We carried out this inspection to see if the trust had made improvements to recruitment procedures since our last visit in July 2011. At that inspection the patient survey results we saw showed very high levels of satisfaction with the accident and emergency and the patient transport service. The vast majority of people said the service met or exceeded their expectations.

People said the staff had explained their treatment, involved them in decisions and assessed their pain. They felt reassured and safe with the staff and most people said the staff were caring and professional.

The patient survey results we saw showed very high levels of satisfaction with the accident and emergency and the patient transport service. The vast majority of people said the service met or exceeded their expectations.

People said the staff had explained their treatment, involved them in decisions and assessed their pain. They felt reassured and safe with the staff and most people said the staff were caring and professional.

We found that the trust took action when things went wrong and stood down staff so that the matters could be investigated and the public and staff protected. However, we found that the trust had work to do to make sure that their recruitment processes were in line with legal requirements and that their patients were fully protected.

People who use the service told us how helpful and efficient the staff are. They told us they had confidence in them. Their comments included; the staff were, “very polite and friendly. They explained what they were doing and were open to questions. They were professionally smart, and were trustworthy.” They also told us the staff were reassuring, “when I made the 999 call, the person who answered the phone continued to talk to me, offering support until the paramedics arrived.” Others said, “my phone call to the 999 service was managed well. They offered advice and were very helpful. The paramedic told me what they were doing and why. They passed on the information about my care well to the hospital staff.” “The service is excellent, they’re always on time and the staff are helpful.”

People we spoke with told us that the staff had involved them in making decisions about their care and treatment. “They explained the checks they were making and were patient and friendly, courteous and polite. I was happy with the decisions they made, and the care I received. When we got to the hospital they explained to the nurses and doctors what they had done.” Another person told us, “they explained what they were going to do, and were very kind and helpful.”

The majority of people who used the patient transport service we spoke with were positive about it. “I was transported carefully to the vehicle in a wheel chair, I was asked if I already had my personal belongings and medicine before being transferred to another hospital.” Another person told us, “the driver and assistant helped to lock my door at home and helped me in the ambulance, they brought me through to reception and found a wheelchair for me.”

People told us they felt safe during the journey and said that an ambulance crew member helped them to put on their seatbelt, and made sure that any wheelchairs were secure. One person commented that, “staff were very helpful, helping to lock my door they were very attentive.”

Occasionally people reported they had experienced problems. They commented to us that the suitability of the transport, equipment and support available varied across the region. One person told us, “my father had an appointment which required an ambulance, a wheelchair and at least two people to assist him, what turned up was a car and a driver, this meant that the appointment was cancelled and rescheduled.”

The trust have to work in co-operation with many other providers throughout the region and we looked at whether this resulted in a co-ordinated service for people. The people who were surveyed by the local involvement network mainly responded positively about transport arrangements made for them. A carer who was escorting a person to the hospital told us, “the ambulance staff always pass information on well.

A person who uses the service told us, "I have a standing arrangement and the clinic arrange it for me." We spoke with a person in an accident and emergency (A&E) department who told us that their records had been transferred from the ambulance staff to A&E staff. This meant they could receive continuity of care.

Some people had experienced some difficulties when revised information had not been communicated to ambulance staff. "When cancelling an ambulance sometimes they would not get the message and come anyway, which is a waste of time."

The people who were surveyed by the local involvement network stated that the ambulance they travelled on was acceptably clean. Comments included, there was "no odour or litter," "it was cleaner than my car," "very clean, can't complain about that," and "the ambulance and staff always look smart." They also said that they were satisfied that the ambulances were safely maintained. One said, "they checked on the seatbelt after I had put it on and checked the wheelchairs were secure.”

People who were surveyed told us they were satisfied with the management of their medication and stated, "I was asked if I already had my personal belongings and medicine before being transferred to another Hospital."

People we spoke with who use the patient transport service were very happy with the consistency of support provided. We spoke to a carer who was escorting a person to the hospital and they told us, “patient transport is a first class service.” Another person who was being transferred by ambulance told us, “I usually have the same people to collect me and they are very good.”

We found that most of the people interviewed by the local involvement network did not know how to complain if they were concerned about the service. The majority of people interviewed did not know who to approach to make complaints or offer compliments. The trust have some difficulty in that they cannot display documents in the ambulances as this may compromise infection control. The staff we spoke with told us they tell people how make complaints if they are unhappy. Only one person who was interviewed knew about the patient advice and liaison service (PALS). Those who did know how to complain or give compliments were most likely to speak to the ambulance staff at the time or later, “I suppose I would contact the ambulance service.”

East Midlands Ambulance Service NHS Trust (EMAS) covers the six counties of Derbyshire, Nottinghamshire, Leicestershire, Rutland, Lincolnshire and Northamptonshire. This is an area which has a population of around 4.8 million people and covers approximately 6,425 miles. The trust employs 3,290 staff over 60 locations.

We carried out a follow up inspection of the East Midlands Ambulance Service NHS Trust from 21 to 23 February and 3 March 2017, in response to a previous inspection as part of our comprehensive inspection programme of East Midlands Ambulance Service NHS Trust in November 2015. In July 2016 we served the trust with a Warning Notice in which we required them to make significant improvements to the quality of health care provided. This was specifically in relation to ensuring there were sufficient staff with the right skill mix and sufficient vehicles as well as requiring the trust to ensure staff received appropriate training, support and appraisal to carry out their roles.

