The Care Quality Commission
  • Ambulance service

Archived: NSL South West Region

16/17 Kestrel Business Park, Kestrel Way, Sowton Industrial Estate, Exeter, Devon, EX2 7JS 0843 357 5700

Provided and run by:
NSL Limited

All Inspections

3 and 4 November 2015

During a routine inspection

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

9, 12 February 2015

During an inspection looking at part of the service

NSL South West Region is a private ambulance service providing non urgent transport between people's homes and healthcare establishments. NSL South West Region provides transport for NHS services in Somerset, Devon and Cornwall. A hospital / ambulance inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary, please read the full report. Below is a summary of what we found.

At our last inspection on the 17 June 2014 the provider did not have evidence of previous training for staff members that had been transferred over under TUPE arrangements. We saw evidence that the majority of staff had not completed the necessary training. We saw arrangements in place for reporting and resolving vehicle defects in Exeter, but this was not consistent at the Redruth ambulance station.

At our last inspection on the 17 June 2014, concerns had been raised with the overall performance of the provider. These were particularly around timeliness of picking up and collecting people from home or hospital. We noted that the provider had made significant improvements in this performance but needed to maintain this to ensure they were consistently providing an effective service to patients.

At our last inspection on the 17 June 2014, we noted the provider did not have systems in place to learn from complaints. Staff told us that not all concerns were acted upon when raised. We noted improvements during our most recent inspection.

There were concerns that the provider did not have robust processes in place for the monitoring of the service to provide assurance that people's needs were met and that the risks to staff and people were identified and addressed.

12 December 2014

During an inspection looking at part of the service

This inspection was to follow up previous non compliance with Regulation 21 and Schedule 3 of the Health and Social Care Act which relates to the recruitment of new staff. We had previously issues a warning notice to the provider regarding their recruitment procedures and processes.

During this inspection we reviewed the personnel files for 24 out of 35 members of staff who had been recruited since our last inspection in June 2014. This included the documentation retained regarding their recruitment process.

We found that the provider had reviewed their recruitment procedures at NSL South West since our last inspection and additional information had been obtained throughout the process. This meant that a disclosure and barring service check had been made for each applicant to ensure they were of good character prior to employing them.

We saw there were gaps in the information some people had provided regarding their work history and the provider had not made a record to show they had fully explored these. References were obtained from a variety of sources with a number of references held for employees being from friends or family. This meant the provider had not consistently followed an effective recruitment procedure / process for each employee which consistently complied with Regulation 21, Schedule 3 or the organisations own policies and procedures.

17 June 2014

During an inspection looking at part of the service

NSL South West Region is a private ambulance service providing no urgent transport between people's homes and healthcare establishments. NSL South West Region provides transport for NHS services in Devon, Cornwall and Somerset. A hospital and ambulance inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary, please read the full report. Below is a summary of what we found.

Is the service safe?

Staff who had been TUPEd from a previous organisation, to NSL, had not received mandatory training. TUPE is the Transfer of Undertakings (Protection of Employment) Regulations 1981. The purpose of the Regulations is to protect employment rights when employees transfer from one business to another. We requested, but were not shown, evidence of the previous training records for these staff members. Transferred staff we spoke with told us their annual mandatory training was out of date . Staff who had been appointed since October 2013 had received appropriate training according to their role. We did not see evidence of action taken in response to defects noted on ambulances.

Is the service effective?

The feedback we received from the organisation which commissioned the provider and from three NHS trusts that provided care to the patients who used NSL, confirmed concerns had been raised about the overall performance of the provider. The staff we spoke to gave us both positive and negative views. Including delays for patients and a positive induction programme.

Is the service caring?

The people we spoke to who used the service told us that they were supported by professional, friendly and trained staff.

Is the service responsive?

The provider used sub contractors to provide additional transport for patients. The provider attended regular quality monitoring reviews with its commissioners. An increase in the number of people who needed transport provided had increased in one area.

Is the service well-led?

Staff told us they felt supported by the team leaders and management structure. Staff told us that not all concerns were acted upon when raised. The provider did not learn from complaints.

27, 28 November 2013

During an inspection in response to concerns

This ambulance provider was awarded the non-urgent patient transfer contract from the NHS clinical commissioning group and began transporting people on 1 October 2013. Most transfers are between home to hospital and the provider's main base is in Exeter, Devon although transfers can take place across the South West or countrywide.

We carried out this inspection because we received concerns from four separate sources about NSL South West Region. Concerns were raised in relation to patient care (people being late for of missing hospital appointments), staff recruitment practices and safety of vehicles.

We contacted the NHS commissioners and four of the NHS trusts in the South West who are customers of NSL South West Region. We also met or spoke with nine staff working at NSL South West Region. We contacted one person who had recently used the service and who had requested to speak with us.

The provider has not met agreed operational targets, although the performance is improving. People have experienced transport delays or transport has not arrived. This meant treatment in hospitals has been cut short, cancelled or has resulted in hospital readmission. However, when people complained to the provider their views were heard and the provider acknowledged responsibility and took action to act to resolve issues.

Staff recruitment processes put people at risk because required background checks have not been carried out for new staff in a timely way. This does not ensure the suitability of staff to transport or accompany people in vehicles.

Vehicles were regularly monitored for defects and were clean.

Quality assurance processes were in place but people remained at risk of not receiving the support they required.