Letter from the Chief Inspector of General Practice

We inspected the NHS 111 service which is provided by North West Ambulance Service NHS Trust (NWAS) on 23, 24, 25 and 26 May 2016. This inspection was undertaken as part of a joint inspection of the whole Trust with the CQC hospital team.

NWAS is the contract holder for the NHS 111 service in the North West and sub-contracts approximately a 20% share of the service to two GP Out-of-Hours (OOHs) providers, Fylde Coast Medical Services (FCMS) and Urgent Care 24 (UC24). Both FCMS and UC24 are registered with the CQC as GP OOHs providers. Blackpool Clinical Commissioning Group (CCG) is the lead commissioner for the NHS 111 service in the North West and holds the contract for the full service with NWAS.

We carried out this announced inspection of NWAS NHS 111 as part of our comprehensive approach to inspecting NHS 111 services. We did not undertake inspections of FCMS and UC24 NHS 111. However as part of the NWAS NHS 111 inspection we visited the two subcontractors call centres in the evening at peak activity times.

Overall NWAS NHS 111 is rated as good.

Our key findings were as follows:

• NWAS worked closely with the lead CCG who commissioned the NWAS NHS 111 service on behalf of all 33 CCGs in the North West.
• NWAS NHS 111 provided a safe, effective, caring, responsive and well-led service to a diverse population spread across the whole of the North West of England.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• All opportunities for learning from internal and external incidents were discussed to support improvement. Information about safety was valued and used to promote learning and improvement.
• Risk management was embedded and recognised as the responsibility of all staff.
• Staff took action to safeguard patients and they were aware of the process to make safeguarding referrals. Safeguarding systems and processes were in place to safeguard both children and adults at risk of harm or abuse, including calls from children and frequent callers to the service.
• Staff had been trained to ensure they used the NHS Pathways system safely and effectively. (NHS Pathways is a Department of Health approved computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call). Once trained there were comprehensive systems in place to monitor staff usage of NHS Pathways including call auditing. An effective action plan was in place to ensure all call audits were undertaken in accordance with NHS Pathways licence.
• The service was monitored against National Minimum Data Set (MDS) and Key Performance Indicators (KPIs). Due to significant staff attrition in late December 2015 NWAS NHS111 struggled to meet the service KPIs. Effective action was implemented to improve their performance in achieving the key performance indicators and this included the recruitment and training of staff. The service met regularly with the commissioner of the service who was kept up to date about performance.
• Patients using the service were supported effectively during the telephone triage process. Consent to triage was sought and their decisions were respected. We saw that staff treated patients with compassion, and responded appropriately to their feedback.
• The service responded effectively to complaints and to patient and staff feedback.
• The leadership within the NHS 111 service was accessible and visible. There was a culture of support, continuous improvement and development of the service.
• All staff spoken with at all four call centre locations were enthusiastic and committed to providing a safe quality service. Staff said they felt supported directly with on the job supervision and support and indirectly with access to online training and guidance.

The areas where NWAS NHS 111 should make improvement are:

• Continue with the implementation of the staff recruitment and training plan to ensure the service is staffed to full capacity.
• Continue with the implementation of the call auditing improvement plan.
• Continue to implement the planned programme to complete staff annual appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

NHS 111 is a telephone-based service where patients are assessed, given advice and directed to a local service that most appropriately meets their needs. For example, this could be an out-of-hours GP service, walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance or late opening chemist.

We inspected the NHS 111 service, located at Middlebrook in Bolton, which was provided by North West Ambulance Service NHS Trust (NWAS) on 24 March 2015. We carried out this announced inspection as part of the development of our approach to inspecting NHS 111 services. Therefore we have not rated the service.

NWAS was inspected in August and September 2014 under the Care Quality Commission’s revised inspection approach. At that inspection the core services: Access to Service, Emergency and Urgent Care and Patient Transport Services were inspected. The focus of this inspection was the NHS 111 service therefore we did not review any of the areas identified for development and improvement at the inspection in August 2014

Our key findings were as follows:

NWAS NHS 111 provided a well-led, safe, effective, responsive and caring service to a diverse population spread across the North West England.

• The NHS 111 had systems in place to mitigate safety risks. Incidents and significant events were identified, investigated and reported.

• The service was monitored against the Minimum Data Set (MDS) for NHS 111 services and adapted National Quality Requirements (NQRs). These data collection tools provided intelligence to the provider and commissioners about the level of service being provided. Action plans were implemented where variation in performance was identified.

• NWAS NHS 111 worked closely with the 33 Clinical Commissioning Groups (CCG) in the North West, who commissioned the service.

• Staff were trained and monitored to ensure they used the NHS Pathways safely and effectively. (NHS Pathways is a licenced computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call).

• Staff were supported to report issues and concerns.

• Patients using the service were encouraged and supported to respond to the telephone clinical triage and their consent and decisions respected.

• The service was responsive and acted on patient complaints and feedback.

• There was visible leadership, with an emphasis on continuous improvement and development of the service.

• The vision to develop and expand the service in accordance with the five-year business plan was being implemented.

There were areas where the provider should make improvements:

• Ensure periodic analysis of complaints, customer feedback and significant events is carried out to identify themes and trends so that appropriate action can be taken if required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During this inspection we looked at elements of the emergency services (999 and urgent care) and patient transport services (PTS) within the North West Ambulance Service (NWAS) specifically focusing on the areas of Merseyside and Cheshire.

The inspection took place over four days in the week commencing 10th February2014. We visited four ambulance stations (St Helens, Whiston, Chester and Warrington), and observed ambulance crews arriving at Whiston and Warrington Accident and Emergency departments.

We were able to observe staff at work in one of the Emergency Operations Centres (EOC) at Anfield in Liverpool to see how emergency calls were dealt with, and how ambulances were dispatched.

We spoke with people who had recently used the service who commented: “I was well looked after and I felt safe”; “They kept my relative dignified”; “They were good and knew what they were doing”; “They were perfect”; “They came quite quickly, I’m not sure, but it wasn’t a long wait” and “They do a marvellous job”.

We also spoke with staff who stated: “Cannot fault availability of equipment – never lacking resources”; “Clinical supervision is good and has improved recently”; “There is a good management team in my sector”; “Yes, definitely [feel supported] – my senior paramedic is fantastic”; “I see dedicated staff who do an excellent job” and “The service is gathering speed, improving and going in a positive direction”.

Care and treatment was planned and delivered in ways that promoted people's safety and welfare. Staff followed agreed assessment and care pathways, helping to ensure appropriate treatment was delivered.

People received safe and coordinated care, treatment and support where more than one provider was involved, or they moved between services.

People who used the service and staff who worked for NWAS were not at risk of harm from unsafe or unsuitable equipment.

Staff received ongoing managerial support, had good access to clinical supervision and had opportunities to update their knowledge and improve their skills.

There were systems in place to assess, monitor and improve performance. Learning from incidents, complaints and investigations took place with appropriate changes being implemented.

For this inspection we targeted the emergency services (999 and urgent care) within the North West Ambulance Service (NWAS) specifically focusing on the areas of Cumbria and Lancashire. The inspection took place over four days in the week commencing 12th March 2012. We visited five ambulance stations (Wigton, Penrith, Preston, Altham, and Broughton), and observed ambulance crews arriving at the Cumberland Infirmary and The Royal Preston Infirmary Accident and Emergency departments.

We were able to observe staff at work in one of the contact centres (999 call centre) at Broughton in Preston to see how 999 calls were dealt with, and how ambulances were dispatched.

As part of the review we asked NWAS to contact people who had recently used the service to get their agreement to speak to us on the telephone so we could ask them about their experience of the care they had received. We carried out six telephone interviews and also used the most recent patient survey information from NWAS.

Where possible we have drawn on evidence collected and seen, in relation to how NWAS manages emergency services, but as the organisation deals with more than just 999 ambulances and urgent care across three distinct areas in the North West our report does include evidence that captures how the wider organisation is managed.

Service users were very happy with the service provided and told us:

“I was very satisfied with the service.”

“The ambulance arrived within 5 minutes, there were no problems. They were very, very good.”

“I can’t fault them.”

“The ambulance staff were friendly, professional, caring and fantastic in every way.”

“The ambulance crew told me everything that was going on.”

“The ambulance staff listened to me and did everything they could to help me and comfort me.”

NWAS staff told us:

"I am really proud of where this organisation has got to and where it’s going.”

“Training is good we are equipped to do the job we do, every year there is clinical refresher training.”

“Performance is good we develop staff and encourage training. There is good communication between staff and managers and good teamwork at both operational and clinical level.”

A number of ambulance staff told us “I absolutely love my job."

The North West Ambulance Service (NWAS) NHS Trust is one of 10 ambulance trusts in England and provides emergency medical services across the North West region, which has a population of around 7 million people. The trust employs 5162 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across the North West.

The trust has 109 ambulance stations distributed across the region, three emergency operations centres, one support centre, three patient transport service control centres, and two Hazardous Area Response Team (HART) buildings (one being shared with Merseyside Fire & Rescue).

