Archived: Ambulance UK Also known as t/a St Bridget's Ambulance Service

Mr Anthony Howell is the provider who owns and manages Ambulance UK trading as St Bridget’s Ambulance Service. The service is registered to provide transport services triage and medical advice provided remotely. From February 2016 to January 2017 there were 67 patient transport journeys undertaken. They do not provide a service for children.

Prior to this unannounced inspection on 13 June 2017, we carried out a planned comprehensive inspection of Ambulance UK trading as St Bridget’s Ambulance Service on 15 February 2017, along with a routine unannounced inspection on 8 March 2017. During that inspection, we found the provider was failing to provide safe care and governance arrangements were inadequate. We found that safe working practices were not followed while providing the service that included poor infection control, inadequate assessments and management of risks. Quality assurance processes were not fully developed in order to identify or mitigate safety risks. We issued the provider with two warning notices under Section 29 of the Health and Social Care Act, 2008, on 16 March 2017 stating they needed to be compliant by 2 May 2017.

Following the inspection in February and March 2017, the provider wrote to the CQC and agreed to a voluntary suspension of the service. This was to allow them to review the service and make the necessary changes following the warning notices in order to become compliant. The service remains non-operational at the time of this report.

The purpose of the unannounced inspection in June 2017 was to follow up on the warning notices and report on progress that had been taken to provide safe care and treatment and ensure governance arrangements were adequate. Following the unannounced inspection in June 2017, we requested further information from the provider, as they had not met fully met the warning notices. We also met with the provider and new manager on 1 August 2017 to clarify some of the information received. This report was focused on reporting on our findings in respect of the breaches as described in the warning notices served.

Services we do not rate

We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight good practice and areas of practice that service providers need to improve and take regulatory action as necessary.

At our unannounced inspection in June 2017 and our meeting 1 August 2017, we found the provider had not taken actions to fully meet the warning notices. Progress was limited, and there was still risk of patients not receiving safe care.

• Overall, the provider had made some improvements in the safety of the service. However, the improvements had been driven by directives from the CQC and we were not assured that the provider had the knowledge or the skills to sustain a safe service if the service were to resume and without close scrutiny and clear instructions from CQC.
• Whilst the provider and the appointed manager were keen to comply with the Health and Social Care Act, we were not assured that they had the depth of knowledge or skills to drive improvements within the service independently. For example, where we highlighted missing policies, the provider would devise a policy as requested but the quality and information within the policy was not always clinically accurate or relevant to the service. Similarly, the provider had completed safeguarding training as this was highlighted in our previous inspection as required but through discussions they were unable to demonstrate a sufficient understanding of safeguarding and associated processes.
• Governance processes had not been developed. An updated risk register was provided but did not include all hazards in relation to the day to day delivery of the service, for example possibility of equipment failure or staff sickness. The risk register did not include a full description of risks, all mitigation in place, or a plan for review of risks.
• Policies and procedures were not effective and did not support the day to day operation of the service. Policies did not always relate to the service and did not provide evidence that the provider had really considered best practice guidance or the requirements of the service. There was a risk of patients receiving care not based on best practice and guidance.
• The Department of Health publishes a Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and Related Guidance (herein The Code). The Code sets out the basic steps that are required to ensure the essential criteria for compliance with the cleanliness and infection control requirements under the Health and Social Care Act 2008 and its associated regulations are being met. Criterion 1 of the Code gives guidance about managing and monitoring the prevention and control of infection and the use of risk assessments to prevent infections in susceptible patients using the service. Through discussion with the provider, it was apparent they had no knowledge of the Code of Practice and, as such, we were not assured the provider was meeting the guidance or had anything similar or better in place.
• The newly created control of infection policy did not relate to the service. The providers cleaning protocol contained items not on the vehicles, so this was confusing to read and could lead to error.

• The policy for managing body fluids including blood that may be contaminated, did not comply with best practice, and advised staff to dispose of infected materials into a ‘plastic waste sack’ rather than designated colour coded bags.

• There was no process in place for the segregation of clean and dirty equipment on the vehicles which presented a risk of cross infection.
• There was no medicines policy in place for ordering, receipt and storage of medical gases as identified at the last inspection. There was no signage and information available to advise the emergency services attending an incident or accident that the vehicle was carrying flammable gases such as oxygen and nitrous oxide (an inhaled gas used as a pain medication). There was also no safety data sheet relating to these products as recommended. Following this inspection, the provider took steps to mitigate these risks. The medical gases were returned to British Oxygen Company on 4 August 2017, as there were no standard operating procedures to manage them safely. However, we were not assured that the provider would no longer transport patients requiring medical gases in the future.