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. As the trust were no longer commissioned to provide patient transport services in Lincolnshire we did not look at that core service.

During this inspection we looked at:

The safety and effectiveness of Emergency and Urgent Care Services.

The safety and effectiveness of the Emergency Operations Centres.

Safety, effectiveness and well led at provider level.

The overall rating for East Midlands Ambulance Service remains unchanged at requires improvement although safety for emergency and urgent care services is no longer inadequate but requires improvement.

Our key findings were as follows:

• The trust had made significant improvements as required by the July 2016 warning notice. However we remained concerned about response times.
• Response times for Red 1, Red 2 and A 19 calls were consistently below the national target and patients were not receiving care in a timely manner.
• There were variable standards of incident investigation, limited recommendations, lack of learning at an organisational level and a lack of evidence that recommendations had been actioned.
• There was a lack of consistency in the management of risk due to trialling a revised risk register proforma.
• Staff did not know about the Duty of Candour requirements or their responsibilities under it and the trust had not consistently fulfilled their responsibilities under the Regulation.
• We found pockets of concern about the potential bullying and harassment of staff who were not confident to report this. We found instances where policies and procedures relating to staff wellbeing were not followed in practice.
• Not all staff had been trained on the use of and supplied with filtered face piece masks (FFP3). Those that had been supplied with a mask did not always have them available for immediate use.
• The trust were not compliant with the requirements of the Fit and Proper Persons Regulation.
• Whilst the trust had a clear vision and strategy, frontline staff were not aware of these.
• Whilst training completion rates for statutory and mandatory training had significantly improved, mandatory training completion rates for equality and diversity and risk management modules were too low and there were challenges in two specific divisions around completion rates in general.
• The trust had taken appropriate actions which had been successful in increasing the number of front line staff.
• Standards of cleanliness had improved.
• The majority of equipment and vehicle checks were appropriately completed.
• There was an increased number of operational vehicles available to deliver emergency and urgent care services.
• Medicines were stored securely and the management of controlled drugs was in line with the trust’s policy. However, we had some concerns about the lack of robust audit trail for access to controlled drugs on solo responder vehicles.
• There were notable improvements in the security of patient records.
• Potential risks to the service were anticipated and planned for in advance.
• The trust had taken action to provide frontline staff with the knowledge and information they needed to respond to a major incident.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice.
• Patient outcomes were mainly above or equivalent to national average levels.
• Staff had received timely appraisals which had been perceived by most to be a meaningful process.
• Improvements in training and development opportunities were evident and staff told us about them.
• Where patients received care form a range of different staff, teams or services this was effectively coordinated.
• Staff were confident in their understanding of the principles for patient consent and the Mental Capacity Act 2005 and they followed them.
• There was a governance framework able to support the delivery of safe, high quality care.
• There was a high level of confidence in and respect for the leadership of the acting chief executive.
• There was increased confidence in the effectiveness of the board and frontline leaders were better equipped with skills and knowledge.
• The culture of the trust from board to frontline staff was overwhelmingly patient focussed. Our inspection team observed caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.
• Staff engagement and satisfaction had improved since our last inspection.

We saw several areas of outstanding practice including:

• The trust had run a highly effective recruitment campaign and received a national award for equality and diversity in recruitment.
• The trust were trialling a pre-hospital sepsis treatment in North and North East Lincolnshire. Where patients presented with the symptoms of sepsis, blood cultures were taken and a pre-hospital dose of intravenous antibiotic therapy administered to the patient. This saved valuable time and provided prompt lifesaving treatment. The results of the study had not been published at the time of our inspection but early indications showed positive outcomes for patients. The trust was the only ambulance trust in England providing pre-hospital care to this group of patients.
• The trust had extended the provision of a mental health triage car in Lincolnshire and also to include patients in Derbyshire increasing the provision of appropriate care and treatment for patients with mental health conditions.
• We observed caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.

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

Importantly, the trust must:

• The trust must ensure patients receive care and treatment in a safe way by meeting national and locally contracted response time targets for Red1, Red2 and A19 categorised calls.
• The trust must take steps to improve EOC call taking response times therefore reducing the number of calls abandoned and the length of time callers are waiting on the phone.
• The trust must ensure all staff know how to report incidents. The trust must ensure serious incidents are appropriately and consistently investigated with lessons learnt acted upon and shared widely.
• The trust must ensure all staff understand the Duty of Candour Regulation and their responsibilities under it.
• The trust must ensure all staff access and attend mandatory training with particular focus on compliance rates for equality and diversity and risk management training.
• The trust must ensure all staff are fitted for and trained in the use of a filtered face piece mask to protect them from air borne infections.
• The trust must increase the percentage of frequent callers who have a specific plan of care.
• The trust must ensure there are systems in place to ensure staff have received, read and understand information when there are updates to trust policies, procedures or clinical practice.
• The trust must ensure they comply with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014).

Professor Sir Mike Richards

Chief Inspector of Hospitals