South Central Ambulance Service NHS 111

South Central Ambulance Service NHS Foundation Trust (SCAS) was formed on 1 July 2006, after the merger of the Royal Berkshire Ambulance Service NHS Trust, the Hampshire Ambulance Service NHS Trust, the Oxfordshire Ambulance Service NHS Trust and part of the Two Shires Ambulance Service NHS Trust. It provides NHS ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire in the South Central region. This area covers approximately 3,554 square miles with a residential population of over 4 million. On 1 March 2012, the trust achieved foundation trust status.

The trust provides an accident and emergency (A&E) service to respond to 999 calls, a 111 service for when medical help is needed fast but it is not a 999 emergency, patient transport services (PTS) and logistics and commercial services. There is also a Hazardous Area Response Team (HART) based in Hampshire. Services are delivered from the trust’s main headquarters in Bicester, Oxfordshire, and a regional office in Otterbourne, Hampshire. Each of these sites includes an emergency operations centre (EOC) where 999 and NHS 111 calls are received, clinical advice is provided and from where emergency vehicles are dispatched if needed. There was a PTS contact centre at each EOC.

Our inspection took place on 10 and 11 September 2014 with unannounced visits on 30 September and 1 October. We inspected the trust as part of our first wave of comprehensive ambulance inspections. We looked at three core services: access via emergency operations centres, patient transport services and emergency and urgent care. The 111 service provided by the trust was not inspected on this occasion. The logistical and commercial training services were also not inspected as these do not form part of the trust’s registration with the Care Quality Commission (CQC).

The team of 48 included CQC inspectors and inspection managers, an analyst and inspection planners and a variety of specialists: The team of specialist was comprised of a consultant physician in intensive care, two nurses working in accident and emergency departments, four paramedic staff, one emergency care practitioner, a paramedic clinical supervisor and development manager , three managers with an operations role, a head of governance, a director of service delivery, two chief executives, a pharmacist, a safe guarding lead, two people with a role in an operations centres and three experts by experience

We did not provide ratings for this trust because this inspection was part of our first wave of ambulance inspections to apply our methodology and develop our understanding of inspecting in this sector.

Key findings

Across the core services:

• Staff were caring and compassionate, and treated patients with dignity and respect.
• Staff were positive about the quality of care they provided for patients and were proud to work for the trust. There was low morale in places and the pressures faced by the trust were recognised. Staff however “lived” the values of the organisation: “Towards excellence – Saving lives and enabling you to get the care you need”.
• Patients told us their experiences of care and treatment was good. They were positive about emergency ambulance response times but there were concerns about the punctuality of patient transport services.
• Incident reporting was increasing on the newly introduced electronic reporting system. The trust was taking action following incidents, but there needed to be earlier and quicker investigation for some incidents. Learning was shared via clinical bulletins, the trust intranet, noticeboards and email. The trust had introduced SCAScade to improve organisational learning from when things go wrong. This included anonymous cases and reflective tools for staff to use on the trust intranet. However, staff in the EOC and PTS needed to be encouraged to use and take responsibility for reporting incidents and also required feedback and shared learning in their areas.
• Staff in the emergency and urgent care service had good knowledge of the Mental Capacity Act 2005, but staff in EOC and PTS needed to have better knowledge to ensure the best interest of patients.
• Safeguarded procedures were being used but needed to improve and the safeguarding lead had a limited capacity to deliver the safeguarding agenda across the organisation. Safeguarding champions in geographical areas were to be developed but this needed to be prioritised.
• Staff had good training opportunities and specialist training on dementia care, learning disabilities and mental health was being improved. Staff were supported with funding for further qualifications and professional development, However, some staff did not always have access to computer facilities to undertake training or the dedicated time to complete it, and attendance at mandatory and statutory training was low.
• Most complaints were responded to within the trust’s target time of 25 days and action was being taken to improve services as a result. Complaints were analysed to identify themes and the trust aimed to share learning, for example, through teams and noticeboards. There was evidence of actions taken as a result of complaints in all services. However, staff told us they did not always get feedback on complaints or concerns raised.
• The trust understood its duties under the Civil Contingencies Act 2004 and all staff were aware of what to do in the event of a major incident. Staff had appropriate training, there was joint working with partner organisations (such as the fire service, police and military), and rehearsals were undertaken as part of preparation and planning exercises.
• The trust had worked with partner organisations including fire and rescue, police, and the environmental agency during the floods in the Thames Valley area in early 2013. The Hazardous Area Response Team (HART) had worked throughout the region and specifically in Wraysbury, Berkshire, 24 hours a day over 4 days, to assist with the rescue and support operation.

Emergency Operation centres (EOC)

• Emergency 999 calls were triaged through NHS Pathways (which is a software system of clinical assessment for triaging telephone calls from the public based on the symptoms they report when they call). There was good compliance to prioritise and categorise calls for ambulance dispatch according to the clinical needs of patients. However, staff knowledge of appropriate dispatch times for mental health patients in crises under a Mental Health Act Section 136 and needing a place of safety, needed to improve.
• There were dedicated triage lines for GPs and healthcare professionals, and for patients who were critically unwell and needed the air ambulance (the Helicopter Emergency Medical Services, [HEMS]) or other specialist services, such as the Hazardous Area Response Team (HART).
• Some safety processes needed to improve, such as incident reporting and raising safeguarding concerns, and some staff needed a better understanding of the Mental Capacity Act 2005.
• Staffing levels were a concern and staff worked long hours, sometimes without breaks. Action was being taken to manage peaks in demand but staff were not meeting target times to answer emergency calls.
• Overall, the trust had referral rates of 8% from NHS 111 to 999 services, and these were better than the service level agreement performance of 10% and one of the lowest in the country. Staff identified the need for further action on managing the demand created by the NHS 111 service, and the trust’s long-term planning against the rising increase in demand for services was ongoing.
• The staff were supportive to patients who called in distress. They listened carefully, explained their actions and involved patients in their decisions.
• Clinical advisors were available to help staff and to support patients to manage their own health when appropriate. The clinical adviser also undertook welfare checks over the phone to ensure a patient’s condition was not deteriorating while they were waiting for an ambulance. The trust was below the national average for ‘hear and treat’, which is the proportion of calls that are dealt with based on provision of telephone advice only. The re-contact rate within 24 hours of ‘hear and treat’ was higher than the national average in 2013-14 but had decreased this year and was below the national average in (April to July 2014).
• Engagement between the trust and the public and patients was being developed further.
• The trust had a clear strategy for the EOC to provide clinical coordination of care across a range of health and social care settings. However, most staff were not aware of this strategy in relation to their service. Governance arrangements needed to improve to support staff to share learning, raise concerns, manage risk and act on performance information. Staff worked well in their teams but some wanted better support from managers, particularly in the northern EOC.

