Yorkshire Ambulance Service NHS Trust HQ

Updated 4 August 2022

Yorkshire Ambulance Services NHS Trust (YAS) was formed in July 2006 following the merger of the county’s previous three ambulance services. The Trust serves a population of over five million people. It covers approximately 6,000 square miles of varied terrain, from isolated moorlands and dales to urban areas, coastal areas and inner city boroughs. The Trust as a whole employs over 5,000 staff and provides 24 hour emergency and urgent care services to a population in excess of five million people, and serves 13 clinical commissioning groups (CCGs).

The NHS 111 service provided by YAS works in partnership with Local Care Direct Which provides out of hours GP care in the West Yorkshire area. YAS NHS111 employs 336 whole time equivalent staff. YAS111 call centres are based in:

Wakefield site:

Springhill 2

Brindley Way

Wakefield 41 Business Park

Wakefield WF2 0XQ

Rotherham site:

Callflex Business Park

Doncaster Road

Wath-Upon-Dearne

Rotherham S63 7EF

The Trust is registered with the Care Quality Commission to provide the following regulated activities:

• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
• Transport services, triage and medical advice provided remotely

During our visit, which focused on services for the West Yorkshire area only, we visited the Wakefield site.

Updated 4 August 2022

Letter from the Chief Inspector of General Practice

We inspected the NHS 111 service which is provided by Yorkshire Ambulance Service NHS Trust (YAS) on 10 11 and 12 October 2016. We carried out this announced inspection as part of our comprehensive approach to inspecting NHS111 services.

Overall the provider is rated as good.

NHS 111 is a telephone-based service where patients are assessed, given advice and directed to a local service that most appropriately meets their needs. For example, this could be patients registered with a GP during working hours, an out-of-hours GP service, walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance or pharmacy .

Our key findings were as follows:

• The YAS NHS 111 had systems in place to mitigate safety risks. Incidents and significant events were identified, investigated and reported.
• The service was monitored against the Minimum Data Set (MDS) for NHS 111 services and adapted National Quality Requirements (NQRs). These data collection tools provided intelligence to the provider and commissioners about the level of service being provided. Action plans were implemented where variation in performance was identified.
• YAS NHS 111 worked closely with the 23 Clinical Commissioning Groups (CCGs) in the Yorkshire and Humber Region, who commissioned the service. Greater Huddersfield CCG acted as lead commissioner for the associate CCGs.
• Staff were trained and monitored to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a licenced computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call). We saw that regular call audits were carried out; however not all staff received face to face feedback on call audits.
• The provider had responded to reported episodes of bullying and harassment within the service. An independent arbitrator had been appointed to carry out an independent review into the issues. Recommendations and measures to improve staff morale had been adopted by the provider. In line with the national mandate the provider had appointed a ‘Freedom to Speak Up’ Guardian to enable staff to raise concerns safely.
• We saw patients contacting the service were supported effectively during the telephone triage process. Their consent was sought, and their decisions respected.
• The service proactively sought staff and patient feedback, and responded to issues identified.
• The provider had a clear leadership structure in place. However we saw that processes for staff supervision and support at team leader level were variable. Not all staff received regular 1:1s or face to face feedback on performance and call audits.
• We saw evidence that staff were able to access career development and secondment opportunities.
• The service had a clear vision and strategy to deliver high quality, safe and effective healthcare and provide good outcomes for patients.

We saw areas of outstanding practice:

• The provider was part of the West Yorkshire Vanguard and had been part of several pilot schemes to improve access to care and treatment. One of these involved improving access to pharmacist support. They had contributed to the development of a Pharmacy Urgent Repeat Medication Scheme (PURM) across the locality which enabled patients to access essential medicines from participating pharmacists out of hours. This scheme is supported by the NHS111 Pharmacy Team who had won a ‘Pharmacy Innovation’ award.

• The provider made use of a comprehensive 'Workforce Management Tool' to forecast anticipated call levels and deploy staff accordingly. The development of this tool and the transformation of planning within the organisation was recognised by a National Planning Award from the Professional Planning Forum.

However there were areas where the provider should make improvements.

The provider should:

• Regularly review the changes recently implemented in the management and leadership structure for call handlers, in order to ensure that all staff receive regular face to face feedback on their performance and call audits via the 1:1 process.
• Continue with steps to improve the access for call handlers to clinical advisors through an active recruitment programme.
• Maintain processes and systems which enable staff to safely raise concerns in relation to working relationships.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 1 February 2017

Overall, the service was rated as Good. This was because:

• The emergency operation centre (EOC) used an evidence based clinical triage system to assess patients.
• They had access to a language interpreter service and text relay service for patients with impaired hearing.
• Paramedic and mental health support and advice were available.
• Staff knew how to report safeguarding concerns. Safeguarding referrals could be made 24 hours a day through the clinical hub
• Staffing levels were scheduled and planned on an electronic system, which took into account previous demand data and forthcoming events.
• Governance processes were in place and there were clear governance structures. Risk registers were reviewed and management were able to describe the current risks to the EOC.
• The culture of the service was open and transparent and staff told us they received good support from their team leaders and duty managers.
• The trust had been involved in a number of initiatives, such as ‘The Blue Light’ programme. The aim of the programme was to improve the mental health of staff working in emergency service by having ‘Blue Light Champions’ to act as support to staff.
• The service was one of the leading organisations in the piloting of the Ambulance Response Programme (ARP) introduced in April 2016. ARP aimed to improve response times to critically ill patients by ensuring an appropriate response to patients first time.
• Incidents were reported, investigated and lessons learnt shared with staff across the organisation. Although the majority of staff received feedback from incidents, there were inconsistencies as some staff had not always received individual feedback. This was also the findings at the previous inspection.

However we also found:

• Not all staff using the evidence based clinical triage system were up to date with basic life support (BLS) training. Up to date training was a requisite for a licence in the use of the system. Following the inspection the trust wrote and assured CQC that by the 1 December 2016 85% of the EOC staff would have BLS training. They also informed us that they had recently been re-accredited by the International Academy and given centre of excellence status. Training on BLS instructions within the dispatcher role was part of the criteria for re-accreditation.
• Not all nursing staff were up to date with safeguarding training.

Updated 1 February 2017

Overall we rated resilience at YAS as Good. Safe and well-led was rated as Good and effective was rated as Outstanding.

• We found good evidence of learning both in local and wider resilience teams. This was supported by good systems for reporting incidents and debriefs.
• Mandatory training levels had been met or exceeded. Staff were able to demonstrate their knowledge around mental capacity and safeguarding.
• Significant improvements had been made with regards to checking equipment and the cleanliness of the environment and vehicles. This had been sustained since the previous inspection.
• Medications management practices were safe.
• Staffing levels were good and in line with national guidance.
• Business continuity plans were robust and the service assessed and responded well to potential risks, service demand and capacity.
• Staff were actively engaged in activities to monitor and improve quality and patient care. Care was evidence based and opportunities to participate in benchmarking, peer review, accreditation and research were proactively pursued.
• Staff were proactively supported to acquire new skills and share best practice and we were provided with many examples of this. Staff competencies were maintained and tested in accordance with National Ambulance Resilience Unit (NARU) recommendations.
• A number of Hazardous Area Response Team (HART) operatives were specialists in particular core competencies such as chemical, biological, radiological and nuclear (CBRN), and safe work at height incidents (SWAH) and provided training and updates to colleagues.
• Staff were patient focused in terms of care planning and delivery, with a commitment to collaborative working based on Joint Emergency Services Interoperability Programme (JESIP) principles which were embedded within the service.
• Information was collated and shared in performance dashboards and in ResWeb which all staff had access to. Information was also shared via a database, ‘PROCLUS’ from national bodies such as NARU.
• There was a clear vision and strategy for the service which was stretching and supported by staff. This linked to the overall trust vision as well as national guidance.
• There was active engagement with a variety of other organisations and a strong focus on collaborative working.
• Leadership was strong at all levels with experienced and knowledgeable staff in post. There was a focus on continuous improvement and motivation of staff towards a shared purpose.
• It had been identified from the previous inspection the changes in practice in some areas needed to be made. It was identified these could not be brought about by an individual person. All staff were involved and accountable for the changes in practice.
• There was a very positive culture within the teams and staff morale was high. There were high levels of engagement with staff, and staff were encouraged to raise concerns.
• The governance arrangements and information related to performance were proactively reviewed.

Updated 1 February 2017

We undertook a comprehensive inspection of the Yorkshire Ambulance Service (YAS) in January 2015. At this time, we rated Patient Transport Services as Requiring Improvement in the domains of safe, effective, responsive and well-led. We rated the caring domain as Good.

• There had been some improvements to incident reporting and there were also some systems in place to monitor risks. However, there was a lack of robust processes and management oversight to ensure staff had learned from incidents or complaints.

• There were identified risks missing from the risk register, so it was unclear what actions had been taken to mitigate these risks.
• There had been some improvements in the maintenance and cleaning of vehicles and the replenishment of equipment vehicles. However, there was inconsistency in what was stored on vehicles and where it was stored. Storage of some equipment was not safe and posed a risk to patients. There were also unsafe vehicles in use and fault reporting was not robust.
• In some localities we found vehicle security to be poor which was a risk to the service.
• There were systems to monitor quality and performance. There had been some improvements in the service’s performance against some of the key performance indicators. However, concerns remained regarding the performance targets not being met for some renal dialysis patients and within the communications and control centre.
• There continued to be staffing vacancies in the communications and control centre. This had a negative impact on patient experience and other stakeholders contacting the service. This also had an impact on the planning and scheduling of patients’ return journeys.
• The business continuity plans for the communication and control centre were not well developed despite actions being identified from a table top exercise in October 2015.