The trust also provides, along with Urgent Care and out of hours partners, the NHS 111 Service for the North West Region. Operating from five sites across the North West, in Greater Manchester, Merseyside and Lancashire and Cumbria.

We last inspected this trust between 19 and 22 August 2014 for the announced element of the inspection, and the unannounced inspection visits took place on 26 and 27 September 2014. As the first ambulance trust inspected under the new model, the trust was not rated as part of this inspection. Additionally the 111 service was not inspected at the time of this previous inspection. We told the trust that they must make improvements to:

• Review the process for pre-alerting hospital accident and emergency departments to make sure that communication is sufficient for the receiving department to be made fully aware of the patient’s condition.
• Make sure that emergency operations centre staff across all three emergency operation centres (EOCs) are consistently identifying and recording incidents as appropriate.
• Make sure dosimeters (that measure exposure to radiation) on vehicles are in working order.
• Improve access to clinical supervision for all clinical staff.
• Review medicines formulary guidance issued to front-line staff to make sure it is current.
• Ensure that all staff are receiving the mandatory training necessary for their role.
• Ensure that all staff across all divisions are consistently receiving appraisals.

Before carrying out this inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the Ambulance Service. These included clinical commissioning groups (CCGs); Monitor and the local Healthwatch.

We carried out our announced focused inspection of NWAS between 23 and 26 May 2016, with an unannounced inspection taking place on 6 June 2016. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We inspected three core services:

• Emergency Operations Centres
• Urgent and Emergency Care
• Patient Transport Services

We also inspected the NHS 111 service provision during this inspection.

Our key findings were as follows:

Leadership and Culture

• There were regional variations in the culture both across the trust as a whole and within regions. Staff in some areas felt very positive about the culture, but in other areas they felt there was a high degree of pressure and that focus was on performance targets rather than care for patients.
• The Chief Executive Officer had recently commenced in a substantive post on 10 May 2016, following a period of covering the post as an interim, from March 2016.
• The urgent and emergency care service was moving towards a clinical leadership model, with more focus on clinical quality and a reduction in operational management. This leadership model included a consultant paramedic for the region and advanced paramedics in each sector. An increase in the number of senior paramedics and decrease in assistant operations managers was planned.
• Staff reported that the new clinical leadership structure with senior paramedics assuming a combined management and clinical leadership role was a positive development. This change had been well received as it provided clearer lines of reporting and less confusion, at the stations where it had already been implemented.
• Staff felt that leadership from heads of service was strong and visible. Heads of service and sector managers had been supported to develop their leadership skills with attendance at higher education courses.
• In Liverpool many of the staff said that staff morale was affected by the building which was cramped with teams located in different rooms.

Staffing

• There were staff vacancies across all areas of the urgent and emergency care service and the overall vacancy rate was 5.7%.
• Staff vacancy rates in North Cumbria were the highest in the trust with 35 vacancies, which represented 20%. The paramedic vacancy rate in this area was 16.7%. One of the initiatives to manage this deficit was the employment of paramedics from other countries. Two paramedics from Europe had worked in Cumbria for some time. The trust had employed 35 new European paramedics in Greater Manchester at the time of the inspection. There were plans to recruit a further 36 with 24 of these being appointed to North Cumbria.
• A high proportion of vacancies related to band five paramedics. A total of 16.2% whole time equivalent (WTE) posts for this role were vacant at the time of our inspection across all areas. This reflected a national shortage of paramedics.
• The staff turnover rate for the 2015/16 period for the service was 7.2%. The trust was looking at new ways to recruit paramedics to fill these vacancies. This included progression programmes for their EMT staff and also international recruitment. The trust’s human resources department was working with managers on developments to improve the retention in Cumbria where rates were higher at 11%. This included the consideration of relocation packages.

Records

• Information relating to patients’ care and treatment was recorded on patient record forms (PRFs) which were paper based forms in a duplicate book. This meant the ambulance service could maintain their own record and also supply one copy to the hospital or patient, depending on whether the patient was conveyed to hospital. They also had one copy without patient identifiable information to use for audit purposes.
• We reviewed 236 PRFs within urgent and emergency care. We saw that, in 218 of these cases, the records were completed in legible handwriting, were signed and dated and the history of the patient incident, treatment provided, medicines administered, assessments of pain and observations were completed.
• There was a limited amount of free text space available to record a full history and clinical assessment. If there was not enough space to complete all details, a second PRF would be completed. Some staff felt a continuation sheet would be beneficial but others told us there was enough space to document all necessary detail. Paramedics on the Manchester urgent care desk completed patient review forms for each patient seen. These records were posted into a locked cabinet in the office and were collected once a month to be stored securely elsewhere in the trust. The urgent care desk team did not have access to the cabinet and, as such, we were unable to review any of these records. This meant there was a risk these records could not be accessed urgently if required.

