moduleswhich ranged from yearly to five yearly. Modules coveredevery year were; basic life support, first aid, infectioncontrol, manual handling, oxygen therapy, dementiaawareness, and patient consent. Other modules wererepeated from every two years to every five years

• The service had identified staff roles and which trainingcourses they needed to complete. They had a skillmatrix that clearly showed which roles needed tocomplete which training course. This also showed whichextra training courses may be relevant to extend theirunderstanding but were not needed for their roles.

• The service had mandatory training modules for staffand met most of their targets. The service was meetingtheir target of 85% compliance for 15 out of their 20modules. With nine of these modules being above 95%compliance. The modules that they met targets forincluded; Basic life support, first aid at work, oxygentherapy, prevent radicalisation, G4S values, anti-bribery,conflict resolution, duty of candour, equality anddiversity, fire safety, health and safety, mental capacityact, safeguarding adult level 2, and safeguarding childlevel 2.

• The service had systems to monitor compliance withmandatory training. The services overall compliancewas within their target. However, there were fivemodules that fell below their target of 85%. Thesemodules were manual handling, dementia awareness,information governance, infection control, and patientconsent. Manual handling compliance was 84% so wasclose to the services target of 85%. Dementia awarenesstraining compliance was 81% so was also close to theservices target of 85%. The service had plans to improvetheir training compliance.

• We reviewed eight staff records and found that theycontained certificates that showed completion oftraining modules. We also saw the records of threesenior managers contained certificates from mandatorytraining courses. Managers explained that theinformation governance module had a low completionrate as it had been redesigned to take account of theintroduction of general data protection regulation(GDPR) in November 2018. This compliance was worsethan the target as they made two courses into onewhich resulted in compliance showing as 58%. However,compliance for the completion of the old course inDecember 2018 was 94%.

• Managers told us the reason for compliance in infectioncontrol training being worse that the target was becausemany staff were due to complete their training inDecember This meant that compliance drops after thisand then returns towards their target in the followingmonths. We reviewed training records that showedthese trends. These records showed that in Decemberthe compliance with infection control training was 95%.

• The service introduced a new training module focusedon dementia awareness and within four months hadachieve 92% compliance in this module.

Safeguarding

• Most staff understood how to protect patients fromabuse and the service worked well with otheragencies to do so. Staff had training on how torecognise and report abuse, and most staff knewhow to apply it.

• The service had identified leaders to support effectivesafeguarding. The service had a level 5 trainedsafeguarding lead, but they were on extended leave atthe time of the inspection. In their absence the servicehad given responsibility for safeguarding to their chiefnurse and this was overseen by the services clinicaldirector both of whom were trained to safeguardinglevel 4 for adult and child.

• The service had access to an independent service tohelp them review safeguarding policy. We reviewedrecords that showed a service agreement describing thisarrangement.

• The service provided training for their staff insafeguarding. All staff were trained to at least level two




child and adult safeguarding. The service had 96%compliance with level 2 safeguarding adults and 97%compliance with level 2 safeguarding children. Trainingwas in line with national guidance.

• The service had a system to process safeguardingconcerns raised by their staff. The service had an up todate policy for safeguarding children and adults. Thiscovered areas such as descriptions of the type of abuseand the role of the safeguarding lead. We reviewed aflow chart that explained the way a concern would beprocessed. This included; what to do if there was animmediate danger, what to do if no immediate danger,and how the concern would be reported to socialservices. The risks about this incident were alsoincluded in this flowchart for consideration by theservice’s managers.

• Staff had access to a 24-hour safeguarding line to thecontrol centre. Details of this call line was seen onvehicles and in depots. The control centre then passedon these concerns to the relevant local authoritysafeguarding team or the governance team to review.

• The service was identifying and referring concerns ofabuse or risk of abuse. We reviewed 21 incidents ofconcerns relating to abuse or risk of abuse raised by theservice’s staff. We found that these showed a range ofissues were being highlighted by their crews. Thisincluded physical abuse, neglect, self-neglect, poorcaring agencies, absences of suitable care arrangementsand mental ill health concerns. The service had reportedall of these to the local safeguarding authority in linewith their policy and national guidance.

• Patient facing staff did not always understand whenthey were responsible for raising a safeguarding concernwithout consent from the patient. The services flowchart to support staff completing safeguarding reportsdid not include advice about the requirementsregarding consent. Four staff based at the Maidstonedepot we spoke with could not tell us when they wouldbe able to raise a concern without consent. Seven otherpatient facing staff we spoke with across the service didunderstand when they would be able to raise a concernwithout consent. In seven safeguarding records wereviewed we saw that consent had not been obtainedfor the referral but the reasoning for the concern stillbeing reported had been recorded in line with nationalguidance.

• Crews had ready access to guidance and informationwhen they had safeguarding concerns. At the Gillinghamdepot, we saw each vehicle had a “blue folder” whichcontained laminated copies of key documents,including a safeguarding prompt sheet. We were told bymanagers that these were in all vehicles.

• The service had an up to date policy on the governmentinitiative called Prevent. This is to; protect vulnerablepeople, challenge the ideology that supports terrorism,and support action against radicalisation.

Cleanliness, infection control and hygiene

• Infection risks were controlled. Staff keptthemselves, and vehicle equipment visibly clean.They used satisfactory control measures to preventthe spread of infection.

• The service had new systems for ensuring highstandards of cleaning were always done. Crews wereusing a new software package that would have themtake pictures of the cleaning they had achieved. Thiswas then seen by managers and the following crew toensure high levels of cleaning had been completed. Atthe Gillingham depot, managers demonstrated the useof a commercially-available software package that hadbeen modified to include a record of end-of-day vehiclecleaning. G4S were piloting the application beforespreading the technology to other bases. The pilot wasregarded as successful. Managers explained the packagewas designed for use with a portable digital assistant(PDA) issued to each crew at the start of their shift.Crews could not close the record for the day until thefinal cleaning task was marked completed and shownby a photograph taken using the PDA.

• Vehicles and equipment were cleaned anddecontaminated to ensure patients and staff wereprotected from acquiring infections during their journey.We saw staff using wipes to disinfect equipmentbetween uses. At both depots we saw unmarked spraybottles which staff said carried an approved cleaningagent. Although staff told us this was not a harmfulproduct it is still good practice to label spray bottles.

• The four vehicles we checked at Gillingham had visiblyclean interiors. The exterior paintwork appeared to becovered by a layer of road grime or salt spray. Butwindows and mirrors appeared clean.




• The four vehicles we checked at Maidstone had visiblyclean interiors. These had visibly clean exteriorsincluding windows and mirrors.

• Vehicles were rotated through deep cleaning every eightweeks and we saw records confirming this. The deepcleaning was performed by a specialist contractor whoprovided a mobile service.

• When vehicles were contaminated and needed extracleaning the service had a guide to help crews decidewhat level of cleaning was needed. This was based onthe type of contamination. If the vehicle needed an extradeep clean, then this was done by the specialistcontractor.

• Staff decontaminated their hands in between eachpatient interaction. We saw antibacterial hand geldispensers fitted to each ambulance and these were fulland working. We saw staff using the gel correctly.Disposable gloves in different sizes were also availablefor staff to use. However, there were no aprons on thevehicles so if crews needed these during a journey theywould have to wait until getting to a hospital or depot.

