Hatzola is operated by The Hatzola Trust. The service provides emergency and urgent care ambulance services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 17-19 January 2017, along with an unannounced visit to the provider on the 31 January 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this service was emergency and urgent care ambulance services.

Services we do not rate

We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following issues that the service provider needs to improve:

• The service did not have suitable systems in place to monitor safety over time, which included learning from incidents. Staff were not aware of actions they should take when a ‘reportable patient safety incident' occurred. We found six examples that would have met the provider’s policy categorisation as a serious incident but had not been reported. Near misses and serious incidents were not identified and there were no systems in place to review safety outcomes for patients.

• Staff demonstrated some understanding of their responsibility to report safeguarding concerns, however there had been no safeguarding referrals made by the service in 2016.

• There was a delay in the escalation of patients with critical conditions. The service had no escalation policy for patients requiring immediate emergency care for critical conditions. The call handlers always put calls through to members, or called one of the two coordinators. They did not immediately call 999 for any situation and there was no policy for doing so.

• We were not assured that patients were assessed and treated in line with best practice and current national guidance. For example, the service did not have clear pathways for common emergency conditions. Ambulance technicians were sometimes working above their competency level. They were responding to calls that were of a more critical nature and more suited for ambulance paramedics.

• Standard operating procedures for call handling were not clear in defining the prioritising of different calls. For example the policy required call operators to wait a set period of time for code one, two and three calls after requesting an ambulance technician attend. Code one calls were for “immediately life threatening situations”. For these, the protocol required the operator to wait three minutes and then contact the coordinator if no units had responded. The coordinator would then decide whether to call the London Ambulance Service for further advice. It was unclear how long this process took in practice and delays can cause serious consequences for patients. For example, cardiac arrest patients have 10% less chance of survival for every minute they don't receive CPR (JRCALC guidance).

• Systems to check clinical outcomes for patients were not in place to enable co-ordinators to be assured that staff were making the right decisions on patients’ care. This meant there was no way to monitor and learn from good or poor outcomes.

• Quality checks on patient care records (PCRs) were not effective to check staff had responded appropriately with the correct treatment. We viewed several PCRs where the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) protocols for treatment had not been followed. Staff told us they followed these protocols.

However, we also found the following areas of good practice:

• Equipment and ambulances were clean and kept in good repair.

• There were systems in place for the segregation and correct disposal of waste materials such as sharp items. Staff had access to personal protective equipment when needed.

• Ambulance technicians were administering medication appropriately and medical gases were safely stored.

• Staff understood how to raise concerns and record health and safety incidents, such as equipment damage or failure, or injury to staff.

• Patients were treated with compassion and respect and their privacy was maintained.

• Patient feedback was overwhelmingly positive about the service. Patients commented they could ring the provider at anytime and ask for help or advice.

• The service was planned to meet the immediate urgent and emergency care needs of local people. There was flexibility, choice and continuity of care which was reflected in the types of services we saw.

• There were very few complaints and those we viewed had been handled sensitively and promptly. Learning and improvements were made when people complained about the service they received.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with a warning notice that affected urgent and emergency services. Details are at the end of this report. We conducted a follow up visit on 20 April 2017 and found that the provider had taken steps to begin to address these issues.

Professor Edward Baker

Deputy Chief Inspector of Hospitals