Governance and Risk Management

• The quality committee met every two months and discussed areas, such as risk and mitigation, safeguarding, response times, complaints, incidents, medicine management, infection prevention, quality improvement and National Ambulance Clinical Quality Indicators. This meant that the executive team only got oversight on these quality areas every two months.
• The board did not have an overview of the reporting and monitoring of serious incidents. This meant there was no monitoring of how quickly serious incidents were reported, timescales for investigations and how quickly actions were implemented following the outcome of the investigation. Serious incidents regularly took longer than the 60 day timeframe (set by NHS England in the serious incident framework) to investigate and conclude.
• There was a trust-wide risk register in place which recorded all operational risks with a score of 12 and above. There was evidence that the register was reviewed and updated regularly. However, there were some improvements required. In particular, some risk descriptions did not clearly describe the risk; some of the information recorded under controls and assurance were not actually controls or sources of assurance; there was no target rating for risks, meaning it was unclear what level of risk the trust was aiming for, and there were a number of risks without actions identified to mitigate the identified risk. Additionally a significant number of risks had been on the risk register for a number of years with little evidence of progress or impact being reported. In addition local risk registers were not totally aligned to the trust wide risk register.

We saw several areas of outstanding practice including:

• The Hazardous Area Response Team (HART) teams in both Manchester and Merseyside were delivering an excellent service to patients. They were proactive in their approach to gaining new skills and forging relationships with other emergency services, to ensure the smooth running of rescues in difficult areas. Their co location with the fire service training headquarters in Merseyside afforded them and all NWAS staff excellent and unique training opportunities. This ensured that they were equipped to deal with and manage a wide range of hazardous emergencies and undertaken formalised de briefs in a multidisciplinary manner.
• The service had community care pathway designed to share information across services and ensure ambulance clinicians were aware of pre-existing care plans for patients being managed by community services. This included when it was most appropriate for patients to be treated at home, involving other professionals or conveyed to an alternative care setting than an emergency department. This was also supported in some areas by the long term conditions teams based at local hospital trusts.
• The community engagement manager was in the process of implementing an electronic application initiative called ‘Good SAM’. This application could be downloaded onto mobile devices and alerts users who have been vetted and checked to a nearby cardiac arrest. Through this initiate the manager had also mapped all defibrillators in the North West area and from August 2016, this information would be available to call centre staff so that they could direct members of the public attending cardiac arrests to these devices.
• All staff we observed were exceptionally caring in their approach and went above and beyond their duty to provide compassionate, supportive care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In Urgent and Emergency Care:

• The service must ensure staff are given adequate opportunities to report incidents and safeguarding issues.
• The service must ensure that staff are reporting all adverse incidents in line with NWAS policy.
• The service must ensure all staff receive the required level of mandatory training.
• The service must ensure that all staff receive the required level of mandatory safeguarding training and ensure that there is a mechanism to check that staff have completed this training.
• The service must ensure all community first responders have the required level of training to undertake their role including how to recognise and act on safeguarding issues.
• The service must ensure that vehicle log books are completed fully and that checks undertaken by managers reflect the true content of the log books.
• The service must ensure that all equipment used in the delivery of patient care is subject to the appropriate and required checks, including that held by the community first responders.
• The service must ensure that vehicles receive deep cleaning when required.
• The service must ensure that controlled drugs are stored, managed and checked in line with trust policy and national legislation.
• The service must ensure that all staff involved in the administration of medical gases, for example Entonox, have received the required level of training to ensure they are competent to undertake this duty.
• The service must ensure there are adequate numbers of suitably qualified staff deployed in all areas.
• The service must ensure that all guidelines and policies used in the delivery of patient care are reviewed and updated at the frequency required.
• The service must ensure that patients have timely access to care and treatment in line with national targets.
• The service must ensure all staff received their annual appraisal.
• The service must ensure all staff have received the required level of training to ensure they are able to exercise their duties in line with the Mental Capacity Act (2005).
• The service must ensure that the consent policy and guidance on mental capacity assessments issued to staff is in line with the Mental Capacity Act (2005) code of practice. The service must ensure there is specialist equipment and training for staff to safely manage the care of bariatric patients.
• The service must ensure that staff received back up when requested in a timely way.
• The service must ensure that risks are appropriately documented, reviewed and updated.
• The service must ensure that any allegations of bullying are taken seriously and managed appropriately with support provided to the staff involved.
• Ensure that departmental risk registers are kept up to date and reviewed appropriately.
• Ensure that processes are robust and effective in relation to safeguarding processes and procedures.
• Ensure compliance with the fit and proper person regulation.

