Archived: NSL South West Region

Updated 25 April 2016

NSL South West Region is part of NSL Limited, a nationwide provider of patient transport services. NSL have provided non-emergency patient transport for the commissioners in Kernow (Cornwall), North and East Devon and Somerset since October 2013. This followed a tender process that identified NSL Limited as the highest scoring and performing organisation that bid to provide these services.

NSL South West Region serves a predominately rural area, but also cities such as Exeter and large towns such Taunton, Truro and Penzance.

We inspected all the key elements of the five key questions including whether the service was safe, effective, responsive, caring and well led. We visited the ambulance stations at Exeter, Redruth, Bodmin, Wellington and Shepton Mallet.

Updated 25 April 2016

NSL South West Region is part of NSL Limited, a nationwide provider of patient transport services. NSL have provided non-emergency patient transport for the commissioners in Kernow (Cornwall), North and East Devon and Somerset since October 2013.

We carried out a scheduled comprehensive inspection on 3 and 4 November 2015 to review the service’s arrangements for the safe transport of patients.

Our key findings were as follows:

SAFE:

• The provider had systems in place for reporting and investigating incidents. We found inconsistency in the reporting of incidents amongst staff. There was no evidence that staff received feedback following investigations into incidents and staff could not tell us where improvements had been made as a result.

• The provider had a statutory obligation to report certain incidents to us, we found that this did not always happen.

• There was inconsistency in the professional development training (mandatory training) between new staff and staff that had transferred from the previous NHS provider. Staff told us that the training courses provided were generally adequate and relevant to their roles.

• We were concerned that staff told us they would only report a safeguarding concern with the patients consent. This was confirmed in the provider’s policy. This had the potential to put patients at risk of further abuse because staff did not report concerns, or their concerns were not passed to the local authority.

• The provider had good systems in place to deep clean the vehicles on a regular basis. All the vehicles and ambulance stations we saw were clean and tidy. Staff washed their hands and made good use of personal protective equipment such as gloves.

• Staff consistently carried out their vehicle checks before each shift and noted any defects. We observed that vehicles were not always repaired in a timely way. There was no overall oversight across the South West with regards to vehicle maintenance and servicing.

• Risk assessments were carried out by staff when necessary. Staff were informed of any special measures that they need to take with each patient such as mobility problems.

• Staff told us they regularly worked additional hours and missed their breaks because of demand. At the time of our inspection, we noted 31 full time vacancies throughout the South West, although the provider told us that most of these were for bank staff. The provider had a recruitment plan in place to recruit ambulance care assistants.

• Incidents that must be notified to the Care Quality Commission were not always done, which is an offence under the Health and Social Care Act.

EFFECTIVE:

• Staff were confident to refuse to transfer a patient if they felt the patient needed more specialist care.

• A patient liaison officer was in place at one acute hospital. This was highly regarded by the hospital and fostered a good relationship between the provider and the trust. It improved communication and transport bookings for patients.

• Staff had been trained in the mental capacity act, but did not feel it had given them enough information or the confidence to undertake mental capacity assessment.

CARING:

• Ambulance care assistants were described as polite, courteous and patient focused. Other health care professionals told us that the staff went above and beyond for their patients. We received very good feedback from patients about the care and treatment they received from the ambulance care assistants.

• We observed staff interacting with patients. They introduced themselves, were friendly and appropriate in their manner. They put patients at ease when they were anxious and chatted with the patients during their journey.

• Staff made sure patients were as comfortable as possible during their journey. Staff made sure patient’s privacy and dignity was maintained especially when transferring to and from the vehicle.

• We observed the ambulance care assistants calling patients to confirm a journey or if there was going to be any delay in picking them up. We noted that these calls were not consistently carried out by all staff every day.

RESPONSIVE:

• Staff were frustrated that they were frequently unable to meet their performance indicators for the collection and arrival times for patients. Staff felt this was a combination between increased demand and poor planning with unrealistic journey schedules.

• There was a lack of resilience. Spare vehicles were available in each ambulance station. However, we saw that these were routinely used on a daily basis because of demand or when other vehicles were off the road.

• There were no facilities for patients whose first language was not English. We saw that one patient had been conveyed for three months with no provision put in place for her language needs. We were told that staff would find it acceptable to use a child to interpret for their parents if necessary.

• Staff were given journey sheets which detailed who the patient was, pick and drop off locations and times and any additional information the crews needed. We found that this information, whilst useful to the crews did not always contain everything they needed to know. We saw examples where the information was completely ignored by the planners with the journey schedules.

• Details of how to make a complaint could be found on every vehicle. Staff were aware of the complaints process and would try to resolve concerns for patients to prevent them becoming complaints. Staff told us they did not receive any feedback once complaints had been made and were not aware of any improvements that had been taken as a result.

• Relationships with the control and planning staff were at times strained. We observed the planners set unrealistic schedules at times that were impossible for the crews to stick to. Some crews told us that they were set up to fail in meeting their targets for picking patients up on time.

WELL LED:

• Ambulance care assistants felt well supported by the team leaders and assistant team leaders. The majority of team leaders and assistant team leaders were visible, accessible and highly respected by staff.Some of the team leaders did not feel as supported by their managers.

• A risk register was maintained but did not reflect the full needs of the service. Some risks had not been updated since May 2015 despite being graded as critical (red rated)

• Daily teleconferences were in place across all the ambulance stations which allowed managers to understand the resources that were available on that day.