• Staff had uniform lockers in the depot office. Staff toldus they cleaned their own uniforms and kept a spare setavailable at their base station should their uniformbecome soiled or contaminated. We noted that all staffwore uniforms that appeared to be clean andserviceable. They had short-sleeved tops that ensuredthey remained “bare below the elbows”. We saw crewswearing watches attached to accessory pouches or beltloops. The removal of items of jewellery from hands andwrists improved the effectiveness of hand washing orwiping.

• Staff had a good understanding of infection preventionand control. We spoke with five patient facing membersof staff who followed national guidance on infectioncontrol and described infection control issues to us.

• In the Maidstone depot we saw four different colouredmop buckets and mop handles in line with nationalguidance. The mop heads used were disposable.

• We saw clinical and non-clinical waste was segregatedcorrectly into different coloured bags. Clinical waste wasstored securely in locked bins while awaiting collectionfor disposal.

Environment and equipment

• The service had suitable equipment and lookedafter them well. The service had some suitablepremises.

• The service had a contract for annual equipmenttesting. While some items we checked did not haveservice labels, we saw equipment records that showedall the items had been tested and serviced in line withmanufacturers’ specifications.

• Records showed the equipment in the ambulances waschecked and tested daily and supplies replenished asneeded.

• We found several concerns at Gillingham depot.Managers described the depot as one of the busierstations in the region. Over 90 staff operated 33 vehiclesfrom the depot, covering shifts from 5am to 11pm with atwo-person crew working overnight. The depot wasbased in a factory site, comprising officeaccommodation and a separate vehicle park withvarious outbuildings. These facilities were sharedbetween a number of co-tenants offering steelfabrication, heavy goods transport and automotiverepair services. While the office block and staff car parkwere sited in a gated compound, the vehicle park wasopen to a public road.

• The office accommodation and staff toilets looked dirty.Managers explained that the cleaner had left. Depotteam leaders took it in turns to clean facilities while anew cleaner was recruited. Based on our observations,the cleaning was not sufficient to meet the demandarising from the number of staff using the offices andthe extended operating hours.

• Vehicle facilities were also insufficient to meet the needsof a busy depot. Parking bays appeared to contain a mixof ambulance vehicles and private cars belonging toG4S staff and other workers. In one corner of the vehiclepark we saw that two shipping containers (in single file)had been positioned next to small metal “garden shed”and security lights atop two or three lampposts. Wenoted the shipping containers were used forconsumable supplies such as gloves and other itemssuch as wheelchairs and stretchers awaiting repair. Theshed contained cages of full and empty oxygencylinders. Three bulk waste containers were locatednext to a shipping container




• Ambulance stations or depots commonly have a facilitycalled a “vehicle make-ready” area. This usuallyincludes all-weather provision for vehicle safety checks(such as tyre pressure, oil and water); vehiclemaintenance; cleaning, equipment stores and wastehandling. There were no spaces reserved for vehiclepreparation and cleaning. Staff working in the area wereexposed to the elements. Inspectors had to pause theirown vehicle checks during a period of rain. Staff told usthat working in the vehicle park was particularlychallenging during winter months.

• Managers stated that vehicle washing was not permittedon the site as the property overlooked the River Medwayand there was insufficient provision for trade effluent(run-off from vehicle cleansing). Water was not suppliedto the vehicle park.

• We observed a vehicle being cleaned during our visit.We saw that the deep clean was augmented by a steamgenerator and industrial vacuum cleaner. We noted theuse of a 240v electric extension cable, which was laidout some 25m across the tarmac park. The contractorexplained that another ambulance had been movedinto the bay adjacent to the shipping container andnearest power point. This ambulance had developed afault and had been towed in for repair. It could not bemoved. This caused a trip hazard as cleaning of vehiclesthen had to be done in spare spaces across the car park.This was also not compliant with guidance leafletINDG231 (2012) from the Health and Safety Executive asthere was no reduction in voltage and no residualcurrent device in use. The guidance says portable toolsthat run from a 110 volt supply are readily available andthat a reduction in voltage is one of the best ways ofreducing the risk of injury when using electricalequipment.

• When we pointed out our safety concern about theextension cable to managers, it was rectified. We werealso told that traffic cones had been ordered that day tohelp control parking in future.

• Each station had colour coded general waste bins andclinical waste bins for disposal of waste. All bins werecollected fortnightly by a private contractor. However, atthe Gillingham depot we saw that there was not asecure area for bin storage. Although the clinical wastebin was locked the overall standard did not meetguidelines because the area was accessible by

unauthorised staff and the area was not well drained toallow for washing down the bins. “Management anddisposal of healthcare waste (HTM 07-01 Section 5.98)”states that bulk storage areas, regardless of location,should be totally enclosed and secure; sited on awell-drained, impervious hardstanding; readilyaccessible but only to authorised people; kept lockedwhen not in use; provided with wash-down facilities andclearly marked with warning signs.

• At the Maidstone site keys were stored in a locked keysafe. This prevented unauthorised staff from accessingthe vehicles.

• The service had a contract with a specialist serviceprovider to do vehicle maintenance. This includedservicing and yearly department of transport (MOT)certificates. We reviewed records that showed acountdown to when that vehicle was due to be serviced.The fleet manager told us that they reviewed this dailyand would not allow any vehicles on the road if theywere out of date. The records we reviewed showed thatall vehicles they had in use had in date MOT andservicing.

• The service considered the fire risks at their sites. Wereviewed a fire risk assessment at the Maidstone depotthat was up to date. We also saw that on both the localrisk registers for the depots that we visited fire risks hadbeen considered.

Assessing and responding to patient risk

• The service used safety monitoring results well.Staff collected safety information and shared itwith staff, patients and visitors. The service usedinformation to improve the service.

• The service had effective measures to alert vehiclecrews to patient risks. We were told by three bookingsstaff that they would ask patients on booking aboutmobility and medical history. They also told us that ifpatient needed a relative or carer to travel with themdue to a medical condition then they would give thecaller a reminder that this may be a good idea. Theserisks were recorded on the journey record and thenhighlighted to the ambulance care assistants thatcollected the patient. The three ambulance careassistants we asked about this in interview confirmedthat they received information about patient risks viatheir digital tablet.




• The service had an up to date policy based on nationalguidance for deteriorating patients. This said that the ifa patient deteriorated during a journey the ambulancecrew were to find a safe place to pull over and call 999for emergency treatment. We were also told about thisby one manager and two crew. This was also confirmedby one manager and two crew when discussingmanagement of a deteriorating patient.

• All ambulance care assistants completed severalmandatory training courses including a three-day firstaid course and a basic life support course. Theseallowed staff to provide patients with basic life support,airway management and support patients with first aid.

• The service prepared their staff to manage aggressive oragitated patients. The service had a policy of notrestraining patients and instead provided de-escalationtraining. The training manager told us this includedadvice about coming down to the level of the patientand reasoning with them. On double crew vehicles theyalso suggested that the crew could try switching theambulance care assistants around as this may helpalleviate the problem and both crews were trained tocarry out both roles.