In Emergency Operations Centres:

• The service must ensure that staff are reporting all adverse incidents in line with NWAS policy and ensure all staff have received appropriate training on the incident reporting system.
• The service must ensure there are robust processes for sharing lessons learned from incidents and complaints with staff across the three sites.
• The service must ensure that all safeguarding concerns are reported in line with the NWAS policy and must improve staff awareness of the safeguarding policy.
• The service must ensure all staff receive their annual appraisal.
• Ensure that risk registers clearly document short and long term risks local to each emergency operations centres (EOC) site as well as to the EOC service as a whole, including control measures that have been identified and implemented, and planned review dates.

In Patient Transport Services:

• The trust must ensure that investigation reports fully reflect the actions taken during an investigation and provide a summary of the root cause of the incident and the lessons learned, in line with trust policy.
• The trust must ensure patient information is kept confidential. The management of patient information provided to volunteer drivers did not promote confidentiality.
• The service must finalise its existing PTS structure and quality reporting framework to ensure that there is a clear oversight of escalation and monitoring of governance, risks and performance of the service.

In addition, the trust should:

In Urgent and Emergency Care:

• The service should consider implementing systems to ensure that feedback from incidents and investigations is consistent and accessible to all staff including community first responders.
• The service should ensure that communication aids for patients with visual or mental capacity impairments are available.
• The service should consider providing training to all frontline staff on the duty of candour and their responsibilities in relation to this.

• The service should consider ensuring that staff with level three safeguarding training are available for staff to access for advice and guidance.

• The service should consider providing training on key safeguarding subjects which crews may come across such as female genital mutilation, radicalisation recognition and human trafficking.

• The service should consider implementing a system to ensure the key codes to access keys in the ambulance stations are changed regularly.

• The service should ensure that all records are completed fully and legibly.

• The service should consider implementing a system by which all staff members involved in the care of the patient can sign for the care they have delivered.

• The service should consider ways to improve staff compliance with the use of patient pathways and care bundles.

• The service should ensure that patients can be provided if necessary with information on how to feedback about the service.

• The service should ensure that complaints are dealt with consistently and in line with trust policy.

• The service should ensure that staff are aware of the trust vision and values.

• The service should consider implementing a more consistent way of monitoring of performance and quality across the regions.

• The service should improve staff engagement and address areas of low morale.

In Emergency Operations Centres:

• Improve EOC staff’s skills in managing calls from children or from people who may have mental health problems, those who may be in crisis, and those living with dementia or learning disabilities.
• Improve communication across all EOC teams, including those working night shift patterns, of changes to procedures or announcements.
• Improve accessibility, and readability, of information transferred by the system to the EOC from NHS111, including the reduction of duplication of information.
• Raise awareness among all EOC staff on the trust’s vision and strategy and how they can contribute to it.
• Consider how the environment at the Liverpool site can be improved, including what reasonable adaptations may be needed for staff who have reduced mobility.
• Review the policy for deploying the HART team and how it reflects the way in which the triage and dispatch system operates in practice.
• All patient records made by the paramedics on the Manchester urgent care desk should be made accessible to relevant staff, as required.
• Review the use of the MPDS system in terms of the tools not being available when a second follow-up call is made.
• Review the Mental Capacity Act (2005) training for all staff.

In Patient Transport Services:

• The trust should ensure all staff have timely access to a computer in order to submit electronic incidents or safeguarding referrals.
• The trust should consider facilitating ambulance crews to meet regularly to ensure new developments and lessons learned from local, trust wide and national incidents can be shared and discussed.
• The trust should explore that all recorded safeguarding incidents have been appropriately referred and that PTS staff are aware of what constitutes abuse or neglect and that they are all clear about the referral process.
• The trust should review the staff training requirements for the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) guidelines to provide a common understanding of how patients are cared for in accordance with their best interests.
• The trust should review its process for maintaining all vehicles in good visual repair and that rusty items are replaced as quickly as possible.
• The trust should review its process for reviewing and updating policies and procedures as appropriate.
• The trust should consider implementing regular refresher driving courses or skills checks for PTS drivers.
• The trust should review the process for ensuring that DNACPR documentation travelling with the patient is in the appropriate format.
• The trust should review the process for responding to and investigating complaints to improve the timeliness of this procedure.
• The trust should review its process for including operational issues within a strategic overview or central risk register related to internal risks.
• The trust should review its PTS operating model to produce a formal vision and strategy for PTS linked to the overarching organisation vision and strategy.

Professor Sir Mike Richards

Chief Inspector of Hospitals