Yorkshire Ambulance Service NHS Trust HQ

Yorkshire Ambulance Service NHS Trust (YAS) was formed on1 July 2006 when the county's three former services merged. The trust covers North Yorkshire, South Yorkshire, West Yorkshire, Hull and East Yorkshire covering almost 6,000 square miles of varied terrain, from isolated moors and dales to urban areas, coastline and inner cities. The trust employsover 4,670 staff and provides 24-hour emergency and healthcare services to a population of more than five million.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, an NHS 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and emergency operation centres (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There is also a resilience and hazardous area response team (HART).

We carried out a focussed follow up inspection of the trust from 13-16 September 2016, in response to a previous inspection as part of our comprehensive inspection programme of Yorkshire Ambulance Service NHS Trust in January 2015. In addition, an announced comprehensive inspection of the NHS 111 service was carried out on 10-12 October 2016.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We therefore did not inspect all of the five domains: safe, effective, caring, responsive and well led for each of the core services we inspected.

We inspected five core services:

• Emergency operations centres
• Urgent and emergency care
• Patient transport services
• Resilience services including the Hazardous Area Response Team
• NHS 111 services.

Overall, we rated all of the five key domains as good which meant the overall rating for the trust was also good.

Our key findings were as follows:

• The trust had undertaken a number of initiatives to improve staff engagement; the staff forum had become embedded since our previous inspection and was viewed positively by staff.
• Relationships between the trust and trade unions had improved since the previous inspection but there still more work for the trust to do.
• Staffing levels throughout the trust were planned and monitored. The trust had challenges due to national shortages however; it was addressing this through a range of initiatives.
• From April 2016 the trust was participating in the national trial of the ambulance response programme (ARP) which helped the service to dispatch appropriate ambulance resources. There were no performance targets for the ARP pilot. The trust monitored its performance on response times.
• At the previous inspection there had been concerns in relation to equipment checks, maintenance of equipment and consumable stock. At this inspection we found the trust had put in place a system to ensure equipment and stock was suitable to use.
• In most of the core services we found infection control procedures were followed and the ambulance stations and vehicles we observed were generally clean. However there were still inconsistencies in the way staff maintained vehicle cleanliness across the PTS service.
• There were systems in place to share learning from incidents and adverse events. Most staff we spoke with confirmed they received feedback by email after reporting an incident. A safety bulletin was produced and shared across the trust to share lessons learnt.
• There were high levels of compliance with safeguarding training at levels one and two and all staff who were determined by the trust to require level three training in relation to their role, had received this.
• From April 2016 the trust had commenced a local review of mortality and morbidity, supported by local audits linked to the trust’s commissioning for quality and innovation (CQUIN) targets to explore all deaths in the care of the trust, where Recognition of Life Extinct (ROLE) had been invoked by YAS paramedics.
• Within the NHS 111 service, call abandonment rate was 2%, compared to the national average of 3%. We saw that 89% of calls were answered within 60 seconds, compared to the national average of 87%.
• Within the PTS service there was a clear lack of management oversight and lack of ownership of roles and responsibilities, and governance systems were not fully embedded throughout the service.

We saw several areas of outstanding practice including:

• The red arrest team provided clinical leadership in the response to cardiac arrest patients, which had improved the success rate in the return of spontaneous circulation (ROSC).
• The restart a heart team was commended for its CPR work with school children. More than 31,000 children were trained in hands-only CPR in conjunction with the British Heart Foundation.
• Community first responders were trained volunteers who were available to attend emergency calls and to provide initial care before the arrival of an ambulance. More than 300 community first responder schemes worked closely with the ambulance service.
• The service supported 670 public access defibrillators across the Yorkshire region which were available for use by members of the public. The scheme particularly helped people to access defibrillators in remote villages.
• A member of the air ambulance crew had completed training in Crew Resource Management (CRM). The qualification enabled the member of staff to undertake critique and feedback of incidents whilst taking account of human factors.
• HART staff presented evidence on the benefits of early antibiotic administration in open fractures. This treatment now has become standard practice within YAS.
• The trust was part of the urgent and emergency care vanguard programme, to support the development of new approaches to the provision of urgent and emergency care. The West Yorkshire urgent and emergency care network aimed to develop an integrated urgent care model for the region, building on the services provided by existing urgent care services.
• The trust 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 had won a ‘Pharmacy Innovation’ award.
• The NHS 111 service had implemented access to palliative care nurses on weekends and bank holidays, who were able to provide support to patients approaching the end of life.
• The trust had 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 also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff.
• Within patient transport services (PTS) the trust must ensure that all ambulances and equipment are appropriately cleaned and infection control procedures are followed.
• The trust must ensure secure seating for children is routinely available in ambulance vehicles.

In addition the trust should:

• The trust should review the training requirements for operational staff in the PTS service for vulnerable groups such as patients living with dementia and patients experiencing mental health concerns.
• The trust should review the arrangements for operational staff to check their vehicle and equipment at the start of the shift to ensure they have sufficient time to complete the checks.
• The trust should review the audit procedures for reviewing the recording of controlled medicines.
• The trust should continue to ensure that equipment and medical supplies are checked and are fit for purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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