This was a follow up inspection to check compliance with a warning notice in relation to the recruitment of staff and a compliance action in relation to the assessing and monitoring of the quality of the service provided. Due to the nature of the service provided we were not able to speak to people who used the service. Their feedback was not required to check compliance as the areas of non compliance identified at the previous inspection were in relation to records and systems.

Recruitment practices had improved and staff had the required recruitment checks in place. This ensured people were cared for by staff who were suitably recruited.

Quality auditing systems had been developed and daily practices were monitored. This meant people could be confident of receiving quality care.

We spoke with the director, manager and an ambulance crew member. The staff were positive about the changes that had been made and the benefits to the team and people who used the service.

This was a follow up inspection to check compliance with previous compliance actions in relation to infection control, requirements relating to workers and assessing and monitoring the quality of service provision. We were not able to speak to people using the service and their feedback was not required to check compliance in these outcome areas.

We saw an infection control risk assessment and audit were in place. Staff had commenced infection control e learning and the service had recently purchased a customised hygiene system for cleaning the inside of the vehicles. This ensured the risks of cross infection were reduced and managed.

Recruitment records did not evidence that the required recruitment checks had been carried out on prior to staff commencing work with the organisation. This was a continued non compliance that had not been addressed and had the potential to put people at risk.

Some quality monitoring systems were in place. These were not sufficient to ensure all areas of practice were monitored to ensure people were provided with a safe, good quality service. This was a continued non compliance that had not been addressed to improve and monitor the quality of the service.

There had been a recent change of director in the company. We spoke with the director, office staff and two ambulance staff. Staff were positive about the change in director. They felt supported whilst recognising improvements that needed to be made.

This was a private ambulance service which undertook mainly private work, with some NHS work. This was a follow up inspection to check compliance with a previous compliance action in relation to infection control and a warning notice in relation to staff training and support. We were not able to speak to people using the service and their feedback was not required to check compliance in these areas.

We saw practices in relation to infection control had improved. Vehicle cleaning schedules were in place, monitored and being further developed. An infection control risk assessment and audit tool had been implemented but not yet completed. Infection control e learning training had been sourced but not yet completed by staff.

We spoke to the registered manager and two ambulance staff. Staff told us they were inducted into their roles and opportunities for training had improved. They confirmed they had an appraisal and were being supported in their roles.

We saw recruitment records were disorganised and lacked evidence of the required recruitment checks to safeguard people.

We observed that quality monitoring systems were not in place in line with the organisations policy to ensure that the service was effectively managed and monitored.

This was a private ambulance service which undertook mainly private work, with some NHS work. It had three ambulances and employed five full time staff and nine part time staff. We were not able to speak to people who used the service. We saw written feedback from users of the service. The feedback was positive and included comments such as "overall excellent service".

Systems were in place to obtain consent and to promote the safety and well being of the person. We saw patient records were maintained. Staff were clear of their responsibilities for completing those and for formally handing over the person at the relevant drop off point.

Policies were in place to safeguard people. Staff were clear of their responsibilities to report and act on any suspicions of potential abuse.

The ambulances were clean and well maintained. Infection control risk assessments, audits and records of cleaning the vehicles were not in place to identify and prevent potential risks of cross infection.

We spoke with the owner, registered manager and four ambulance staff. Staff were clear of their roles and felt supported in those roles. Staff said they were responsible for maintaining and updating their own training. They were required to keep a record of their training to maintain their registration. We saw staff were not being formally trained and updates in training were not provided. Staff were not supervised or appraised in their roles either to benefit people.

Inter-County Ambulance Services Limited is an independent medical transport provider based in Chalfont St Peter, Buckinghamshire. The service provides patient transport, medical cover at events, and a repatriation service. Services are staffed by trained paramedics, ambulance technicians, ambulance care assistants and first responders.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 9 November 2016, along with an unannounced visit to the station on 21 November 2016.

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.

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 systems and processes in place for incident reporting was not robust and there was no evidence of staff learning from incidents.

• While staff had a clear understand of what constituted abuse and had received training the arrangements for safeguarding vulnerable adults and children were not robust. This was because there was a not a clear pathway for staff to follow to report concerns. This had been addressed by the unannounced inspection, when a flow chart had been implemented.

• The service had a medicine management policy. However, they did not have any medicine protocols to support staff to administer medicines safely. On the unannounced inspection, a policy had been introduced which gave clear guidance, which medications different grades of staff could administer.

• There were no formal systems in place to ensure staff were suitably appraised or received clinical supervision.

• There were limited policies and guidelines to support staff to provide evidence based care and treatment. The service acknowledged this and was working to implement new policies.

• There were no effective governance arrangements in place to evaluate the quality of the service and improve delivery. Audits were not undertaken and therefore learning did not take place from review of procedures and practice.

• There was no formal risk register in place at the service and therefore we had no assurances that risks were being tracked and managed, with plans to mitigate risks.

• A vision and strategy for the service had not been developed. The service did not formally engage all staff, to ensure that the views of all staff were noted and acted on.

• There was limited provision on vehicles to support people who were unable to communicate verbally or who did not speak English.

• The service had not had a CQC registered manager in post for over six months. They had submitted an application but remained unregistered. Since the inspection, we have received notification that the compliance manager is now registered with the Care Quality Commission as the registered manager.

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

• Staff followed infection prevention and control procedures to reduce the spread of infection to patients. They kept vehicles clean, tidy and well stocked. The system for servicing vehicles was effective, with accurate records kept.

• Staff working for the service were competent in their role and followed national guidance when providing care and treatment to patients. They knew when to escalate concerns so patients’ needs were responded to promptly.

• The service utilised its vehicles and resources effectively to meet patients’ needs Staff were able to plan appropriately for patient journeys using the information provided through the booking system.

• Staff we spoke with were aware of their responsibilities regarding duty of candour and understood the importance of being open and transparent with patients when things go wrong.

• Recruitment processes were in place so all staff employed had the experience and competence required for their role, together with pre-employment checks had been carried out.

• The service had a system for handling, managing and monitoring complaints and concerns.

• The service took prompt action where issues were found at the announced inspection and this was supported by our findings at the unannounced.

Information on our key findings and action we have asked the provider to take are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals