Zot Limited

Updated 18 December 2020

Zot Limited is an independent ambulance service which provides Patient Transport Services (PTS). The service opened in 2018 and is based in North West London. Zot Limited registered with CQC in September 2018 and started providing services in February 2019. The service transports non-emergency patients to and from community locations, airports, hospitals and patients’ home addresses, primarily within London with some transfers across the whole of the United Kingdom. The service transports both adults and children and has two vehicles used for PTS.

Zot Limited currently has no contracts or service level agreements in place. Following our last inspection, Zot Limited was suspended between January 2020 and April 2020. The provider started providing transfers again on the 24 April 2020. Since then the provider has carried our 186 journeys. Of these 185 transfers were adults and one journey was a child. All jobs the provider undertakes are ad-hoc and short notice bookings.

Zot Limited registered with the CQC on 5 September 2018. The registered manager has been in post since the service opened.

The provider updated their registration following the January 2020 inspection and was now registered to provide the following regulated activities:

• Transport services, triage and medical advice provided remotely
• Treatment of Disease, Disorder and Injury (TDDI)

Following our last inspection on 21 January 2020, the provider was rated ‘inadequate’ and placed in special measures. This was because we identified significant safety concerns and breaches in the following of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 Safe care and treatment and Regulation 17 Good governance. Section 10 of the Health and Social Care Act 2008 makes it an offence to carry out a regulated activity without being registered to carry out this activity with the CQC. At the last inspection, we also identified the provider was carrying out the regulated activity of TDDI without being registered with CQC to do so. Due to breaches in these legal requirements, we imposed a Section 31 Urgent suspension of a regulated activity. Zot Limited took action to address the regulatory breaches. The Section 31 notice was addressed by the provider during the suspension period. The provider did not start providing transport until required actions were completed.

To help us carry out our comprehensive inspection, we interviewed all three members of the senior management team and PTS crew. We also examined 33 patient booking forms and numerous documents including the provider’s staff records, policies, risk register and audits.

Updated 18 December 2020

We conducted a short notice unannounced comprehensive inspection of Zot Limited, which is a Patient Transport Service (PTS) to see if improvements had been made since our inspection in January 2020. We inspected Zot Limited as part of our continual checks on safety and quality of healthcare services and to look at all parts of the service that did not previously meet legal requirements in the January inspection. At that time, we rated the provider as inadequate and the provider was suspended due to concerns we had about the quality of the services. The provider was also placed in special measures. Following the January inspection, Zot Limited regularly engaged with CQC around the improvement action plan.

Overall, we found the provider had made significant improvements since our last inspection. Our rating of Zot Limited improved. We rated it as requires improvement because:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. We reviewed records from all five staff files and saw staff members had been re-trained in all areas of mandatory training since the last inspection. Staff knowledge on mandatory training topics such as safeguarding and consent had improved.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The safeguarding policy was up to date with relevant national guidance and the safeguarding lead was now trained to the recommended level.
• The service controlled infection risks. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. There was a good understanding of national guidance for COVID-19 and good access to personal protective equipment (PPE).
• All staff had been re-trained in the use of equipment by a qualified trainer. Staff were able to demonstrate how to use pieces of equipment such as the patient carry chair. The provider had also purchased a children’s harness for the second vehicle to keep children safe during transport. All equipment was well maintained and serviced as per manufacturer’s guidance.
• The provider had updated their Deteriorating Patient Policy so that it was in line with the scope of practice of a Patient Transport Service (PTS). Staff had a good understanding of the signs of a deteriorating patient and knew to call 999 or attend the nearest emergency department if this happened.
• The provider had introduced an exclusion criteria as part of their booking process. This ensured patients were risk assessed for suitability to a PTS service before accepting the transfer. The booking form also contained an assessment designed to exclude patients displaying COVID-19 symptoms, as the provider was currently not transporting these patients.
• The provider had enough staff with the right skills and competencies for a PTS. This ensured patients were kept safe from avoidable harm.
• Patient booking forms were now completed for each patient and contained all relevant details and information about the person being transferred. The registered manager was now auditing all booking forms staff fully completed them.
• The provider had improved the way they managed patient safety incidents. An incident reporting log was now in place and all incidents were investigated and any learning identified and shared as per the incident reporting policy. Staff awareness of incidents and what they should be reporting had improved.
• The provider was monitoring performance against Key Performance Indicators (KPIs) for arrival and departure times and had good compliance.
• The consent policy had been updated and patient consent was documented on the booking forms. Staff knowledge of the mental capacity act and deprivation of liberty safeguards had improved.

