Premier Care Direct is operated by Premier Care Direct Limited. It is an independent ambulance service with the head office being based in Doncaster, South Yorkshire. The service provides patient transport for renal dialysis patients.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 20 March 2018. A responsive inspection had been carried out on 5 December 2017 following concerns received by CQC about the service..

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.

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 a registered manager in place at the time of our inspection. It is a condition of the provider’s registration that there is a registered manager in place. There had been no registered manager since March 2016 . This is a breach of the condition of the provider’s registration.
• The service had limited systems to monitor the quality and safety of the service. The service did not carry out any audits to measure the quality and effectiveness of the service delivered. There were potential risks to staff and patient safety, through lack of observation and monitoring of performance.
• Governance arrangements to monitor the quality and safety of the service were not robust.
• The service did not have an effective risk register. The service had not identified the risks associated with not meeting key performance indicators and the patient outcome, as well as adequate contingency during severe weather conditions. The service was unable to demonstrate how these risks were mitigated and escalated in order to protect patients.
• Policies and procedures were generic and had not been adapted for the service. Policies and procedures were not regularly reviewed and updated.
• The service did not ensure clinical waste was disposed of in accordance with the clinical waste regulations.
• Arrangements for safeguarding vulnerable adults and children were not robust. The service had not appointed a safeguarding lead. Not all staff had received safeguarding training at an appropriate level to ensure they were aware of their responsibilities. There was a risk therefore that staff would not be able to recognise and report potential safeguarding concerns.
• The service did not have an effective system to ensure all staff were up-to-date with mandatory training requirements.
• The service did not have an effective recruitment procedure. Appropriate criminal records checks through the disclosure and barring service (DBS) had not been carried out for each member of staff.
• Appraisals had not been carried out for staff that had been employed for 12 months.
• The service did not have an effective system for cascading and sharing any lesson learnt from incidents, accidents or complaints in order to improve the service and patients experience.
• The service was not meeting the Accessible Information Standard (AIS) to ensure people who have a disability, impairment or sensory loss get information that they can access and understand.

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

• The managers had developed a vision and strategy of the organisation.
• The service had undertaken a root cause analysis following the unannounced inspection on 5 December 2017.
• All vehicles and the ambulance station were visibly clean and systems were in place to ensure vehicles were well maintained.
• Staff demonstrated pride in their role and we heard examples where they had shown care and compassion when transporting patients. The service gained feedback from patients using a patient feedback form.
• All equipment necessary to meet the various needs of patients was available.
• The service had improved the incident, accident and complaints reporting procedure.

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 four requirement notices details of which are at the end of the report.

Ellen Armistead Deputy Chief Inspector of Hospitals (North Region), on behalf of the Chief Inspector of Hospitals

Premier Care Direct Ltd provides a patient transport service to people in the South Yorkshire area.

We carried out a focused unannounced inspection on 5 December 2017 to review the service’s arrangements for the safe transport and care of patients as we had received information of concern about the service. A data request under Section 64 of the Health and Social Care Act 2008 requesting further information about the concerns was sent to the provider on the 21 November 2017 which included clarification of governance arrangements, training provision and the complaints procedure. The provider did not return all the information requested by this legal requirement.

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. As this was a focused inspection, we inspected only the relevant key lines of enquiry under the safe and well led key questions.

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 patient transport services. We did not have the opportunity to observe and review individual staff practice at this focussed inspection.

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.

• There were no effective systems for reporting, investigating and learning from incidents. We were concerned that the provider had not differentiated between incidents, issues and complaints. We were not assured that incidents had been reported, investigated, documented appropriately, and that that learning resulted from these.

• We were informed prior to the inspection that there had been two incidents of moderate harm. However, when we reviewed all incidents, we saw that there were more incidents of harm. We were not supplied with any root cause analysis, or informed how learning took place.

• We were told at inspection that there had been no occasions in the previous year where the Duty of candour (DoC) had been applied. However; we saw that there were documented incidents where the DoC was required. There was no process in place for staff to identify and apply this. The DoC is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

• From the evidence reviewed we were not assured that all staff had received mandatory training including moving and handling, infection control and health and safety.

• The safeguarding arrangements for children and vulnerable adults were not robust and the related policies were not available at the time of inspection. Following the inspection we saw a draft policy which was to be submitted to the clinical governance team for approval. It showed the logo of another provider closely linked to Premier Care Direct so staff may not have been aware that it applied to their own practice.

• The safeguarding training for staff did not reflect national guidance and local networks.

• There was no appraisal policy in place and the provider could not provide evidence that staff had received an appraisal at the time of inspection. Therefore we could not be assured that staff had their developmental and training needs discussed with their line managers or whether they were met.

• There was no effective process whereby new members of staff who had not yet had their Disclosure and Barring Service (DBS) checks returned were supervised by appropriate members of staff.

• There was a lack of effective governance arrangements in place for this service. Premier Care Direct was closely linked to another provider and shared the same board and managers at operational level. Premier Care Direct and the other provider were registered with CQC as separate legal entities.

• We were concerned about the lack of up to date policies available which meant staff did not have access to current guidance and procedures.

• The provider did not respond fully to the data request sent under Section 64 of the Health and Social Care Act 2008.

Following this inspection, we wrote to the provider with our concerns and asked them to take action to comply with the regulations.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North), on behalf of the Chief Inspector of Hospitals

We spoke with four people who used the ambulance service they told us the service was excellent, they also told us they were collected on time; staff were polite, considerate and very helpful.

One person said, “You can’t fault them they are spot on.” Another person said, “Nothing is too much trouble for them.”

We spoke with members of hospital staff who contracted the ambulance service. The feedback from the hospital contracting department was positive. We were told that staff from Premier Care Direct were polite, accommodating, easy to communicate with and provided a service which was excellent. They told us the service exceeded the national key performance indicators. One staff member told us, “They go the extra mile, the patients’ very rarely have to wait for the transport, mostly the drivers are waiting for the patients’ to finish,”

Staff demonstrated an understanding of how to support people. There were systems in place to help make sure people's needs were assessed so that they were transported appropriately.

Staff received appropriate professional development and training. Staff were also able to obtain further relevant qualifications.

The provider had an effective system to regularly assess and monitor the quality of service that people received.