• The service also had patient transport liaison officersthat were based in the large hospitals across the region.Mangers told us these staff were responsible for carryingout extra checks on patients’ needs after the hospitalbooked transport. This was to ensure the correct type ofbooking has been made to meet the patient’s mobilityand medical needs.

Staffing

• The service had enough staff with the right skills,training and experience to keep people safe fromavoidable harm and abuse and to provide the rightcare and treatment.

• The service reviewed staffing levels and demandsplaced on the service. The service calculated staffinglevels during the tender process for the Kent andMedway contracts. We were told by managers within theservice and within the clinical commissioning groupthat the service had reviewed the calculation of staffinglevels in relation to the demand for the service.

• The service had cover arrangements for sickness andleave. We saw records that showed the service had a

sickness rate of 6%. The service had two seniorambulance care assistants at each of their bases. Wewere told by staff these staff would cover for ambulancecare assistants that were off sick at short notice. Wewere also told by mangers that if they had notice ofleave or that someone was going to be off sick for anextended period these shifts would be put out for bankcover. The service operated each of their contracts withan extra 18% resilience level above the establishmentfigure. This allows cover for sickness, annual leave andtraining.

• The service had processes to meet the staffing levelsagreed with their commissioners. We saw records toshow that in February 2019 the service had 383 full timeequivalent (FTE) of the agreed 399 FTE. They also had 8FTE waiting for vetting clearance and another 7 FTEscheduled to start induction training. They also had 8FTE staff leave in February. Managers told us thatagency staff who worked with the service for 13 weekswere offered permanent posts and that over the pastthree months 13 ambulance care assistances had joinedtheir permanent staff in this way.

• The services arrangements for using bank and agencystaff kept people safe. Managers and crews told us thatagency and bank staff completed the same inductiontraining as permanent staff.

• In April 2019 the service used 62,085 hours ofsubstantive staff, 4,313 hours of bank staff, 1,793 hoursof overtime and 1,500 hours of agency staff. The servicehad no unfilled shifts.

• We reviewed eight staff records which showed that theyhad enhanced disclosure and barring service checksdone within the past three years. The service has apolicy to repeat the enhanced disclosure and barringservice checks every three years. The review date hadbeen recorded in these records. Four records wechecked had references for the past five years ofemployment. The remaining four records were for staffthat had been transferred from another provider as partof a contract transfer. We saw records to confirm this forthese other four staff. The service did not repeatreference checks for these staff as they assessed theprevious provider’s vetting process and found it was inline with their own. The service did, however, repeat thedisclosure and barring service checks.




Records

• Staff kept records of patients’ care and treatment.Records were clear, up-to-date and available to allstaff providing care.

• The service managed peoples’ records in a way thatkept people safe. The service did not use paper records.We saw staff used hand held digital tablets to recallpeople’s records. We saw in patients’ records there werenotes made about extra support that may be needed orpreferences the patient had asked for.

• Staff had timely and straightforward access toinformation that they needed to deliver safe care. Theservice had electronic records that contained keyinformation that were accessible by booking staff,control room staff, and vehicle crews. We saw in theserecords there were tick boxes for common conditions, asection for mobility, a notes section for this journey anda notes section for the patient that would recordprevious issues. We saw in the four records we reviewedthese were completed as expected. We also saw in onerecord an alert to crews that the patient was epilepticand a description of how this presented in this patient.Booking staff told us that when they record a note thenthere was a box to tick that alerts the crews to read thenotes section.

• The service had clear process to identify and recordpatients that had a do not attempt cardio pulmonaryresuscitation (DNACPR) order and the vehicle crew feltconfident in their understanding of this process. Thiswas recorded at the booking stage and then crews werealerted to this via their digital tablets. The crews wouldthen ensure they had a valid DNACPR order. Wereviewed an incident report that described how apatient that become unresponsive on going to leave award advised hospital staff of the DNACPR order.

Medicines

• The service did not hold any medicines or medicalgasses apart from oxygen.

• The service stored medical gases safely. We saw “indate” cylinders of oxygen securely stored on vehiclesand in purpose-built cages at the both sites. Cylinderson vehicles were positioned so the fill gauges could be

seen. Cylinders and regulators appeared to be clean(dust and oil free) and immediately usable. The medicalgas cylinder storage cages were compliant with TheDepartment of Health Technical Memorandum 02-0.

• We saw clear, marked segregation of full and emptycylinders to help prevent crews’ accidently taking anempty cylinder onto a vehicle.

• At the Gillingham depot the oxygen was stored in asmall shed. It was correctly marked with suitable hazardlabels. We noted eight empty cylinders next to one ofthe cages. A staff member told us that the oxygendelivery service driver was expected, and these wouldbe removed. The shed was locked.

• The service had an up to date medicine policy thatdescribed the use of oxygen. We reviewed records thatshowed the service had an agreement with a privatesupplier to restock their oxygen supply when needed.

Major incident response planning

• The service planned for emergencies and somestaff understood their roles if one should happen.

• We saw the service had a plan to support hospitals inthe event of a mass casualty incident. This had beenshared with control staff and the managers. This planhad not been shared with vehicle crews yet as the planhad only been made recently.

• The service had plans to allow them cope with adverseweather. We reviewed the services heat wave and coldweather business continuity plan. This had details ofsuppling patients and staff with water and extrablankets.

• The service had a general business continuity plan foremergencies. We review this and found it was up to datewith details of how to prioritise patients by groups. Thisput the patient with the highest clinical need first; forexample, renal patients were in the highest prioritycategory. Both these plans included consideration totheir staff welfare in these situations of extra stress.




Are patient transport services effective?

Good –––

We had not inspected this service before and therefore hasnot been rated before. We rated it as good because theservice had up to date policies based on national guidance.They also had an in-house induction program taught overten days face to face. However, appraisal rates were belowthe services target.

Evidence-based care and treatment

• The service provided care based on nationalguidance and evidence of its effectiveness.Managers checked to make sure staff followedguidance.

• The service had policies and guidance documents tosupport staff to provide evidence-based care. Wereviewed their policies for; infection prevention andcontrol, serious incidents, medicines management, donot attempt cardio pulmonary resuscitation orders,open and honest care policy, and mental capacity.These policies were up to date and based on currentnational guidance. These policies all clearly recordedwhen they were to be reviewed which ranged fromyearly to three-yearly.

• The service monitored crews’ adherences to guidance.We were told by managers that they did supervision ofvehicle crews by coming on vehicles as observers. Wewere also told by crew and managers that all managerstook part in “back to greens” program that involvesmanagers going out on vehicles acting as a second crewmember of double crew vehicles. This was called “backto greens” as the vehicle crews wear green uniforms.This allowed managers to keep up to date with currentissues about implementing their policies.

• The service ensured that staff had access to the policiesand guidance. We saw that office staff could accessthese on a shared drive. Vehicle crews showed us thatthey could access the policies and guidance via hardcopies at each base station and there was also a folderon each vehicle that contained guidance information.

Response times / Patient outcomes

• The service monitored the effectiveness of care andused the findings to improve them. They comparedlocal results with those of other services to learnfrom them.

• The service collected booking time, departure time andarrival times. This was monitored against their keyperformance indicators. These indicators were set bythe commissioners of this service. We reviewed theseand found the service had 29 indicators and of these 17were exceeding their targets, three were not applicableand nine were below their target. The records that wereviewed showed that five of the six targets that werenot meeting their targets were within 5% of the target.Details of the six targets they did not meet are below.

• The first of these targets not met were outpatientjourneys booked on the day of travel. The requiredstandard was for the service to have patients arrive ontime and no more than 75 minutes prior to theirappointment time. The service required two hours’notice for these journeys. The target was 80% and theservice achieved 77%, although this had improvedthrough the last 12 months.

• The second of these targets not met was outpatientjourneys booked on the day of travel for time boundpatients. The required standard for these patients’journeys to arrive no later than 15 minutes before theirappointment. The service required two hours’ notice forthese journeys. The target was 80% and the serviceachieved 29% in February 2019. However, this had beenhigher during the past 12 months but not above theirtarget.

• The third of these targets not met was patients bookedin advance for discharge from hospital. The requiredstandard was for the service to collect all patients within75 minutes of the booked time. The target was 80% andthe service achieved 76% in February 2019.

• The fourth of these targets not met was for renalpatients not to spend more than 60 minutes in a vehicle.The service had a limit of 20% but was at 22%, this hadincreased over the past six months. Managers told usthat this increase had been due to capacity in renalunits causing patients to need to travel long distancesfor renal treatment.

• The fifth of these targets not met was for patientstraveling due to a transfer of care from one hospital to




another hospital where the destination was within Kentand Medway. The required standard was for patients tobe transported within two hours of the booked readytime. The target was 80% or above but the serviceachieved 77%.

• The sixth of these targets not met was transfers ofpatients booked in advance for travel from a hospital toanother hospital. The required standard was for theservice to collect all patients within 75 minutes of thebooked ready time. The target was 80% and the serviceachieved 79%.

• The last three targets not met were also related towaiting times for patient transfers from hospital tohospital. These three targets were sometimes not metand sometimes met. They were also in some monthsnot applicable due to not having any patients thatrelated to these targets. The target for these were 80%and the service achievement varied from 0% to 100%.

• The details of the seventeen targets that the service met.Three of these were related to arrival times of patientsto outpatients’ appointments. These had a target of80% and the service achieved 84% for two and 100% forthe third.

• The next target met was for patients returning fromoutpatients’ appointments. The required standard wasfor all patient to be collected within 75 minutes of thebooked or made ready time. The target for this was 80%and the service achieved 90%.

• The fifth target met was for patients booked on the dayreturning from outpatients’ appointments. The requiredstandard was for all patient to be collected within 75minutes of the booked or made ready time with twohours’ notice. The target for this was 80% and theservice achieved 98%.

• The sixth and seventh targets met also related topatients returning from outpatients’ appointments. Therequired standard for these two targets was for no morethat 1% of patients to wait over 4 hours. The service hadachieved 0% for these. There are two standards for thisthat are split into patient booked on the day and thosebooked in advance.

• The next two targets met related to renal patient’soutpatient appointments arrival and return journeys.The standards for these were for patients to arrive on

time but not more that 15 minutes before theirappointment and to be collected for their return journeywithin 30 minutes of their booked ready time. The targetfor both was 80% and the service achieved 86% and93%.

• The tenth target that was met related to patientsbooked on the day of travel for transfer from anotherhospital for outpatient appointments. The standard forthis was for patients to be collected within 15 minutes ofbooked ready time with two hours’ notice. The targetwas 80% and the service achieved 90%.

• The next three targets met related to patient beingdischarged from hospital. The first standard was tocollect all patients within two hours of being bookedready. The target for this was 80% and the serviceachieved 80%. The other two targets had a standard ofnot more than 1% of patients to wait more than fourhours to be collected and the service achieved 0% and1% for these. These two targets were separated forpatients booked on the day and in advance.

• The next target met was for the service to not abort orcancel journeys as the result of the services provision.The target for this was 0% and the service achieved this.

• The last three targets that were met related to timespent in the vehicles by patients. The standards forthese related to distance to travel and maximum timefor that distance. The target for these three was for notmore that 20% of patients to exceed the times and theservice achieved 1%, 3% and 4%. Although thisexcluded renal patient that had their own target.

• The service recorded their performance monthly andover the past 12 months there had been improvementsin most of these indicators. The commissioners gave uspositive feedback about the service and their culture toprovide continuous improvements. However, we hadalso been contacted by other stakeholders withconcerns about long waiting times for collection afterappointments, on discharge from hospital and fortransfers from one hospital to another.

• The service had satellite navigation systems in everyvehicle. They had geofenced their main pick uplocations. This meant that when vehicles left one ofthese locations the control team would beautomatically notified of this. Vehicle crews whenarriving or leaving any other locations had to press a




button on their digital tablets to record their locationand the time. This allowed the service to monitor theirperformance. This system also monitored the speed ofvehicles and notified managers of any breaches ofspeed limits.

Competent staff

Coordination with other providers andmulti-disciplinary working

• The service made sure staff were competent fortheir roles.

• The service provided appraisals for staff but completionof these was not consistent across different job roles.This varied from ambulance care assistants with 85%having completed an appraisal to managers with 87%having had an appraisal. The other job roles werebetween 52% and 66%. The managers and ambulancecare assistants appraisal completion rate met theservices target of 85% but other roles were below theservices target of 85%. We were told by managers thatthis year they had switched to a new appraisal year onlyallowing them eight months to complete a year’sappraisals. This was to align their appraisal year with therest of the G4S group.

• Appraisals were used to look for positives as well asareas for development. Managers told us that staff ifstaff had development needs then training would beoffered that was tailored for their individual needs.

• The service supported staff to improve theirunderstanding of how to support their patients. We sawin appraisal records that the service had careerdevelopment planner. Mangers told us this was targetedat ambulance care assistants and allowed them tochoose a pathway to structure their development.

• The service had a training program for new staff.Managers told us this was a ten-day face to face training.This included two days to cover the e-learning topicswith support. The next three days were for manualhandling training. They then spent one day gettingfamiliar with vehicle checks and with the trainers theypracticed using the equipment. They then completed athree-day first aid at work course. On the final day theydid a day of assessments with the trainers on everythingthey had learnt. If new starters needed to then theycould repeat the sections that they had not understood.

• If new starters were sick during this training, then theyre-join the next course at the start of the section thatthey were sick for and then complete the remainingdays. New starters would not be allowed to act as crewbefore completing the full ten days. The service hasplans to increase this ten-day training to 15 days. Afterthe ten-day face to face training they had a week ofshadowing other crews. The service introduced a buddysystem to give extra support to new starters. However,we had received concerns from patients, staff andstakeholders about the services training of new staff.

• The service had systems to support staff that workedremotely or alone. We were told by ambulance careassistants that they did at least one week of shadowingafter their induction training. Managers told us aboutthis as well and we saw records that confirmed that thishad been completed. Ambulance care assistants alsotold us that they had supervision as part of theirappraisals. This would be one of their managers comingon a journey with them to review their developmentneeds.

• The service had a plan to improve their monitoring ofadherence to training. The training manager told us thatat the time of the inspection the trainers were onlytrained to assess staff in a simulated environment, butthe plan was to train the trainers so that they couldassess staff with patients. This would allow them toprovide supervision for ambulance care assistances toassess their continued competence.

• The service had a system to monitor their ambulancecare assistants driving licences. Licences were checkedon recruitment and then repeated yearly. The fleet teamcarried out yearly checks of online driving licences andthen any issues were reported to the depot manager.We saw in the eight staff records we reviewed divinglicences checks had been completed.

• New ambulance care assistants undertook a drivingtraining session where their driving skill would beassessed. Extra training was given if any concerns aboutstaff driving were identified by this process or viacomplaints. The training manger told us that this extratraining would be tailored to the needs identified.

• The service monitored their staffs’ driving performance.Driving skill was monitored via a digital system thatrecorded aspects of driving such as; acceleration,




breaking, collisions, and cornering speed. This systemthen reports driving quality to the driver’s manager.Managers and crew told us this system was also used toaward the best driver of the month.

• As a non-emergency service, no vehicles were fitted withblue lights or sirens so there was no requirement foremergency response driver training.

• The service coordinated with local stakeholders toprovide effective care. Mangers at the service andcommissioners from the local clinical commissioninggroups told us that they had regular meetings. Thesemeetings were to discuss performance data, forexample transport times, incident, risks and complaints.

• The service had patient transport liaison officers thatwere based within local hospitals. These were to helpfacilitate discharges and transport arrangements.Managers told us that the local trusts had found these tobe helpful.

• The service had improved their handover process withhealthcare professionals. There had been a recentincident that identified a lesson to be learnt abouthandover processes. This had been shared via theservices lessons learnt leaflets. This included asking staffto record what was handed over by who and to who.

• The service used a third-party independent ambulanceservices to provide support on both ad-hoc andpre-planned basis, to meet its contractual obligationswith the commissioners.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff understood their roles and responsibilitiesunder the Mental Health Act 1983 and the MentalCapacity Act 2005. They knew how to supportpatients experiencing mental ill health and thosewho lacked the capacity to make decisions abouttheir care.

• The service had support for staff to understand how tohelp patients that lacked capacity to make a decision.We looked at their mental capacity act policy that hadbeen reviewed in April 2019. The service providedmental capacity act training for all staff and 95% of staffwere up to date with this training.

• The service sought patients consent in line with nationalguidance. We observed three ambulance care assistantsthat acted inline with the service’s policy when theyasked patients for consent. However, we did notobserve any patients that lacked capacity so wereunable to see what crews would do if patient lackedcapacity in practice.

Are patient transport services caring?

Good –––

We had not inspected this service before and therefore hasnot been rated before. We rated it as good because patienttold us the crews treated them with compassion andprovided support when needed.

Compassionate care

• Staff cared for patients with compassion andkindness.

• During our inspection, we observed patient transfersand saw that staff treated patients with dignity andrespect. Staff interacted well with patients in a friendlyway and with good humour. We noted that staff werealways courteous and professional.

• Feedback from patients and stakeholders was positive.One staff member from the trust said the service waswonderful and the drivers were superb and worked totime. One patient said that crews went above andbeyond to ensure their safety and wellbeing.

• We were not able to talk to patients on the day ofinspection. However, the service provided us withtelephone numbers of patients that had consented tobe contacted for feedback.

• Following our inspection, we spoke to nine patients andthe feedback was positive. Patients told us, and we hadobserved, that staff were attentive and paid due regardto their needs.

• Patients’ privacy was respected at all times and crewmembers addressed patients in the way they wished tobe addressed. Patients told us they were now used tomany of the staff, and staff were polite. Staff rangpatients to inform them they were on their way about 30minutes before pickup, so they had ample time to




prepare. However, patients told us the new staff did notalways introduce themselves, although they wore theiridentification badges with their name and photographon display.

• There were paper-based patient feedbackquestionnaires in the vehicles and in transport loungesfor patients to fill out. The service carried out patientsatisfaction surveys where paper questionnaires weresent to random patients each month for feedback abouttheir experiences with the service. However, during ourinspection, we saw crew did not always offer patientsthe feedback questionnaires. Patient satisfaction resultsfor February 2019 showed that of the 796 patientsfeedback sampled, 78% would recommend the serviceto family and friends. Also 99% of respondents said“yes” they felt staff were friendly and helpful and offeredassistance when needed.

Emotional support

• Staff provided emotional support to patients tominimize their stress.

• Staff understood the impact a patients’ condition, careand treatment had on their wellbeing. We saw that staffwere sensitive towards patients and treated them withempathy. Staff were considerate, reassuring andpatients were allowed to do things at a comfortablepace.

• Patients we spoke to told us staff took time to check ontheir wellbeing, in terms of discomfort and wellness.One patient told us staff always sensed when they werenot feeling well. Another patient, who suffered fromanxiety, also said staff seemed to sense when they werein a low mood. Patients told us staff always found a wayto lift their mood and “by the end of the journey theywere smiling”.

• The service supported the emotional needs of childrenwell. When children were being transported, the serviceusually sent two crew members. Staff ensured childrenhad their favourite toy for comfort. Patients wereaccompanied by a carer, parent or responsible adult forreassurance.

Understanding and involvement of patients and thoseclose to them

• Staff involved patients and those close to them intheir care and treatment.

• Staff told us patients and relatives were given clearinformation over the telephone at the time of bookingtransportation. Patients and relatives were informedabout times they would be picked up before and aftertheir appointments by the booking team or the crewstaff. Patients could discuss any concerns or raiseobjections at any time. Although one patient told usthey were picked up too early before their appointmentsand they often had to wait up to one hour at the place ofappointment which could be a long wait.

• Staff communicated with patients and their relatives ina way they understood. Patients were given enoughtime to ask questions and staff took time to explain howthey were going to be transported and cared for in acalm, friendly and respectful manner. Patients couldattend appointments with a carer or relative if theywished and could be accommodated safely.

• During our inspection, we saw that staff encouragedpeople to take part in their care and treatment. Staffwere supportive of patients to manage their own health,care and wellbeing and maximise their independencebut were there to help when needed.

• Staff discussed patients’ care and treatment with themand took time to address all questions and concerns,such as whether they would make their appointmentson time and who would be picking them up after theirappointments.

• Crews double checked to ensure that patients were fit totravel. Staff reminded patients to check they hadeverything they needed such as care plans,appointment letters and mobile phones. Staff ensureddoors were locked and patients were in possession oftheir home keys before departing to ensure patients didnot have cause to be distressed.

Are patient transport services responsiveto people’s needs?

Good –––

We had not inspected this service before and therefore hasnot been rated before. We rated it as good because the




service had staff within hospitals to assist in the patientflow. Also the service had a system to identify patients withextra needs and this alerted the crews that were assistingthese patients during transport.

Service delivery to meet the needs of local people

• Patient transport services were planned anddelivered in a way that met the needs of localpeople.

• Service delivery was a contractual arrangementbetween G4S forensics and medical services limited andKent and Medway clinical commissioning groups (CCGs),coordinated by the NHS West Kent CCG for thecommissioners.

• The main service was a non-emergency transport forpatients who were unable to use public or other meansof transport due to their medical condition. Patienttransport services were mostly provided to patientsattending hospitals, diagnostics, renal and outpatientclinics and those being discharged from hospital wards.The service was also commissioned to transfer mentalhealth patients between inpatient services across Kentand Medway, where such transfers posed no significantrisk to the service and crew. Risk level was assessed bybooking clinicians along with the call handler goingthrough a mental health pathway to determine if thepatient could travel with them.

• The service had a booking system for patients attendingmedical appointments. The majority of patienttransport bookings were pre-planned and in some casesthe service scheduled patient transport on “ad hoc” onthe day services to meet the needs of patients. On theday, bookings were responded to quickly via telephone.We observed effective communication between amanager and a crew member as part of serviceplanning.

• All patient transport bookings were coordinated bymanagers throughout the day. The service operated a24-hour, seven days a week service to meet the needs ofpeople who needed transport. Crew staff workedindividual rotas and rotas were planned to ensure therewas cover at all times. Staff were not forced to workoutside of their planned hours.

• The service monitored their call handling. We reviewedrecords that showed waiting times on calling to book ajourney had improved over the last 12 months.

Meeting people’s individual needs

• The service took account or peoples’ individualneeds.

• Staff had completed an equality and diversity anddementia awareness course as part of their mandatorytraining every year. Staff we spoke with had a soundunderstanding of the cultural, social and religious needsof patients, and staff practiced this in their work.

• Patient’s condition and individual needs were identifiedat the booking stage for transportation. The service useda flagging system to identify patients with complexneeds such as people living with dementia, learningdisability and those with a physical disability. Theservice also had staff attached to each trust known aspatient transport liaison officers (PTLO) who assessedand identified patients with complex needs. The servicemade all reasonable adjustments to accommodate andtransport patients such as providing a mobility assistiveequipment like wheelchairs or ensured patients had anescort.

• Crew staff were made aware of patients with complexneeds including those living with dementia, learningdisability and mobility difficulties via a booking formand on a handheld electronic device. Staff ensuredpatients who had a package of care were not left athome on their own without being safe, supported andcared for.

• Patients who had out-of-area and long-distanceappointments were well cared for. Crews stopped atservices to allow them to stretch their legs and to getrefreshments. Patients told us that staff always asked ifthey would like a five-minute toilet break throughoutthe journey.

• Crew staff sought consent from patients before carryingout any manual handling. Patients were moved withconsideration to the outside temperature and staffensured patients were comfortable. Staff ensuredpatients wore adequate clothing, vehicle heating wasturned on and patients were offered blankets when theyfelt cold during transfers. Patients told us staff turned onthe air conditioning during hot summer months.




• All ambulance vehicles we inspected were wheelchairaccessible with ramps. There were carry chairs andstretchers available to help patients who had mobilityproblems or walking difficulties.

• The service had bariatric trolleys which were used tosafely transport patients with body weights of up to300kgs and could accommodate their associated bodymass.

• Patients whose first language was not English wereencouraged to bring a friend or relative who could act asan interpreter for basic communication. In cases wherethis was not possible or appropriate due to the nature ofthe conversation, the service had a contract with anexternal interpreting and translation service who couldprovide verbal translation in 257 languages. The servicealso provided patients with written material in differentlanguages as needed. These included picture cards forsimple communication of patient needs and feelingslike pain, toilet, and happy.

• The service ensured that children and young peoplewere always transported by at least two members ofcrew staff. Children were always escorted by a carer or aparent, and staff ensured they were safe andcomfortable at all times.

• The ambulance service did not transport deceasedpatients. However, the service had a care pathway forpatients who were an end of life transfer with significantrisk of an unplanned death. As part of the pathway, thebooking team ensured they captured the do notattempt cardiopulmonary resuscitation (DNACPR) andall related requirements. All spiritual, cultural andreligious needs of the patients were discussed beforecommencement of their journey. Ambulance staff weremade aware of the information via their handhelddevice, and staff told us they respected and made allattempts to fulfil patients’ wishes.

Access and flow

• Patients had timely access to care and treatment.

• The service had a contractual key performance indicator(KPI) with the Kent and Medway clinical commissioninggroups (CCGs). The service had regular meetings withthe commissioners to discuss their performance.Performance results from April 2018 to February 2019indicated that the service mostly met its targets.

However, outpatients’ arrivals for journeys booked onthe day were below the target. For more detail on theservice performance against these targets see the abovesection “patient outcomes/response times”.

• The service was designed to ensure patients had timelyaccess to care and treatment and to increase flow. Thepatient transport service operated a 24-hour, seven daysa week service at four of their stations. Four of the otherfive stations operated a twenty-four-hour serviceMonday to Friday, and one station operated from 6am to8pm.

• All journey times were calculated at the time of booking,and patients were given an appointment time. Theservice ensured that at the time of booking, they hadthe resources to complete all patient journeys, such asthe correct number of staff, type of vehicle andequipment to avoid delays.

• Potential delays were discussed with patients, carersand hospital staff by telephone. When there was a delayor cancellation due to unforeseen circumstances suchas an accident or vehicle breakdown, other crew teamswere quickly redeployed to complete the journeys. Stafftold us base team and managers were also available tocarry out patient transport journeys when needed.

• There was a patient transport liaison officer (PTLO),employed by the provider, at the host trust to facilitatecommunication between the hospital and crew staff.The PTLO ensured crews had the right equipment andvehicle, which helped reduce delays and expeditepatient discharges from hospitals.

Learning from complaints and concerns

• The service treated concerns and complaintsseriously, investigated them and shared lessonslearned with all staff.

• The service had a complaints policy which wasdeveloped using the NHS complaints procedure andwas easily accessible to all staff.

• Complaints were acknowledged within three workingdays and responded to within 25 working days.Complaints were acknowledged, investigated andresponded to by a complaint resolution officer (CRO)with support from administrative staff.




• Operational managers and the clinical governance teamreviewed all complaints. Themes and trends, andlessons learnt from the complaint were discussed at thelocal and central senior management team meetingsmonthly. Lessons learned were sent to all staff via aweekly newsletter. We saw information about outcomesof complaints investigation and lessons learnt ondisplay at the ambulance sites we visited. We spoke tostaff that had seen these displayed.

• There were patient feedback forms available in thevehicles with information on how to make a complaint.Patients made a complaint by contacting the complaintteam on telephone or they could make a complaint onthe website. The service carried out a patient survey todetermine if patients knew how to make a complaint.Results for February 2019 indicated that of the 711patients who completed the survey, 77.5% of themknew how to make a complaint.

• The service had received 132 complaints betweenDecember 2018 and February 2019. The main themes ofthe complaints were long wait for transport and missedappointments. The service had a system that monitoredvehicles that were going to be late and had controllerphone clinics to try and arrange for patients to still beseen.

• We reviewed five patients’ complaints and saw thatresponses were provided in a timely way, were clear andthe process was thorough. Although the service did nothave data to show how many complaints were upheldor not upheld, there was learning from complaintswhich led to a change in practice. For example,following previous complaints about call handlingtimes, the service had separated the call centres tostreamline and improve the service. We were madeaware of a high-profile complaint. The service quicklyprovided an apology to the patient and acted to protectpatient safety. The service also started an investigationinto the incident.

Are patient transport services well-led?

Requires improvement –––

We had not inspected this service before and therefore hasnot been rated before. We rated it as requires

improvement because some staff told us they did not feelsupported by their managers. Also, we found the servicehad a procedure relating to concerns of abuse or risk ofabuse that was not fit for purpose. However, the servicehad oversight of their risks and sought out improvements.

Leadership of service

• The service had managers at all levels with theright skills and abilities to run a service providinghigh-quality sustainable care.

• A managing director was the strategic lead for thisservice they were also the registered manager. Theyreported to an executive management for the regionwithin the wider company. The service also has anominated individual that led on quality improvementand compliance. At the time of the inspection thenominated individual was on extended leave. Theservice had identified another member of staff to fill thisrole in their absence.

• The service had a senior management team that ran thepatient transport services. This was led by the managingdirector. The service had a governance team to maintainand manage improvement to the service which reportedto the senior management team.

• The day to day operations were run by two generalmanagers who each managed half of the service. Eachof these managers was supported by an operationsmanager. They then each had several depot managers.These depot managers were responsible for managingthe patient facing staff. The patient facing staff includedambulance care assistants and senior ambulance careassistants.

• Most leaders were visible and approachable. We weretold by most staff that they felt supported by their linemanager but that they did not often see the seniorleadership team. There were also some staff that told usthey did not feel supported by any managers.

• The service had a program to develop junior managersto give them skills to progress. We heard from threejunior managers that were being supported through anadvanced management course. This course includedtraining on the wider operations within the G4S group.

Vision and strategy for this service




• The service had a vision for what it wanted toachieve and workable plans to turn it into actiondeveloped with involvement from staff. However,patients were not included in the development ofthis vision and strategy.

• The services vision was to provide a safe, caring,specialist transport service which actively supportedthose in their care. They aimed to achieve this through amulti-skilled workforce using up to date technology tobe effective in supporting people with complexrequirements. We saw posters with this vision displayedin depots.

• Mangers we spoke with were able to explain the servicesvision. The patient facing staff we interviewed couldexplain the principles of the vision to provide good carehowever, they could not recall the service’s vision.

• The service had a strategy to focus on delivering thebasics to support patient centred care. Alongside thistheir strategy was to invest in growth which includedimproving efficiency and care.

• We saw the service had plans to expand to cover otherareas of specialist transport. Mangers told us they wereworking with vehicle provider to develop new vehiclescustomised for this new area of transport.

Culture within the service

• Most managers across the service promoted apositive culture that supported and valued staff,creating a sense of common purpose based onshared values.

• Most staff felt supported valued and respected by theirmanagers. Nine staff we interviewed told us they weresupported and valued by their line managers. We heardabout a staff member being supported by their managerwith an emotional situation. However, some staffreported not feeling they could talk openly to their linemanager.

• The service had a system to report issues withouttalking to their line manager. This was called the speakout program. This was an independent and confidentialwhistleblowing system. However, we heard from twostaff that felt they had no way to report their concerns.

• Call centre staff told us that they felt well supported bytheir managers. They reported seeing their head of

support services regularly. They also reported that themanaging director had visited to talk to staff last monthwhich they appreciated as they were on the other sideof the country and this made them feel included in theservice.

• Staff felt proud to work for the service. All managers andstaff we spoke with told us that they felt proud to workfor the service as they were helping people every day.One ambulance care assistant reported that they hadretired but wanted to do something to help people sojoined the service. Another ambulance care assistanttold us that they enjoyed helping their patients get totheir appointments as some of them felt isolated soenjoy the conversation.

• Staff were passionate about their roles and werededicated in providing excellent care to patients. Stafftold us the highlight of their day was getting patients totheir appointments and back in good time and seeingthe smiles on their faces.

Governance

• The service used a systematic approach tocontinually improve the quality of its services andsafeguarding high standards of care by creating anenvironment in which excellence in care wouldflourish. However, not all their proceduressupported this high standard.

• The service had clear governance processes overseen bythe managing director. At the time of the inspection thehead of governance was on extended leave, so theservice had appointed an interim head of governancefor this period.

• The service had a clear governance structure and staffunderstood who investigated incidents. We saw postersin staff rooms that displayed lessons learnt fromincidents. Managers told us that the member of staffthat had reported an incident would also receivefeedback about the incident. However, some staff toldus they did not receive this feedback.

• The service had systems to monitor the quality of theirsubcontractors. Managers told us that they performedaudits on their subcontractors to hold these providers tothe quality and principles of G4S Patient TransportServices - Kent & Medway (G4S). These audits includedareas such as checking staff files, training records,




policies, CQC certificate of registration, cleaningprocedures, clinical waste systems, vehiclemaintenance, and driving license checks. These auditsare completed twice a year.

• The service subcontracted services to six providers. Wereviewed five audits for these providers covering theareas listed above and showed that they werecompliant with the standards that G4S set for them.They included a judgement about each question thatwas required to be answered and the evidence thatsupports this judgement. For example, staff training hasrecorded that five staff file were checked for certificatesand attached to the audit file is the providers traininglog. The sixth service was a taxis service that is out ofscope of regulated activity, but they did audit staff filesat this service and set standards for training required.This training required included; basic first aid, infectioncontrol, patient dignity, care and safety, manualhandling, equality and diversity, safeguarding adults’level 2, and confidentiality and data protection. We alsoreviewed one audit of a service that did not meet G4Sstandards, so the audit was stopped, and thesubcontract was withdrawn from this service.

• The service had a governance and procurement team.We reviewed this teams standard operating proceduresthat list the areas they required to be covered in theaudit before work could be subcontracted to theseservices. This included CQC registration number,confirmation of disclosure and barring service checks,vehicle age inline with G4S policy, date and summary oflast CQC inspection, any improvements recommendedby CQC and actions taken to address these and acompleted audit of the service.

• We reviewed two sets of senior management meetingminutes and these included discussion on risks,incidents, safeguarding and improvements. Thesemeetings occurred once a month.

• The service had audit programs that were carried outeach year. The services governance team carried outyearly CQC style audits once a year for each site. Theyalso completed health and safety audits yearly for eachsite. We found the service were not sending notificationsof safeguarding incidents in line with legalrequirements.

• We found that the service had a procedure for staff tofollow when dealing with incidents relating to abuse orrisk of abuse relating to their regulated activity. Wefound that staff followed the service’s procedure forreporting incidents relating to abuse of risk of abuse butthat five incidents that should have been reported toCQC were not. The service’s procedure did not help staffidentify when incidents should be reported to CQC. Wealerted the service to this and they immediatelyreviewed their practice and started a retrospectivereview of their incidents log against their updatedprocedure.

Management of risk, issues and performance

• The service had effective systems for identifyingrisks, planning to eliminate or reduce them, andcoping with both the expected and unexpected.

• The service has a corporate risk register and local riskregisters for sites. We reviewed one corporate riskregister and two local risk registers. These risks,mitigating actions taken, a plan for reducing each riskand who was responsible for these actions.

Information Management

• The service collected, analysed, managed and usedinformation well to support all its activities, usingsecure electronic systems with security safeguards.

• The service had integrated computer-based businessmanagement systems to support the business andoperations. These systems were setup with individualpassword protected access for each person whichallowed access to systems they needed to fulfil theirrole. This also allowed the service to restrict access tosystems people did not need. They had an informationsecurity system to protect all private and confidentialdata. This included password protection on staff’sdigital tablets.