Emergency and Urgent Care

• Front-line 999 services provided an emergency response to people with life threatening emergency or urgent conditions. Overall, during 2013/14, the trust was meeting national emergency response targets for 75% of calls to be responded to within 8 minutes. The national categories are for Red 1 calls (for patients who have suffered cardiac arrest or stopped breathing) and for Red 2 calls ( for all other life threatening emergencies). Red 1 and Red 2 calls added together and are referred to as Category A calls. The category A target is to have a vehicle that could convey a patients to hospital arrive at the scene within 19 minutes for 95% of cases. This target was also met.
• The trust had the highest percentage of ‘see and treat’ in the country (that is, managing patients at the scene without the need for ambulance transfer to hospital). The re-contact rate within 24 hours of this treatment was higher than the national average in 2013-14 but was  decreasing.
• The trust used a Resource Escalation Action Plan (REAP) as a way of forecasting performance and service delivery. There was moderate to high pressure on the service during our inspection and the trust was communicating effectively with hospitals to align conveyancing decisions against waiting times and the capacity to receive patients. This included having hospital ambulance liaison officers (HALOs) to support the timely handover and safety of patients in A&E departments and to monitor and respond to situations, particularly at times of increased demand for services. There was effective planning and preparation for major incidents and the trust had worked effectively with partner organisations.
• The trust was monitoring long waiting times and had introduced measures to ensure that people were monitored while waiting and that high-priority calls took precedence. There was an impact however on people who may be in a healthcare setting but awaiting transfer to another hospital for acute care and for people at a distance from an ambulance station. The trust was taking action to reduce these waiting times.
• The service followed safety procedures overall, but needed to improve infection control practice and the management of medicines. Staff had a good understanding of the Mental Capacity Act 2005 and of safeguarding procedures although the timeliness of reporting concerns and referrals needed to improve. The performance of the external contractor to ‘make ready’ ambulances (that is, to prepare ambulances, for example,  in terms of cleanliness and appropriate equipment) was monitored but the quality of their work required better supervision and monitoring. Ambulance crews had allocated time to check vehicles but told us they spent more time rechecking vehicles to ensure they were ready for use.
• The trust was affected by the national shortage of paramedics and there were a high number of vacancies. The allocation and skill mix of staff were appropriate but staff worked long hours and some reported stress and fatigue. There was a rising demand for services that was above predicted levels. The trust had introduced shift changes to help manage resources to meet demand in emergency services and new rotas were being introduced to further improve the work life balance of staff. The trust used private providers to ensure service cover and these providers were appropriately monitored. Staff spoke positively about the level of communication on issues and they understood the need to match resources and demand, and requested further ongoing dialogue around these issues.
• National evidence-based guidelines were used to assess and treat patients. Patients experiencing a heart attack did receive pain relief although this was not always the pain relief that was nationally recommended. Patients experiencing a heart attack were transported quickly to hospital. Patients that had had a stroke had appropriate care but there could be delays in their transport to hospital. Some hospital staff identified the need for better pain relief for children in certain circumstances.
• The coordination of emergency care with hospitals and GPs was good overall, but needed to improve for heart and stroke care in Buckinghamshire and for mental health patients in crisis across the four counties. The trust was working with its partners and had action plans to improve care in these areas.
• The trust was ranked the best in the country for patients who had had a cardiac arrest and stopped breathing, who then after resuscitation, had a pulse/ heartbeat on arrival to hospital. This is called return of spontaneous circulation (ROSC). The trust had improved its effectiveness of action taken when staff witnessed a cardiac arrest and was fourth best in the country this year (April to August 2014) a change from eighth best in 2013-14.
• The trust was ranked the best in the country for patients who had had a cardiac arrest and survived to be discharged from hospital.
• Staff explained treatment options to patients in a way that they, or their relatives, could understand. Patients, and relatives or carers, received good emotional support if they were in distress. There was support for vulnerable patients, such as those with a learning disability, bariatric patients and people whose first language was not English.
• Engagement between the trust and the public and patients was well developed through a variety of channels, such as social media, surveys, newsletters and liaison work.
• The trust had a clear vision and strategy for the service to provide mobile healthcare and to coordinate care in hospital, the community and people’s homes. Staff were supportive of the strategy and worked well together in teams and with their managers. There were good governance arrangements to monitor performance and quality and to manage risks although more action was needed on ongoing risks.

Patient Transport Services

• Patient transport services (PTS) provided non-emergency transport for patients who attend, for example, outpatient clinics or day hospitals, or were discharged from hospital. Commissioners had identified eligibility criteria for the service and the trust was working with 12 clinical commissioning groups to monitor performance and compliance.
• Staff followed the eligibility criteria designed by commissioners and were also working to improve the signposting of people to other services if they did not meet the criteria.
• Procedures to ensure the safety of services needed to improve, specifically around incident reporting, equipment checks and safeguarding procedures. Most vehicles were visibly clean. ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) orders were understood and used appropriately, but staff had limited awareness of the Mental Capacity Act 2005.
• There were staffing vacancies and staff felt stretched, particularly in the dispatch team where this had an impact on the planning and scheduling of transport. The trust was using volunteers and private providers to cover driving shifts. There needed to be better governance arrangements for private providers and for driving and employment checks for volunteers.
• The trust had made significant changes to the IT system in the PTS on the day of our inspection. Anticipated resource and capacity risks needed to be better managed, for example, problems with the new IT system had caused a serious disruption to transport arrangements for many patients during our inspection
• Dispatch staff did not always have appropriate assessment information, from hospitals or patients or from their own records. Patients sometimes did not have an appropriate vehicle or equipment, and transport sometimes had to be reorganised. The system to plan journeys was manual and often reactive based on a lack of timely and coordinated information and this had caused delays to patient transport.
• The trust was not meeting performance targets and this was having an impact on patients’ care and treatment. Patients were experiencing delayed and missed appointments for outpatient consultations and diagnostic scans, and renal dialysis, and some were choosing to curtail their treatment in order not to risk missing their transport home for fears of excessive delay. Some hospitals had reorganised clinics, for example, to finish early to accommodate the vagaries of the PTS. There were good examples of multi-disciplinary working with GPs and health professionals in hospitals.  The trust had been working with other providers to improve the coordination of care and some progress had been made.
• Patient surveys were regularly undertaken; these were positive about the service but identified delays. Patients we spoke with were positive about the care and compassion of staff. However, they were concerned that the service was not effective and that they were not given enough information about delays, missed appointments and the eligibility criteria.
• Many patients told us they had been distressed and anxious waiting for transport, but did not know whom to contact within the service. Call handlers were overwhelmed with calls about service delays and only half of all calls were answered.
• There was good support for vulnerable patients (for example, those with dementia or a learning disability), and carers and escorts could travel in the ambulances too. A policy for the transport of children needed to be developed.
• The trust had a clear strategy for the development of PTS to support safe non-emergency travel between people’s homes and healthcare settings, but most staff were unaware of this strategy. Governance arrangements needed to improve in order to assess and manage risks. Although staff worked effectively in teams, many wanted the management and leadership of the service to improve and for the trust to prioritise PTS services alongside the emergency 999 service.

We saw several areas of outstanding practice:

• We observed many examples where staff demonstrated outstanding care and compassion to patients despite sometimes working in very difficult and pressured environments. Staff “lived” the values of the trust “Towards excellence – Saving lives and enabling you to get the care you need”.
• Representatives of the trust attended local youth organisation meetings, village fetes and school assemblies. The trust had developed a child-friendly first-aid book printed specially for schools and the wider local community.
• The trust provided an innovative learning resource to their frontline staff using the educational resource centre and film centre at Bracknell. The staff were involved in making films which supported learning around new guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).
• The trust had introduced a lifesaving automatic external defibrillator (AED) locator mobile phone application. By using GPS, this app locates the nearest AED in the event of a cardiac arrest. In total, the app identified over 800 AEDs across four counties.
• A new initiative was the introduction of a ‘Simbulance’: a large command vehicle fully equipped with simulation learning activities. It was an innovative virtual classroom facility in that it gave ambulance staff the opportunity to experience realistic medical situations inside an ambulance saloon.
• Operation centres had direct access to electronic information held by community services, including GPs. This meant that the staff could access up-to-date information about patients (for example, details of their current medication).
• Trauma risk management (TRiM) was in place to provide confidential support to staff who may have been affected by traumatic incidents or conditions. Staff were assessed 3 days after a traumatic event and again after 28 days. Thirty-two TRiM practitioners gave peer support and advice, and there was also an external counselling service. The early intervention had both reduced sickness absence and improved the welfare of staff.
• The Helicopter Emergency Medical Services (HEMS) showed innovative practices and learning taken from combat zones. The team now had the equipment and skills to give blood transfusions and perform ultrasound and blood gas tests. In some circumstances, this bypassed or reduced the time a patient had to spend in the accident and emergency (A&E) department, and meant they could receive treatment immediately on arrival at the hospital. HEMS was also planning to introduce a night service, so it would operate 24 hours every day.
• The introduction of a midwife to the clinical support desk (CSD) in the Southern House emergency operation centre had improved the outcomes for expectant mothers and their new babies. The 24-hour labour line started as a pilot in May 2014. It gave women in labour access to advice and support, whereas the ‘professional’s line’ enabled medical professionals to speak to a midwife 24/7 during a woman’s labour and birth. The service had over 1,600 calls in the first eight weeks.
• The trust provided a service on Friday and Saturday nights in the city centres of Portsmouth (Safe Place) and Southampton (ICE Bus) to provide support, first aid and transfer to hospital if required for the public enjoying a night out. This had been set up in partnership with other organisations such as the Hampshire Police, the local council, volunteers and the local street pastors
• The trust had a clinical lead in mental health and learning disability. This role was unique among ambulance trusts. The lead had established a national mental health group for ambulance trusts, and worked with partner agencies such as the Royal College of Psychiatrists and the College of Policing. The introduction of mental health practitioners into the EOC was supporting operational practice and care to mental health patients.
• The trust had worked in partnership with Oxford Brookes University to provide staff with extra opportunities to develop their careers by becoming a paramedic, and to counter the national shortage of paramedics. A foundation degree course was to start in January 2015. The training covered an 18-month period and included in-hours training. The trust’s investment had been significant in terms of the time taken to negotiate the resources and facilities for the programme and the release of staff from work duties.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the trust must ensure that:

• Staff uptake of statutory and mandatory training meets trust targets
• Staff in EOC and PTS understand the Mental Capacity Act 2005
• All EOC and PTS staff receive safeguarding training to the required level so that they are able to recognise signs of abuse and ensure there are robust arrangement in place for staff to report concerns within the agreed timescale.
• Emergency call takers answer calls, and the emergency medical dispatchers dispatch an ambulance within target times

In addition the trust should ensure that:

• Procedures for incident reporting continue to improve and staff in EOC and PTS have appropriate training and are able to report incidents directly. There must be timely investigation of incidents, staff must receive feedback and learning must be shared.
• The risks around IT vulnerability in the EOC and PTS are appropriately managed.
• Infection control practices are followed and ambulance stations (resource centres) and vehicles are effectively cleaned and deep cleaned.
• There are suitable arrangements to ensure that equipment regularly checked and fit for purpose.
• Staff are aware of the appropriate steps to take to reduce the risks to patients left unattended in PTS ambulances because of staff working alone.
• Appropriate equipment is available in all areas for the transport of children in PTS and this continues to be rolled out for emergency transport.
• Volunteer drivers in PTS have the appropriate safety and employment checks before working within the service.
• The trust to continue to work with partners and ensure the planning and scheduling of PTS improve to prevent delays and missed appointments, and to reduce the impact on the clinical care, treatment and welfare of patients.
• The governance and security arrangements for the management of controlled drugs need to be improved in Hampshire.
• Recruitment of staff in all areas continues and there are specific staff retention plans in response to identified reasons as to why staff leave.
• Staff in PTS receive appropriate training on dementia care, learning disabilities and all staff continue to received training in mental health conditions.
• Anticipated resource and capacity risks in PTS continue to be appropriately identified, assessed and managed.
• Pain relief continues to be appropriately administered for patients with ST segment elevation myocardial infarction (STEMI) and pain relief for children is effectively monitored.
• Continue to work with acute trusts to review protocols for the non- critical transfer of hospital patients.
• There is better coordination of care between providers, in particular for cardiac and stroke services in Buckinghamshire and mental health services.
• Complaints are responded to within the trust’s target of 25 days. All staff in EOC and PTS receive feedback from complaints and learning is shared.
• Operations staff in PTS are appropriately resourced to be able to answer telephone calls.
• Patients (or people acting on their behalf) using the PTS  are made of aware of how to complain or send compliments about the service.
• Staff in PTS have regular supervision and the trust should raise awareness amongst staff about the professional and career development opportunities within the trust.
• The formal structure of team meetings is in place for all staff groups and staff are given the opportunity to attend, share information and raise issues or concerns.
• Staff have a better understanding of the trust’s vision and strategy as it applies to their service in EOC and PTS and staff communication continues around service changes and development.
• Leadership in the northern EOC and PTS supports staff and action is taken to improve staff morale where this is low.
• Staff in PTS receive feedback from the completed patient satisfaction surveys.
• There are better governance arrangements within EOC and PTS to share information with staff, so that staff can raise concerns and risks are appropriately identified, assessed and managed.
• There are better governance arrangements for private providers of PTS and make ready services.

Professor Sir Mike Richards

Chief Inspector of Hospitals