London Ambulance Service NHS Trust

Updated 4 March 2022

Our rating of the trust stayed the same. We rated it as good because:

• There were enough front-line ambulance staff to care for patients and keep them safe. Staff had training in the key skills needed for their role. Most staff understood how to protect patients from abuse and managed their safety well. Managers monitored the effectiveness of the service and made sure staff were competent in their roles.
• The services-controlled infection risks and followed professional practices with this regard. Staff understood their duty to raise concerns and report incidents and near misses. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff assessed risks to patients, acted on them and kept good care records of treatment and care provided. Information was shared where required in a safe manner with other health agencies. Staff provided good care and treatment, gave patients pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers and helped patients and their carers find further information and to access community and advocacy services.
• There were systems to alert staff to specific safety or clinical needs of a person using the service and to provide additional support. Steps were taken to respond to capacity issues by transferring calls between sites.
• Services were available seven days a week. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service engaged well with patient groups and the wider community to plan and manage services and all staff were committed to improving services continually.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Most staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.
• Leaders used a range of monitoring tools to measure performance and achievement of national targets. Action was taken where improvements were needed. Complaints were responded to in line with the trust’s standards.
• The service promoted equality and diversity in daily work and provided opportunities for career development. There was a general culture of inclusivity and of teamwork across services.

However:

• Despite the trust having increased the staffing in the Emergency Operations Centres, there was a lack of consistency in staffing levels and the rota system was unreliable. This impacted on staff’s ability to respond to incoming telephone calls to the Emergency Operations Centres. Temporary agency staff used in IUC did not always have the required level of skill needed to provide a responsive service to callers. The availability of clinical advisors in the EOC impacted on staff’s ability to get advice as quickly as needed.
• The incident reporting culture had continued to improve and there was evidence of improvements made as a result of learning from such events. There was however, some variation in EOC staffs understanding and use of the incident reporting process. Although learning from incident review processes was communicated in several ways, staff working in EOC and the IUC reported not having time to read some communications and therefore, were not aware of some updates.
• Although mandatory safety training rates had improved since the last inspection, some expected targets had not been met. Staff working in EOC had educational breaks built into their shifts but reported not having enough time to update themselves or complete on-line learning.
• Line managers in EOC and IUC were not always assessing their staff’s competencies following the completion of mandatory training and regarding expected practices within their roles. There were gaps in some of the role specific training of IUC staff.
• Although appraisal rates had improved in EOC, some staff did not have the opportunity to have feedback on their performance through supervision or an annual review.
• Whilst staff had access to policies, procedural guidance and other useful information, where updates to these resources was required, action had not always been taken to do this. However, we saw systems had been put in place to address this area as soon as the matter was brought to the executive’s attention.
• Although the trust had done work to improve safety and security, some areas and vehicles were still not secured to a consistent standard. The provision of equipment had improved to front line vehicles and staff, there were some items which remained less available or were not yet provided and some items had passed the expiry date. This was like our previous findings.
• The stock rotation of some locally managed medicines and consumables needed to be tightened to ensure out of date stock was identified and removed.
• The servicing of vehicles was not always happening in a timely way causing reduced availability to staff.
• Although people could access the service when they needed it, there were regular delays in responding to initial telephone calls made by the public to the EOC.
• Team meetings did not routinely take place for the sharing of information and one-to-one meetings were cancelled in IUC due to demands on the service. Opportunities were sometime missed to help staff understand the priorities of the service and what was being done to manage these and other issues.
• Several staff in EOC were not fully aware of the trust’s vision or how they could contribute to its achievement. Senior leaders were not as visible and approachable as staff expected, although the executive team had carried out several staff engagement activities to address this.

Updated 3 January 2020

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

• The service did not have always have enough staff working within both EOC’s.
• Not all staff understood how to protect patients from abuse. However, the service worked well with other agencies when abuse was highlighted.
• The design, maintenance and use of facilities, premises and equipment did not always keep staff safe.
• Staff did not always have opportunity to learn from incidents and managers did not always ensure actions from patient safety incidents were implemented and monitored.
• Managers did not always appraise staff’s work performance and did not always hold supervision meetings with them to provide support and development.
• At the time of inspection, staff did not always have access to updated policies.
• Staff did not always feel leaders understood and managed the priorities and issues the service faced. Leaders were not always visible and approachable in the service for staff.
• The service did not always operate effective governance processes. Staff were clear about their roles and accountabilities but did not always have regular opportunities to meet, discuss and learn from the performance of the service.

However:

• All those responsible for delivering care worked together as a team to benefit patients.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• It was easy for people to give feedback and raise concerns about care received.
• Staff were overwhelmingly positive about the culture within both EOC’s and the inclusivity of the organisation.
• The trust employed a mental health nurse (RMN) who was available within EOC to offer support and guidance to staff on matters relating to patients experiencing mental ill health.