However;

• The provider had updated a number of their policies so they were up to date with relevant national guidance. Whilst all policies had been reviewed and were up to date we noted no policies had version control. Therefore, there was no record of what had been added or removed from policies following changes. Therefore, we could not be assured staff knew about the changes.
• The provider took into account peoples individual needs at the time of booking. However, there were limited facilities available to ensure these needs were met. For example, there were no communication aids available to support those who could not communicate verbally. Following the inspection, the provider informed us they had ordered communication aids for both vehicles.
• The provider had a complaints procedure in place, however we were not assured it was easy for patients and relatives to give feedback.
• The provider had improved risk management and a risk register was now in place, which listed each risk to the service and what actions the provider was taking. However, risk management was not fully robust. The risk register did not provide detail as to why each item was a risk to the service or dates when risks were last reviewed. The process for removing risks from the risk register was also not established.
• The provider had improved clinical governance within the service. However, the clinical governance meeting had no terms of reference and meetings did not state quoracy. Whilst the same items were discussed, there was no documented agenda.
• Whilst there was a document called the quality and strategy document 2020 to 2022, knowledge about the aims of this amongst staff was poor. The leadership team stated compliance with CQC was the overall focus at the moment.

Updated 18 December 2020

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

• Mandatory training had improved since the last inspection. All staff had attended mandatory training modules again over a period of five days. Training was completed via training providers and e-learning. There was systems and processes in place to support ongoing compliance with mandatory training.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The safeguarding lead was now trained to the recommended level and the safeguarding policy was up to date with relevant national guidance.
• The provider controlled infection prevention and control risks. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. Personal Protective Equipment (PPE) was in use in response to the COVID-19 pandemic and used in a way that kept people safe.
• The design, maintenance and use of facilities, premises and equipment kept people safe. All staff had received training from a suitably qualified trainer on the safe use and management of equipment. Staff were able to show us how to use pieces of equipment such as the patient carry chair and a child’s harness.
• The provider had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The provider had introduced an eligibility criteria to ensure patients were assessed for suitability to a Patient Transport Service (PTS).
• The completion of booking forms had improved and the registered manager conducted monthly audits to ensure compliance. Booking forms were completed with all the key information required to ensure the safe transfers of patients, including pre-transfer risk assessment, COVID-19 screening, medical history and next of kin details.
• The provider had registered for the regulated activity to Treatment of Disorder, Disease and Injury (TDDI). This ensured they were registered to supply oxygen on vehicles. All staff had been trained and had competency assessments in the use of oxygen. Oxygen was stored securely on vehicles and a policy was in place around its use.
• The provider had improved how they managed patient safety incidents. Staff recognition of the types of incidents that needed to be reported had improved. The registered manager had an incident reporting log, which detailed the incident, the learning and what actions had been taken.
• The service provided care and treatment based on national guidance. Evidence-based practice and policies were up to date. The registered manager checked to make sure staff followed guidance and had signed up to receive regular updates when new guidance came out.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
• The provider was monitoring Key Performance Indicators (KPIs) to ensure good performance around arrival and departure times. The provider currently had no contracts or service level agreements in place, however was monitoring KPIs to ensure their journeys were timely.
• Staff supported patients to make informed decisions about their care and treatment. They followed the provider’s policy around documenting consent on booking forms. Staff understanding of the Mental Capacity Act 2005 and consent had improved.
• The leadership team had undergone further training and employed an external contractor to support them in improving clinical governance within the service. The senior leadership team were meeting on a monthly basis to discuss performance and risk.
• The service had made significant improvements to support an open and transparent culture. Staff were encouraged to report when things went wrong and it was clear there was a no-blame culture. Staff told us they were very supported by the management and morale was good. There were regular team meetings with all staff and this was evidenced with staff meeting minutes.
• The provider improved their information management and were no longer sending photographs of booking forms to staff. Staff now took the patient booking forms with them on journeys and returned them to the office following the completion.

However:

• The provider had updated a number of policies to ensure they were referencing relevant national guidance. The policies did not have any version control so there was no record of what information was removed or added to the policy.
• The provider took into account peoples individual needs at the time of booking. However, there were limited facilities available to ensure these needs were met. For example, there were no communication aids available to support those who could not communicate verbally. Following the inspection the provider informed us they had ordered communication aids for both vehicles.
• Systems for patient engagement were limited and it was not easy for patients to give feedback or raise concerns.
• Clinical governance meetings were now taking place on a monthly basis. However, there were no terms of reference in place. When we asked the registered manager about this he was unsure what we meant by terms of reference.
• The risk register did not describe or provide information about why each risk item was a risk to the service. The provider also did not have a formalised procedure in place for closure of risks from the register once the risk score was low. The dates that each risk were last reviewed was not documented. However, the provider had significantly improved risk management since the last inspection. There was a risk register in place and risks were discussed monthly during clinical governance meetings. The management were aware of the biggest risks to the service and mitigations were in place to reduce risks.
• The provider had a documented strategy. However, staff were unable to tell us what the strategy for the provider was.