• Local governance meetings had started which fed concerns through to the overall governance forum for NSL. This forum reported to the trust board for NSL.

• Monthly quality reports were provided to each of the three clinical commissioning groups (Cornwall, Somerset and Devon). These reports contained performance information, details of any incidents and complaints and information on training.

• Communication from senior management to staff was felt to be poor. There was a system of organisation team briefings, but staff meetings were infrequent. Team leader meetings were supposed to take place monthly, but these were not consistent.

• Staff had been kept informed of the on-going contractual issues that were taking place at the time of our inspection (NSL had terminated all three contracts with the assumption that it would re-tender for the contracts).

• Staff told us they enjoyed their jobs and were very patient focused.

• Patient feedback forms were available on each vehicle and the service received positive feedback via these forms. As an example 77 out of 86 people said they would recommend the service in Devon to other people.

We saw several areas of outstanding practice including:

• We observed outstanding care and treatment provided by ambulance care assistants towards their patients

• The overall feedback we received from patients and other health care professionals showed that the ambulance care assistants went above and beyond in their care of their patients

However, there were also areas of poor practice where the location needs to make improvements, including:

• The provider must put systems in place to give an oversight across the South West on the servicing and maintenance of vehicles.

• The provider must have appropriate systems in place to make sure vehicle servicing and repairs are carried out in a timely way and that vehicles with defects are removed from service pending repair.

• The provider must have appropriate systems in place to make sure safeguarding concerns are recorded and reported to the local authority.

In addition the location should:

• The provider should have appropriate systems in place that encourage staff to report incidents, and that they are provided with feedback following the investigation.

• The provider should improve the governance arrangements across the South West Region to have reassurance that consistent practice is being achieved across all six ambulance stations.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 25 April 2016

We found there was inconsistency with staff reporting incidents. Some staff had no hesitation in reporting incidents, whilst others told us they didn’t report them. When incidents were reported, they were investigated properly and actions taken where necessary. We also found inconsistencies in the training offered to new staff compared to the training offered to staff who had transferred over from another organisation. Staff had received training in adult and child safeguarding at level one. However, the service transported children and none of the staff used to care for children had received training at level two. This was contrary to national recommendations. The majority of staff we spoke with said they would only report a safeguarding concern if the patient gave their consent. This potentially put people at additional risk of abuse because concerns were not shared in a timely way with the local authority. We found the provider had systems in place to make sure patients were not put at risk due to cross infections by making sure vehicles and equipment were cleaned appropriately. Equipment was found to be serviced according to manufactures instructions. However, we saw evidence that showed vehicles were not always maintained or repaired in a timely way. This put patients and staff at risk by travelling in vehicles with defects. Risk assessments were completed by staff when necessary and appropriate. Staff were informed of particular needs for each patient. Staff told us they regularly worked additional hours and missed their breaks because of demand. The provider had a recruitment plan in place to manage their vacancies across the region.

New staff had all received a comprehensive induction at the start of their employment. They were able to shadow more experienced staff and received probationary reviews at regularly intervals. Staff who had transferred over from the previous NHS Provider had not received this induction which lead to inconsistencies in the training staff received. Staff were expected to attend three one hour training sessions and complete an annual workbook to refresh their skills. We had concerns that three hours per year was insufficient time to cover the necessary topics for mandatory professional development. Staff had received training in the mental capacity act but did not feel it gave them enough information for them to judge people’s capacity to give consent. Staff did not transport a patient if they had assessed they did not have the necessary skills in which to do so safely. Each vehicle had bottles of water for patients should they need it. Where patients had been scheduled for longer journeys, the referring hospital would provide the patient with a snack box for the journey.

We found the staff at NSL South West Region to be extremely caring and dedicated towards their patients. We received very good feedback from patients, other health care colleagues and care home managers. We observed very good communication between ambulance care assistants and their patients. The ambulance care assistants treated patients with dignity and respect and at times went out of their way to make sure the patient was comfortable. Crews called patients to inform them if they were going to be late and also to confirm the journey was still planned.

We saw examples of where the planners scheduled journeys that were impossible for the crews to make. There was a lack of resilience with the vehicles across the south west, to cope with the demand. The service had no facilities for patients who did not speak English. Staff encouraged relatives to accompany patients to act as interpreters and told us they would also use children to interpret. This put patients who did not speak English at risk of being unable to make their needs known to staff whilst on a journey. Specially adapted ambulances were available to accommodate bariatric patients. Crews were provided with journey sheets which contained all the information the staff needed such as assistance with mobility. We saw evidence that in some cases; this information was not followed. Each vehicle had details for patients on how to raise concerns or make complaints. Staff we spoke with were aware of the complaints process and could direct patients accordingly.

There was no central system in place to provide managers with an overview of their fleet across the south west. A risk register was in place but we saw that it did not always reflect the needs of the service and some risks had not been actioned. Staff were not aware of the overall vision and strategy for NSL South West Region or NSL Ltd. Staff had concerns that the three contracts had been terminated and some were concerned for their jobs. Staff told us they felt supported by their team leaders and assistant team leaders. We had concerns about the level of support and training the team leaders and assistant team leaders and the managers received. Patient feedback forms were carried on every vehicle, although they were not completed regularly. Those that were completed, overall were very positive about the service they had received. The last staff survey was completed in November 2014.