Updated 29 June 2017

• Since the 2015 inspection much progress had been made to ensure the service met national standards and LAS was able to provide an effective and timely response to planned events and catastrophic incidents.
• The number of paramedics in the HARTs had increased and was line with NARU guidance.
• There had been a significant improvement in attendance at specific training for HARTs.
• Response times were now in line with national standards.
• Security at the HART sites had been improved and action taken to mitigate risk.
• The uptake of appraisals was much improved and staff were positive about the training they had attended.
• There was effective partnership working with organisations across London for major events along with multi-agency training.
• Staff were using evidence based practice and working to national guidance for HART/CBRN/MTFA.
• Although unable to observe EPRR providing care, LAS provided us with examples of positive feedback from patients/public about care provided by staff.
• Improvements since the 2015 inspection meant the EPRR were able to respond more effectively to severe or catastrophic disruptions to normal activities in the community.
• HARTs were meeting national response times.
• There was a clear leadership structure and staff were aware of the structure.
• Staff were positive about their immediate line and local managers but, some still felt more could be done to improve communication and taking action in response to feedback from staff.
• Systems to monitor the quality and safety of services were in place and there was some feedback at local level.

However:

• Learning from significant events attended by EPRR staff was shared but learning from incidens in other areas was not so well developed.
• The HARTs were still using leased vehicles at the time of the inspection but, permanent HART specific vehicles were on order and due to be delivered in May 2017.
• The trust business continuity plan needed to be aligned with other trust policies/plans.

Updated 27 November 2015

Some staff were unclear which type of situations needed to be reported as incidents and a culture of under-reporting was evident; however actions were taken to make changes in practice when incidents had been reported. Awareness of safeguarding principles and processes was variable among PTS staff.

Several oxygen cylinders were found to be significantly out of date, and daily vehicle checks were not being completed when required.

Cleanliness of vehicles and equipment used for PTS were not consistently at the expected standard.Some personal protective equipment (PPE), such as gloves, were available on PTS and NET vehicles, however none of the vehicles we inspected contained the full complement of PPE as LAS guidance required.

Clear patient eligibility criteria were in place and key performance indictors (KPI) were identified for each contract. PTS achieved slightly below the KPI target of 95% throughout 2014/15. Service level agreements formed part of the provider contracts and updates were sent through to the service which had commissioned PTS at regular intervals.

PTS crews received regular teaching sessions delivered by work based trainers, either in groups or on a one to one basis if needed. NET crew and control room staff received additional training to complement their new roles.

During our inspection, all observations of care provided by PTS showed patient dignity being maintained and patients treated kindly. PTS crews were respectful to patients and treated them with compassion. Patients and their relatives were complimentary about their interactions with PTS crews and gave examples where crews had tried to create a positive transport experience.

The booking process did not account for the needs of palliative care patients, which meant these vulnerable patients often had long waits for transport. Other care providers also described patients having long waits for transport home. PTS did not proactively inform patients or care providers of delays to their transport.

There was demonstrable inconsistency of service oversight within PTS management, such as overseeing day to day tasks, like the accurate completion of daily vehicle checks. Incident reporting and response was also variable depending upon the overseeing manager.

The PTS management team had a thorough understanding of the diminishing workload PTS was facing and had presented a structured exit plan in early 2015, which had been presented to the finance and investment committee, but had yet to receive board approval. There were clear aims for the NET service and plans for its expansion. Staff were positive about the PTS managerial team and their interactions with them.

Updated 3 January 2020

Our rating of this service stayed the same. We rated it as good because:

• Risk assessments were undertaken for each patient. Risks were managed well.
• Mandatory training was provided in key skills and most completed it as required.
• Patients who were at risk of deterioration where quickly identified and managed accordingly.
• On the whole the service 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.
• Records were clear and up-to-date, we found they were stored securely and were easily available.

Patient safety incidents were managed well. Staff understood their responsibility with regards to incident reporting. Incidents were investigated and learning was shared with staff.

• All patients were partners in their care, they were supported by staff to understand their treatment and to make decisions about their care.

• Patients were provided with information on how to make healthier lifestyle choices.

• Staff were supported by clinical experts who gave advice to ensure patients received the correct treatment and care.
• Date was used by the service to analyse how it was performing. Data was accessible to staff when it was needed.

However

• Security at station was still an issue, stations and vehicles were left unlocked. Certain pieces of equipment were routinely not available for staff to use as part of their daily work.
• Fleet staff did not receive training in the new ambulance vehicles the service were introducing to the fleet.
• The storage of medicines in kit bags needed to improve. The stock rotation of some consumables needed to be tightened to ensure out of date stock was identified and removed.
• The trusts policies and procedures were not always updated in a timely manner.

• Managers were not always visible and approachable for staff and patients. Staff were not always supported by managers to develop their skills.