We visited St John Ambulance East Midlands Region and talked to staff and managers. It was not possible to speak with patients during our visit but we talked with relatives of patients and people who buy services (commissioners) afterwards.

We found that before people received treatment they were asked for their consent and the provider acted in accordance with their wishes. If people did not have the capacity to consent, the provider acted in accordance with legal requirements. A relative told us, “I’ve never had any problems with the crews. They went through each procedure and explained. They were very accommodating. I certainly wouldn’t have any grumbles; they do what they can to help us.”

We found that people’s health, safety and welfare was protected when they moved between different services. This was because the provider worked in co-operation with others. A commissioner of services told us, “As a general overview patients are safe.” A Commissioner had written to thank staff for their understanding when providing transport for a patient from a hospice environment.

We found that people were protected from the risks associated with medicines because appropriate arrangements were in place.

We found that people were usually protected from unsafe or unsuitable equipment, although some maintenance records were not available during our visit. The provider had to take action whilst we were there to ensure safe and appropriate disposal of a sharps box.

We visited St John Ambulance East Midlands Region offices in Chesterfield where we met with staff and reviewed documents and policies. In addition we visited an ‘ambulance station’ in Nottingham. We spoke with four organisations that have used St John Ambulance East Midlands Region for events that they have run. This included Nottingham city council’s events team and the Capitol FM Arena in Nottingham. We spoke to the East Midlands Ambulance Service (EMAS) who use St John Ambulance East Midlands Region's services to support their own.

Everyone that we spoke with about St John Ambulance East Midlands Region, said they were happy with the service they received which they found reliable, professional, flexible and efficient.

None of the organisations had ever had need to make a formal complaint to or about St John Ambulance East Midlands Region, and any difficulties were described as minor teething problems that were quickly sorted out in face to face discussions.

All of the organisations said they were very happy with their working relationship with St John Ambulance East Midlands Region, and in one case the organisation said they were looking to extend and develop their contract with them.

All of the organisations we spoke with about St John Ambulance East Midlands Region said they had no concerns whatsoever with regard to patient safety or welfare while people were receiving care and support from them.

St John Ambulance East Midlands Region is operated by St John Ambulance. St John Ambulance East Midlands Region provides emergency and urgent care and patient transport services.

St John Ambulance East Midlands Region is part of St John Ambulance, a national first aid charity. St John Ambulance provides a number of services including first aid at events, emergency and non-emergency patient transport services and first aid training. The objective of the organisation nationally is the relief of sickness and the protection and preservation of public health. Both volunteers and employed staff are involved with the services provided by St John Ambulance East Midlands Region.

St John Ambulance East Midlands Region provides ambulance services across a number of counties in the East Midlands Region, through a contract with one local NHS ambulance trust. The service also provides a falls service known as FIRST (Falls Intermediate Response Support Team) contracted through the local clinical commissioning group. There is an events service that provides first aid support at public events. St John Ambulance East Midlands Region has contracts with a number of organisations, which hold events in the local area and provides first aid at these events. However, some aspects of events activity is un-regulated, the CQC only regulates activity where patients need to be transported from an event for further medical treatment.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection between 6 and 8 March 2017, along with an unannounced visit on 15 March 2017.

We visited three ambulance operation bases at Newark, Derby and Chesterfield which is also the main administrative base. We visited the falls service (FIRST) and attended one event where St John Ambulance East Midland’s Region staff and volunteers provided cover.

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 areas of good practice:

• Vehicles and stations were visibly clean and tidy, with evidence of regular deep cleaning of vehicles.

• Servicing, MOT and insurance for ambulances were all up to date.

• Staff knew how to report incidents. There was a system in place to report incidents of all levels, and we saw changes had been made because of incidents.

• Staff demonstrated a good understanding of their responsibilities around safeguarding.

• Staff carried out structured patient assessments and clinical observations, which were appropriate for their level of competence.

• Staff followed evidence-based care and treatment and nationally recognised best practice guidance. All staff had access to the Joint Royal College Ambulance Liaison Committee (JRCALC) guidelines 2016.
• The majority of staff within the organisation had received a recent appraisal.
• All staff received training on the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards as part of their induction training. We saw staff asking patients for consent before starting treatment.
• St John Ambulance had recently launched the national continuing professional development (CPD) portfolio to ensure staff had up to date skills and knowledge to carry out their roles effectively.
• We observed good multidisciplinary working between crews and other NHS staff when treating patients. We saw good co-ordinated care and transfer arrangements when handing the care over to NHS staff.
• Staff showed compassion and treated patients with dignity and respect throughout their treatment or care. They were kind and emphatic to the patient and respected their privacy.

• Patients and their relatives were involved in decisions about their care and treatment. We observed staff explaining details of the plan of care and checking to ensure understanding and consent.
• Staff supported patients to manage their own care and wellbeing and maximise their independence.

• Service leads worked with a local NHS ambulance trust and other commissioners to provide services, which met the needs of local people.
• Staff had access to translation services for patients who may not speak English as their first language.
• The service received low levels of complaints. Those that were received were resolved appropriately and in a timely way.
• There was a national vision, strategy and values, which most staff were aware of and shared.
• Following the restructuring in 2016, the organisation had formed a new quality and standards directorate. Service leads were focusing their efforts on strengthening the governance framework with health and safety, audit and assurance under one directorate.
• There was a national action plan to drive improvements in substantive staff and volunteer engagement.
• There was a publicly accessible website, which contained information for the public including details of services offered and how to make a complaint.

However, we also found the following issues that the service provider needs to improve:

• Security arrangements for ambulance stations were not robust. The ambulance station at Newark was unsecure and inspection staff were able to access buildings, equipment, medical gases, medicines and vehicles unchallenged.
• Medical gases at Newark ambulance station were stored in cupboards, which were not always locked. The stock control system was ineffective as there was not always spare stock of medical gases stored within the ambulance stations.
• Staff were not following the organisational policy for the disposal of clinical waste at ambulance stations.
• There were no effective systems for the management and control of confidential patient sensitive information. Staff posted completed patient report forms through the royal mail postal system with no formalised or routine system of tracking that the information had been either sent or received. Following our inspection the organisation said there was a system in place for tracking patient report forms had reached the intended destination. During our inspection we did not find evidence to suggest this was carried out in this region. No further assurances were provided to the inspection team following the inspection.
• Staff were mixed in their view of the leadership of the service. Not all staff were able to describe leaders as accessible, visible or supportive.
• We found morale amongst substantive staff was generally low and related to communication, job security and career development.
• There were small pockets of staff within Ambulance Operations who raised concerns about some management practices at some locations. Staff described a blame culture and fear of reprisal, although said that this was around personal issues rather than patient issues.
• There was alignment with most of the issues recorded on the risk register and those the leaders has identified as challenges. However we found the risk around patient sensitive information had not been identified or assessed.

• Issues highlighted during our announced inspection were not shared with local managers before our unannounced inspection seven days later; therefore, we had no assurance around the cascade of information to staff.

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 urgent and emergency services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals