Criticare UK Ambulance Service is an independent ambulance service. The service provides a patient transport service including high dependency transfers and transfer from events.

We carried out an unannounced focussed inspection on 29 August 2018. This inspection was conducted to assess compliance against a warning notice, which was issued to the provider on 12 January 2018. CQC generally follows up on warning notices within days of such notice coming to an end. The warning notice for this organisation expired on 12 March 2018. The warning notice follow up was delayed and we engaged with the provider until the follow up visit.

Our inspection targeted the key concerns identified in the warning notice.

At our inspection we found there were many areas where the provider had still not made any progress. For example, we found the following:

• There were no systems to make sure the vehicle was safely cleaned between patient journeys and reduce the risk of cross-infection.

• There were no established systems for quality assurance including overarching document which clarified expected targets and how these measured the service performance.

• The provider had limited processes to minimise risks and the impact of risks on patients, staff and others.

• There were no systems or processes for staff to follow to maintain a secure and accurate record for each patient about the care and treatment provided to and of decisions taken.

• Patient records were consistently not held securely and controls were not used to ensure only authorised personnel accessed them.

• There were no records to confirm that equipment on had been checked and properly maintained. We found the registered manager, who was not qualified to service equipment, undertook such tasks.

• Following this inspection, we told the provider that it must take some actions to comply with the regulations. We issued the provider with one warning notice and three requirement notices, which affected patient transport service. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South) on behalf of the Chief Inspectors of Hospitals

Criticare UK Ambulance Service is an independent ambulance service. The service provides a patient transport service including high dependency transfers, medical cover at events and training.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 13 December 2017, along with an unannounced visit to the service on 21 December 2017.

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 issues that the service provider needs to improve:

• There were no formal governance arrangements . Whilst senior staff were able to describe systems and processes there was no formal record or evidence of these. This had a significant impact on many aspects of the service.

• There were no systems to monitor the safety or quality of the service. Audits were not undertaken and therefore learning did not take place from review of practices and procedures.

• The service did not have recruitment procedures to ensure all staff were subject to a robust check of their suitability and experience for the role. There was no evidence that the service consistently carried out pre-employment checks on staff.

• Staff did not consistently report incidents and the service did not have a clear system for identifying trends to implement learning from incidents.

• Staff did not consistently complete and record essential daily checks such as vehicle maintenance and equipment checks. The patient stretcher was not included on the essential checks prior to staff attending a patient transport request.

• The service did not have an effective robust understanding and governance processes for the use of restraint. Staff did not recognise that physically holding a patient to prevent them from harming themselves or others was restraint and staff did not receive training. The policy for the use of handcuffs did not outline a clear criteria where handcuffs could legally be used. The service had not followed its own governance procedures for the reporting of use of handcuffs.

• We found there was inconsistency over the documentation used for patient records and booking patient transport journeys. There was no clear process and staff could choose to use either paper or electronic patient records. Patients’ medical records were not securely and there was a risk of unauthorised access.

• There was no formal process to triage or assess patients at the time of booking. This included assessment of patients’ mental capacity. Staff did not always undertake risk assessment to monitor the individual risks to patients.

• Arrangements for safeguarding children were not adequate. Staff did not always have training appropriate to their role and the policy for safeguarding children did not reflect national guidelines or specify training requirements.

• There were no formal systems to ensure staff received regular appraisals on their performance and development. There was no competency framework to assure the service that staff were competent to undertake their duties work in line with best practice guidelines. The service did not formally record the induction for new staff members.

• Not all staff had completed mandatory training appropriate to their role. Some training such as practical manual handling was not provided at all by the service.

• There were limited clinical policies and guidelines to support staff and provide evidence based care and treatment. Staff did not have access to the most up to date Joint Royal Colleges Ambulance Liaison Committee clinical guidelines.

• There was no provision on ambulance vehicles to support people who were unable to communicate verbally or for whom English was not their first language.

• Information for patients on how to make a complaint was not readily available in the vehicles or on the company website. The service did collect patient feedback.

However, we also found the following areas of good practice:

• Vehicles were visibly clean and there was evidence staff had carried out deep cleans on the vehicles at regular intervals. There was access to personal protective equipment for staff and clinical waste facilities.

• Equipment on vehicles was well maintained and the service kept an asset register to ensure clear documentation of when equipment needed to be serviced.

• Staff were aware of how to report a safeguarding concern and there were examples of when they had done so. Senior staff could also demonstrate they had investigated and learnt lessons from safeguarding referrals made to the company.

• Staff demonstrated a good knowledge of their responsibilities in regard to the Mental Health Act (2005). There were several examples where staff gave examples of working in the best interests of patients.

• The service provided opportunities for staff to undertake additional training which was not mandatory to their role.

• There was evidence the service had investigated and learnt from complaints.

• Staff spoke highly of the senior leadership team and felt they were supportive and visible. Staff felt they could contact senior staff and any time for support and advice and concerns would be taken seriously.

• Staff enjoyed working for the service and were passionate about providing high quality care to patients. Staff told us there was a sense of teamwork amongst the 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 one requirement notice and took enforcement action against the provider. Details are at the end of the report.

Amanda Stanford

on behalf of the Chief Inspector of Hospitals