• The service used information technology systems tomonitor and improve the quality of care. The serviceused a secure system to store patient information. Thissystem was updated live so as soon as call handlersrecorded information crews could assess this. Theservice also had a system to record the movements oftheir vehicles, so they could audit performance and lookfor areas to improve efficiency.




• The service has clear and robust performance measureswhich were reported on monthly. Some of these wereset by their commissioners but others were set by theirmanagers. For example, we saw records showingmanagers were monitoring sickness rates were workingon ways to improve them.

Public and staff engagement

• The service engaged well with patients, staff, thepublic and local organisations to plan and manageservices, and collaborated with partnerorganisations effectively.

• The service engaged with patients that used theirservice and those close to them. The service carried outpatient feedback surveys which were offered to patientswith every journey. The service used the results of thesesurveys to produce monthly reports. We reviewed two ofthese reports. In these reports’ trends were highlightedand negative feedback quotes were recorded. Thesereports were reviewed by the service’s managers.

• The service held engagement meetings with renalpatients. Managers told us they had received feedbackfrom these patients that they did not wish to fill in ajourney feedback survey for every journey as they travelsix times a week with the service. The service had theirrelationship manager attend the renal units in person toreceive feedback from these patients. We reviewedrecords that showed they had spoken with 136 patientsto gain their feedback. From this they picked up a trendthat patients felt the vehicles were uncomfortable, sothe service has worked with their vehicle provider toimprove the comfort in the vehicles.

• The service carried out a yearly global staff survey. Theresults are reviewed for trends. The service also had alocal staff health and wellbeing survey that wascompleted yearly. This showed that there had been animprovement in staff saying the service takes action tosupport their wellbeing; in 2017 this was 19% but in the2018 this was 79%. This local survey also identified that37% of staff report that they had felt unwell due to stressin the past 12 months. The service had produced amental health awareness guidebook and leaflet for tipsto reduce stress.

• The service produced a monthly staff newsletter. Wereviewed a staff newsletter that included;congratulations to the employee of the month, issues

that had been reported by staff and what had beendone about these, and information about staffengagement days. One of these incidents related tocrews being able to refuse to accept patient that areunsuitable for the transport that was booked for them.The leaflet reminded staff that they are to risk assesseach patient and the service support them in theirdecision to refuse when needed. The staff engagementmeetings were advertised to alert staff when there willbe one at their site. There was a reminder about the G4Sglobal employee engagement survey. However, two staffreported that at their site a suggestion box had beenremoved with an explanation from their managers.

• The service had counselling and stress support serviceavailable to all staff.

• The service had awards for employee of the month,employee of the year and best driver of the month.Employees that were given these awards were given agift and any staff nominated for these awards wereinvited to a gala dinner. Staff could be nominated forthese awards by managers or their colleagues.

• The service had meetings with their commissioners. Wereceived positive feedback from the servicescommissioners about the services focus onimprovements. They also highlighted that the servicehad improved over the past year increasing theirengagement with the commissioners and drivingimprovements in some of their performance indicatorsbeyond the targets.

• We received positive feedback from some otherstakeholders reporting that the service had increasedtheir engagement with them over the past year.However, we also received negative feedback fromsome stakeholders saying the service did not alwaysattend engagement meeting they had agreed to attend.

Innovation, improvement and sustainability

• The service was committed to improving servicesby learning from when things go well and whenthey go wrong, promoting training, research andinnovation.

• The service has introduced a new geofencing system tonotify the control room when a vehicle arrives or leavesone of the large hospitals in the region. This reduced theinput needed from the vehicle crews. The fleet team




were also looking at a way to make the systemautomatically identify when vehicles arrive at patients’addresses and smaller sites that were not included inthis system.

• The service had a trial running of a new way to completethe vehicle checks. This system monitored the crew’sperformance while they input the checks that wereneeded. This included using the sensors in the digitaltablet when checking a vehicles tyre treads to ensurethat the crew were moving around the vehicle.

• The fleet team had improved their defect reportingsystem. This now allowed crews to take pictures ofdefects in vehicles to be added to the report. Thisallowed the subcontractor that carried out repairs tomore accurately assess the repair needed. This in turnallowed them to send out staff suitable for the repairwith the correct equipment more efficiently.

• The service had identified that for their renal patientsthat travelled with them six times a week may not want

to complete a journey feedback form for each journey.The service had introduced a patient relationshipmanager that goes out to renal units to gather feedbackfrom these patients in person.

• The service reviewed feedback from patients asking tobe able to travel in their own wheelchairs. This was notpossible at that time. The service had then worked withtheir vehicle provider to modify new vehicles to haverestraints to allow patients to safely travel in their ownwheelchairs.

• The service had introduced the role of patient transportliaison officer. These staff were based in large hospitalsand performed extra checks to make sure that thecontrol room had correct information so that the crewand vehicle sent to transport the patient was suitable.These staff also went to wards to identify patients thatcould be transported home earlier in the day to reducethe peak in demand for transport at the end of the day.




Outstanding practice

• The service was running a trial of a new vehiclechecking application. This used the crews’ digitaltablet to record the information and ensureadherences to the guidance. For example, crews hadto take a photo after cleaning had been done toshow the result.

• We saw records from when staff had been in difficultand distressing situations but still identified signs ofabuse and reported their concerns.

• Incident investigation was completed in a positiveway by managers looking for improvement not toblame staff. Then learning was shared via leafletsproduced for staff.

• Patients gave positive feedback about the way staffwent above and beyond to care for them.

Areas for improvement

Action the hospital MUST take to improve

• The provider must take prompt action to addressconcern identified during the inspection in relationto the governance of the service. The service mustensure that all required statutory notification to CQCare completed.

Action the hospital SHOULD take to improve

• The service should check understanding of whenstaff can raise a safeguarding concern withoutconsent from the individual.

• The service should take action to improve thefacilities at their Gillingham site.

• The service should improve their appraisal rates.

• The service should give all staff feedback aboutincidents they report.

• The service should remind all their staff of theimportance of introducing themselves to patientsand check this.

• The service should offer all patients a satisfactionsurvey.

• The service should improve the way they share theservice’s vision with staff.

• The service should consider how its managers couldbe more approachable and reassure staff they canapproach them for support.

• The service should consider how all staff can providefeedback about the service.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Transport services, triage and medical advice providedremotely

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

17.- (1) Systems or processes must be established andoperated effectively to ensure compliance with therequirements in this Part.

(2) Without limiting paragraph (1), such systems orprocesses must enable the registered person, inparticular, to — (b) assess, monitor and mitigate the risksrelating to the health, safety and welfare of service usersand others who may be at risk which arise from thecarrying on of the regulated activity; (d) maintainsecurely such other records as are necessary to be keptin relation to— (ii) the management of the regulatedactivity;

The service had a procedure for staff to follow whendealing with incidents relating to abuse or risk of abuserelating to the regulated activity. This did not ensurenotifications for all incidents that should be notified toCQC were completed.

Regulation 17 (1)(2)(b)(d)(ii)

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


g4s health services (uk) limited g4spatienttransport ... · g4s health services (uk) limited...

Documents