We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 30 April 2018.

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 areas of good practice:

• The service had clear incident management system for reporting, reviewing and responding to incidents with feedback processes for shared learning.

• There were suitable policies and procedures for raising safeguarding concerns which staff were aware of. The service is in the process of providing enhanced safeguarding training for staff in line with national guidelines.

• There were appropriate and comprehensive risk management structures in place with suitable risk assessments and a risk register which was informed by regular review of outcomes and quality monitoring. This included planning for safe staffing levels and relevant contingencies.

• There were safe systems for managing medicines at the service with regular audit checks and effective processes for supply and disposal.

• The service monitored environmental safety and infection control with regular equipment and hygiene checks.

• Records were managed effectively and securely with regular scrutiny as an integral part of quality monitoring.

• Staff had access to current guidance and protocols based on national guidelines which they could reference through phone apps and on the provider website.

• The provider monitored adherence to guidelines via spot checks, audits of patient record forms and patient outcomes via a clinical dashboard.

• There were effective systems for assessment and planning of support and care provided by the service with regular briefings.

• The service provided regular training for staff to ensure competence levels were maintained as appropriate and supplied updates and relevant guidance on the staff resource section of the website, including additional information and guidance using a range of methods.

• Staff received regular appraisal and review which was recorded in personal records.

• Systems were in place to ensure staff maintained their professional registration and were

• up to date with their mandatory training and clinical skills

• Consent was well evidenced and there were up to date policies relating to capacity and consent in adults and children as well as staff training.

• The service took account of diversity and there was a multi-faith phrase book available for use if required.

• The service demonstrated effective management of complaints, with analysis and learning available to staff.

• The service had an enthusiastic and proactive registered manager with a senior management team to provide operational oversight and clear organisational structure. There were clear mission statements and a business development plan was in progress.

• The service had an up to date risk register and a range of quality assurance processes which demonstrated regular review and actions to maintain and improve performance and respond to any concerns.

• Staff were positive about the culture at the service and there were good systems for engagement and communication with staff using a variety of media and feedback processes.

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

• Although the service used a central database to monitor mandatory training, records were not always clear or up to date.
• The service had recruitment processes in place, however not all staff had a record of pre-employment reference checks.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (area of responsibility), on behalf of the Chief Inspector of Hospitals