However:

• Most staff told us they felt proud to work for the trust. Patient transport service (PTS) staff felt their immediate operational managers supported them in their role, although there were some reports of a disconnection between staff and senior managers.
• There were robust plans in place for fluctuations in demand, staffing shortages and for adverse weather conditions.
• The compliance rates for mandatory training and staff appraisals showed a significant improvement from our last inspection.
• During the course of our inspection, we saw examples of staff demonstrating a caring and compassionate approach to supporting patients. We observed patients dignity being maintained and patient being treated in a respectful way. We also received some very positive feedback from patients and their carers regarding the PTS staff who demonstrated a real commitment to delivering a good service.

Updated 1 February 2017

At our previous inspection in January 2015, the service was rated as Requires Improvement overall. In September 2016 we rated this core service as Good because:

• The trust had put in place processes for risk management and clinical governance of the service. Risks were rated and a review date specified which showed each risk was recently reviewed.
• Positive changes to the executive leadership of the service were recognised and appreciated by staff; the chief executive was seen as approachable.
• The trust was participating in the national trial of the ambulance response project (ARP) which helped the service to dispatch appropriate ambulance resources to patients.
• Outcomes for patients had improved; for example practice to support the return of spontaneous circulation (ROSC) and involvement with regional and national sepsis networks had strengthened the sepsis pathways and improved clinical quality outcomes.
• Staff worked closely with hospital providers of emergency and other providers of services including fire and rescue and community responders to coordinate appropriate pathways of care for patients.
• Staff were able to report incidents readily and learning from the investigation of incidents was shared.
• Infection control procedures were followed and ambulance stations and vehicles were clean. A vehicle “make ready” service had been introduced in some stations. There were plans to introduce this across the service.
• Equipment and consumable supplies were readily available and arrangements for disposing of out of date items were in place.
• The workforce plan developed during 2016-17 reflected demand profiles for each area and planned workforce numbers and recruitment were monitored weekly. The workforce plan was communicated and understood by staff which helped to support retention.
• Records contained appropriate and sufficient information about the patient and their condition and were fully maintained and audited.
• Patients with deteriorating conditions were identified promptly and escalated for appropriate treatment. Pathways for assessing and responding to patients who experienced trauma, suffered from chest pain or experienced a suspected stroke were followed.
• Medicines were stored securely and administered safely. Oxygen and analgesic gases were secured securely and were in date. Secure storage for medicines was also maintained in acute hospitals. We saw medicines cabinets were securely locked with access only permissible by ambulance service crews. Controlled medicines were stored in ambulance stations in a locked room within a locked safe and the room was alarmed.
• The learning and development of staff was supported. All staff new to the service received thorough induction and training and the service was taking steps to ensure staff received an annual appraisal and clinical supervision. Most staff had completed their mandatory training.
• The culture of the service had improved. Public engagement for the service had developed and included roadshows and community partnership events. Local engagement events had attracted more than 3,000 members of the public. Consultation arrangements with staff included a newly established multi union partnership and the staff forum was embedded.
• Staff knew how to deal with complaints they received, complaints were investigated and we found some evidence that learning was shared with staff. For the 12 months prior to our inspection the service had met agreed due dates in 96% of cases and has achieved an average response time of 21 working days for all services. The service had a standard of 85% for quality audit outcomes, and was achieving 86% at the time of our visit.
• Innovation was encouraged through support for national initiatives and locally based research projects.

However:

• The allocated time of six minutes for crews to check their vehicle and equipment at the start of their shift was insufficient for all essential equipment to be checked.
• The recording of medicines administration contained some discrepancies which were not always identified through audit procedures. At an emergency department we visited, when we checked the stock of controlled medicines, we found the items issued had been audited incorrectly, so that one item was shown incorrectly as in surplus. The service addressed this issue at the time of our visit.
• Records were not always securely stored on ambulance vehicles. We raised this with the trust during our visit and at our unannounced inspection we found that procedures had been changed to protect the security of records.
• It was not always possible for ambulance crews to access secure vehicle seating for children.
• Disposal of clinical waste and sharps was variable in a minority of vehicles and ambulance stations.
• Further work was needed to ensure a target number of staff (at least 85%) received an annual appraisal. The service had in place a recovery plan to achieve 90% appraisal rates by 2017-18.
• Specialised equipment to support bariatric patients needed to be made available and accessible to all emergency ambulance crews.
• Front line staff we spoke with could not articulate the vision and strategy for the service.