This report describes our judgement of the quality of care at this location. We based it on a combination of what we found when we inspected and from all information available to us, including information given to us from people who use the service, the public and other organisations.

SSG UK Ambulance - South is operated by SSG UKSAS. The service provides emergency and urgent services and patient transport service. Most of services provided are commissioned by NHS trusts.

Following our inspection on 23 August and 04 September 2018, we rated the service as inadequate and placed it in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

We also served the provider with two warning notices relating to breaches for safe care and treatment and governance. The provider was required to be compliant and make the necessary improvements by 23 November 2018.

We carried out an unannounced focus inspection at the provider’s headquarters in Rainham, Essex on 28 November 2018 and the Fareham station on 6 November 2018, to review compliance with the two Warning Notices. We did not look at all the domains and key questions, instead we focused on specific areas of concerns in the Warning Notices.

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.

Our inspection targeted the key concerns identified in the warning notice.

At our inspection we found the provider had not made progress on all issues identified in the warning notice. Issues outstanding were;

• Medicines including controlled drugs (CDs) were not managed safely and in line with best practice guidelines which may impact on the safety of patients.

• There were no audits of CDs which were stored off site and individual paramedics’ CD registers audits were not consistently undertaken. We found that compliance with installation and storage of home CDs had not been assessed for all paramedics storing CDs off site.

• The provider was considering re introducing administration of medicines via patient group directions. However, the procedures and staff training had yet to be developed.

• The provider was unable to produce accurate data relating to the number and batch number of CD ampoules issued to individual paramedics.

• Policies for the management of medicines had been developed; however, this was not currently effectively managed as the staff could not access these.

• The process for managing risks was not effective, risks were not consistently identified and action plans developed to mitigate these. The management team were not aware of the serious risks we identified during the inspection.

• There were significant risks of misappropriation of CDs as staff who had left the service remained in possession of CDs and had not been returned to the service.

• The process for the use of patient group directions (PGD) had not been resolved as these had not been fully developed in line with National Institute for Health and Care Excellence (NICE) guidelines and approved for use. These have not been approved by commissioners.

However, they had addressed the following issues in the warning notice:

• The meeting including monthly board meetings and committee structure had been developed but not implemented at the time of our inspection. Procedures for sharing this information with the staff were being developed but not implemented at the time of the inspection.

• The provider had suspended the destruction of CDs and other medicines while they develop procedures for their safe destruction.

Following this inspection, we concluded the provider was not compliant with all aspects of the warning notice.

Following this inspection, we told the provider that it must take some actions to comply with the regulations. We also issued the provider with two requirement notice(s) that affected SSG UK Ambulance - South . Details are at the end of the report.

Name of signatory

 Dr Nigel Acheson

Deputy Chief Inspector of Hospitals

SSG UK Specialist Ambulance Service – South is operated by SSG UK Specialist Ambulance Service Ltd. The service provides emergency and urgent care and some patient transport services. The services are predominately commissioned by NHS trusts.

We carried out an unannounced focused inspection of the service on 6 November 2018. This was to follow up on specific concerns we had identified at our inspection on 23 August 2018 and 4 September 2018 which were not covered in warning notices issued following those previous inspections.

We did not look at all the domains and key questions, instead we focused on specific areas of concern.

The service had 18 frontline emergency response ambulances, five patient transport vehicles and six secure vehicles all based at the Fareham station. The secure vehicles were used for the transport of mental health patients, these vehicles all had a secure area or cell.

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.

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

• Absence of effective and safe medicines management process.
• No clear audits of controlled drugs (CDs). CD registers at station and held by paramedics not fit for purpose.
• No effective and safe process for the distribution, storage and return of CDs.
• An ineffective staff database which did not provide the service with clear information regarding staffing numbers, the skills of staff and their primary operational location.
• Lack of clear communication from senior leaders to operational staff.
• Lack of effective risk management within the organisation.

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

• Improved security at the station and medicines room.
• Improvements made to secure transfer documentation.
• Clear and consistent completion of patient care records by crews.

• Local leaders at the station had responded positively to verbal feedback provided at the previous inspection.

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 two requirement notices that affected emergency and urgent care. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South), on behalf of the Chief Inspector of Hospitals

SSG UK Ambulance – South is operated by SSG UKSAS. The service provides emergency and urgent services and some patient transport service and all services are commissioned by NHS trusts.

We carried out a responsive review of the service to follow up on some concerns we had received relating to medicines, staffing, overall management of the service and one of the provider’s ambulances being involved in a road traffic collision (RTC). This RTC is subject to a Police investigation and as a result this inspection did not examine the circumstances of the incident.

We carried out the unannounced part of the inspection on 23 August 2018 along with another unannounced inspection to the provider’s headquarters on 04 September 2018.

The service had a combination of patient transport, emergency response ambulances and five secure vehicles. The secure vehicles were used for the transport of mental health patients, these vehicles all had a secure area or cell.

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

• Medicines were not managed safely and securely which may impact on the safety of patients. This included receipt, storage and disposal of controlled medicines.

• There was no evidence that paramedics and technicians had completed the appropriate training and competency to administer medicines safely.

• The administration of medicines via patient group directions was not effectively managed which posed risks to patients’ safety.

• Incidents which affected the health and welfare of patients were not reported in line with the Care Quality Commission’s requirement as part of the provider’s registration.

• The staff who undertook the transfer of mental health patients did not follow national practice guidance and risk assessments were not completed. We were not assured that patients were adequately safeguarded from the risks of harm.

• The use of mechanical restraints had not been risk assessed and procedures for their usage were not fully developed to ensure the least restrictive means were used on potentially very vulnerable patients.

• The recruitment process did not ensure only suitable individuals were employed. Records of checks and fitness of staff were not available or incomplete.

• There was a lack of an effective system to review fit and proper persons being employed. Pre- employment checks for directors were not all available to assess the fitness of the directors.

• Not all staff had completed training appropriate to their role. Training such as practical intermediate life support, medicines management and safeguarding children had not been completed by all staff.

• There was no competency framework to provide assurance that staff were competent to undertake their role in line with best practice.

• There were limited clinical policies and guidelines to support staff and provide evidence based care and treatment. Those policies and guidelines that were in place included out of date information, referred to roles that were not in place.

• There was no effective incident reporting system and process in place and limited evidence of learning from incidents to improve practices and minimise the risks of these re-occurring.

• There was an ineffective governance process that did not provide assurance and leadership.

• There were limited systems to monitor the safety and quality of the service. Audits were not undertaken and therefore learning did not take place from the review of practices and procedures.

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

• There was a process that was followed to ensure vehicles were serviced regularly and they were roadworthy.

The service was rated as inadequate overall. I am placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Following this inspection, we told the provider that they must take some actions to comply with the regulations and that they should make other improvements, even though a regulation had not been breached, to help the service improve.

We also issued the provider with two Warning Notices and four requirement notices that affected SSG UK Ambulance – South. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals