Exora International Limited is operated by Exora International Limited. The service was registered with the Care Quality Commission (CQC) on 23 August 2017. The service provides a patient transport service (PTS). The provider is registered for the regulated activities: transport services, triage and medical advice provided remotely and treatment of disease, disorder and injury.

The service transports non-emergency patients to and from community care locations, airports, hospitals and patients’ home addresses. The service transports both adults and children. Exora International Limited does not have fixed contracts with any providers. In 2018, the service carried out 2156 journeys. 95% of the jobs the service undertakes are ad-hoc and short notice bookings.

The service has three ambulances equipped for patient transport only.

We carried out a short notice announced inspection of the PTS core service using our comprehensive inspection methodology on 2 April 2019 and 4 April 2019.

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.

We rated the service requires improvement overall because:

• Staff including the safeguarding lead were not trained to the recommended level of safeguarding training for children and adult safeguarding.

• The service's safeguarding policy did not reflect current national guidance.

• There was no medicines administrations protocol on the safe use of nitrous oxide with oxygen and no detail in the medicines management policy around the safe and effective use of medical gases. There were no clear guidelines detailing when staff would be required to use nitrous oxide with oxygen. We were unable to find competency assessments for members of staff trained to administer nitrous oxide with oxygen.

• We had concerns around the storage of medical gases at the service’s office. The service had not taken advice from the relevant authorities around the storage of these gases. We raised these concerns with the registered manager on the day of the inspection who immediately ordered a new cage for the gases and arranged for an assessment by the local fire service.

• Deep cleaning records we viewed showed gaps for some vehicles indicating that not all of the vehicles were deep cleaned monthly as per company policy.

• Equipment servicing logs we reviewed did not match the dates written on servicing stickers on equipment. We were therefore not assured that equipment was being regularly serviced and recorded by the provider.

• We were not assured that all incidents were being reported. There was no formal record kept of incidents that were low risk, no harm or near misses. The service also did not have an incident reporting policy.

• The service did not have a system to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected. The service did not routinely record risks. There were a number of risks we identified which were not recorded, for example the storage of medical gases.

• The service conducted very few audits. We saw audits for deep cleaning of vehicles and equipment checks, however we did not see an infection prevention control audit. The service did not have a clinical audit policy and the service did not audit areas such as complaints, booking forms, incident investigations and performance indicators.

• The service did not use a translation service for patients whose first language was not English. Staff told us patients who did not speak English as their first language, were often accompanied by a relative or interpreter.

• Staff were not aware of the vision or values of the service.

However, we also found that:

• All staff we spoke with demonstrated a good understanding of safeguarding children and vulnerable adults. Staff were able to identify the potential signs of abuse, the process for raising concerns and what would prompt them to report a concern.

• Throughout our inspection, all staff were observed to be ‘bare below the elbow’ and adhered to infection control procedures, such as using hand sanitisers after each patient contact and cleaning equipment with antibacterial wipes after each patient transfer.

• Equipment we inspected on the ambulances were suitable for the patient groups that the service transported. For example, vehicles had bariatric wheelchairs and stair climbers for patients with a high body mass index as well as paediatric harnesses when children were being transported.

• The service used an electronic booking system which contained a comprehensive checklist to assess patient risk and ensure patients booked in could be transferred safely. The checklist had several tabs which control room staff filled out to ensure that all information could be gathered to understand specific patient needs. This included information such as the patient’s mobility and whether the patient had steps at their home address and required equipment to transfer from their home to the ambulance.

• Staff received yearly appraisals and told us they were useful. We viewed appraisal records which showed that all staff had up to date appraisals.

• The Mental Capacity Act and consent formed part of mandatory training and staff we spoke with showed a good understanding of mental capacity and deprivation of liberty safeguards. All staff were up to date with Mental Capacity Act training.

• Feedback from patients confirmed that staff treated them well and with kindness. We observed episodes of care on patient journeys and saw that staff were compassionate and respectful with patients. Staff ensured patients’ privacy and dignity was maintained.

• The service was able to provide a flexible service for patients and give precise pick up times. The service specialised in accommodating short notice bookings and all three vehicles were multi-purpose which meant that a range of patient transfers could be undertaken with suitable equipment.

• Staff spoke highly of the visibility and involvement of the registered manager and told us that they frequently attended jobs with them. Staff told us they felt supported by the organisation and could approach the registered manager with any issues that they had.

• Staff spoke of good teamwork, and an open, honest, patient-focused culture within the organisation.

• Staff we spoke with were knowledgeable about the duty of candour and aware of their responsibility to be open and honest with service users.

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, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals, on behalf of the Chief Inspector of Hospitals