• The provider was unclear whether they would or would not be providing storage for patients’ own medicines during journeys in the future. We were not assured that if the service was reinstated they would safely store or manage patients’ medicines through each journey.

• The patient booking form had been updated. However, whilst there was a booking form there was no guidance in place to support staff to complete the clinical aspects of the booking form such as assessing, managing or mitigating patient risks.

• Whilst a medical equipment checklist had been put in place, there was no associated procedure to ensure this was routinely completed.

• The provider had no record keeping policy in place.

• There was no clear written guidance on how the minimum number of staff on a patient transport journey would be risk assessed. We were not assured through discussions with the provider that the service would provide the correct number of staff for each patient journey.

• There was no audit plan in place. We were not assured that the provider planned to audit the effectiveness of the service.

We found the following actions had been taken:

• Though not in use at the time of our inspection, the three vehicles were clean and maintained appropriately.
• A review of equipment had been completed and a checklist developed. Though the equipment was not in use at the time of our inspection, a random check showed that equipment was within the use by date on the packaging.
• The ‘evac chair’ had been replaced, and staff had received training on how to use the ‘evac chair’ safely.
• The new manager and two staff supporting the service had now received safeguarding training at the appropriate level. The new manager had received training at level 3 and the two staff supporting the service at level 2.
• The provider had appointed a manager who would be responsible for the overall management of the service.

Following this inspection, the provider agreed to continue the voluntary suspension of the service. 

Full information about our regulatory response to the concerns we have described in this report will be added to a final version of this report we will publish in due course.

Professor Edward Baker

Chief Inspector of Hospitals

Mr Anthony Howell was the provider who owned and managed Ambulance UK trading as St Bridget’s Ambulance Service. The service provides a patient transport service (PTS) and is registered to provide transport services, triage and medical advice provided remotely.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 15 February 2017, along with an unannounced visit to the service on 8 March 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, 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 complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following issues that the service provider needs to improve:

• The provider did not have a manager in place consistently for the day-to-day management of the regulated activity.

• The provider did not have an effective system to assess, monitor and improve the quality and safety of the services provided. There was no evidence of incidents reporting and any learning to improve practices.

• Information was not readily available to patients or their carers about how to make a complaint or raise a concern about the service. The complaints system in place did not support service users to not identify themselves, if that was their choice.

• Effective systems and processes were not in place to implement the statutory obligations of duty of candour.

• Staff had not received training related to management of patients they were caring for as part of patient transport services. Staff recently recruited did not have documented evidence that induction training completed.

• Not all staff had completed mandatory training for the equipment used in the patient transport vehicles.

• The safeguarding process was not fully developed which did not protect patients using the service.

• Medicines were not managed safely or securely. The service used medical gases. There was no medicines management policy in place with clear lines of accountability.

• Staff had not checked emergency equipment to ensure equipment was within use by dates and fit for purpose. There was no expiry date on the oxygen mask we checked, and no guidance regarding flow rates.

• The provider was not always completing pre-employment checks as detailed in their own recruitment policy.

• Staff did not follow infection control policy and procedures to safeguard patients from the risk of cross infection. This included no spillage kits on the vehicles at our planned inspection.

• Staff had not fully completed the patients booking forms and details of persons undertaking the role were not always recorded and signed.

• There was no risk register and the provider was unable to demonstrate how risks identified and escalated in order to protect patients. There was no process where risks could be assessed, tracked, managed or mitigated.

• There was no governance structure for the service and no formal means of discussing clinical issues within the service.

• There was no process to collect patients’ data in order to monitor and improve patients’ outcomes.

• There were no performance management or checks to ensure staff had the required qualification for the role they were performing.

• Policies and procedures had not been developed to support practices for patient’s transport services.

• Staff had not fully completed the ambulance vehicle checklist and conditions of use form prior to each patient journey.

We found the following areas of good practice:

• An annual satisfaction survey of patient/ relative feedback was undertaken by the service. There was a 26% response rate and demonstrated high levels of satisfaction with the service.

• Relatives we spoke with commented that staff were kind, caring and sensitive.

• Staff we spoke with said they could approach the provider if there were any concerns.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two warning notices to be compliant by 2 May 2017, and two requirement notices, due to the level of concerns and immediate actions they needed to take. Details are at the end of the report. The provider following the inspection voluntarily suspended the service. We will be returning to inspect the service before any further regulated activity is provided.

Professor Edward Baker

Deputy Chief Inspector of Hospitals