As part of the preparation for the review we visited the Emergency Operations Centre (EOC) to see how 999 calls are dealt with. We spoke to a range of staff who work there.

We visited seven ambulance stations across the West Midlands and spoke with 64 staff. We visited Dudley, Worcester, Coventry, Stoke, Shrewsbury, Birmingham (Bristol Road) and Chelmsley Wood ambulance stations. We visited four Accident and Emergency departments (A&E) so that we could observe ambulances arriving at A&E and where possible speak to people, relatives, front line ambulance staff and staff employed at the hospitals.

We spoke to seven people in A&E departments. One person told us "I was brought in to A&E about thirty five minutes ago on a two man crew. The ambulance arrived within five minutes. The crew listened to me and explained what they were doing they asked for my consent they were polite and responsive. They asked about my medical history and allergies."

People told us that front line ambulance staff asked for their consent before giving any treatment. They told us they were listened to and treated with respect by ambulance crews.

As part of the review we asked the trust to contact people who had recently used the service to get their agreement to speak to us on the telephone so we could ask them about their experience of the care they had received. We carried out nine telephone interviews. People told us they were listened to and treated with respect by front line ambulance crews. People told us:

"Staff kept me calm and they told me everything that they were doing."

"The crew spoke to me they explained everything. They made me comfortable and took me to hospital."

"Consent was asked for everything they did."

The Patient Transport Service (PTS) is also operated by the trust and provides non urgent patient transport. People who use this service told us that the ambulance staff are very good but they sometimes have to wait a long time at the hospital for their return journey. One person told us about the administration problems they have when booking regular PTS journeys and this had caused them some concern.

We carried out 23 telephone interviews with managers of care and nursing homes across the West Midlands area. They were very positive about the service that the trust provides. They told us:

"Staff always maintain people’s privacy and dignity."

"Ambulances arrive very quickly. I have no concerns with West Midland Ambulance Service. They seem to explain everything to the patient and make sure that their dignity is maintained. They listen to what you have to say about a person’s health and then they take over and do what they have to do."

Front line ambulance staff told us that they have annual mandatory training and clinical updates so that their skills and knowledge are kept up to date. However many staff said they need further training on supporting people who are not able to consent to treatment.

Complaints are seen as a positive process by the trust from which improvements to the service are made. The trust works with community organisations and seeks the views of the public about the ambulance service and how it can be improved.

Ambulances were clean and staff had a good understanding of infection control procedures so risks to people are minimised.

West Midlands Ambulance Service NHS Foundation Trust (WMASFT) is one of 10 ambulance trusts in England and provides services to the following six counties:

• Herefordshire

• Shropshire

• Staffordshire

• Warwickshire

• West Midlands

• Worcestershire

WMASFT serves a population of approximately 5.6 million, covers 5,000 square miles and provides services to 26 NHS trusts.

The services employs over 4,500 staff including Paramedics, Emergency Care Practitioners, Advanced Technicians, Ambulance Care Assistants and Nurse Practitioners) and is supported by approximately 1,000 volunteers, over 63 sites and responds to around 3,000 '999' calls each day. WMAS operate from 16 fleet preparation hubs across the region and a network of over 90 Community Ambulance Stations.

The trusts primary role is to respond to emergency 999 calls, 24 hours a day, 365 days a year. 999 calls are received in one of two emergency operation centres (EOC), based at: Millennium Point, Brierley Hill (Trust HQ) and Tollgate Drive, Stafford where clinical advice is provided and from where emergency vehicles are dispatched if required.

In addition, the trust provides a patient transport services, employing 400 staff, a Hazardous Area Response Team of 49 staff and provides clinical teams to three air ambulances. Air Ambulance services in the region were provided by the Midlands Air Ambulance Charity. Paramedics and doctors on the service are funded by the charity but are provided by WMAS. The Air ambulance service was not included as part of this inspection.

We carried out this inspection as part of the CQC’s comprehensive inspection programme. We carried out our announced inspection between 27 June 2016 to 1 July 2016 and conducted unannounced inspections on 13 and 14 July 2016. We inspected the following core services unannounced:

Patient Transport Services

Hospital Ambulance Liaison Officer (HALO) at one NHS trust.

Emergency and Urgent Care

Overall, the trust was rated outstanding. We rated safe, responsive and well led good and we rated effective and caring as outstanding.

Our key findings were as follows:

Safe

• Incidents were reported in line with trust guidance and staff received feedback following untoward incidents.
• All staff did not fully understand the process or the terminology for duty of candour, but were fully aware of the need to be ‘open and honest’ regarding incidents.
• There were reliable systems, processes and practices in place across the majority of areas to keep patients and staff safe and safeguard from abuse and avoidable harm.
• Emergency and Urgent Care services (EUC) and Resilience services surpassed the trusts mandatory training targets of 85%, however, PTS did not meet this target, for example PTS Stoke scored between 34 and 54%, as the staffing levels were not sufficient to provide relief for staff to attend training.
• Records were stored securely, with a clear audit trail.
• Staff were competent in their roles and provided with timely appraisals and learning opportunities. We saw consistently high standards of cleanliness and infection control prevention in the majority of the ambulance hubs, community stations, control rooms and vehicles.
• Across the majority of areas, the supply of equipment, storage and maintenance was good. In Worcester, we found there was confusion regarding whose responsibility it was to test the defibrillator therapy cable. We escalated this the same day and it was quickly resolved with the senior management team.
• The trust medicine management policy was in place and the majority of staff followed the policy on a daily basis.
• There was a strong culture of improving medicine safety with clear governance pathways to ensure that learning was acted upon throughout the trust.
• There was a good skill mix and level of staff to meet the needs of patients and keep people safe across all areas.
• All of the staff we spoke with told us they had either received training or were booked on to participate in response to major incident training and that was part of the mandatory training programme. Resilience staff attended 68 multi-agency exercises between February 2015 and June 2016. These included firearms sieges, flooding, simulated explosion and fire in a nightclub premises, readiness exercises for international sporting events, and communications exercises.

However, we also saw;

• We saw challenges around Prescription only Medicines (POM's). For example, at one of the Worcester hubs we visited, we counted 56 recording errors between the 13 April and 29 June 2016, which staff had not been reported as incidents.

• We inspected an HDU vehicle at PTS Stoke and saw not all CD’s were stored appropriately.

• In PTS, we saw staff did not always carry out equipment checks and sterile environments were not always maintained.

• Staff were not aware of incidents that had affected change so learning was not always shared, which potentially meant missed opportunities to improve patient care trust-wide.

• PTS staff did not consistently lock ambulances when parked at the hubs or outside homes when collecting patients.

• Within EUC Erdington hub we saw dirty equipment and sluice area, where under the sink and floors were soiled and visibly dirty.

Effective

• Between April 2015 and March 2016 the trust was the only ambulance trust to meet all national targets for response times for the most immediately life threatening calls and answering 999 calls.

• The trust was part of a national pilot designed to change the way that ambulances respond to patients and was actively working with external providers and services to improve patient outcomes.

• The trust was a part of an operational delivery network, it was developed to manage the care and treatment for patients with major trauma.

• The design and functions of the regional co-ordination centre (RCC) within the EOC provided excellent specialist support for the local community.

• All staff were actively engaged in activities to monitor and improve quality and outcomes. The trust encouraged widespread opportunities to participate in benchmarking, peer review, accreditation and research.

• Within Resilience, credible external bodies such as a Joint Emergency Services Interoperability Programme (JESIP) and National Ambulance Resilience Unit (NARU) recognised high performance. The continuing development of staff skills, competence and knowledge was recognised by the trust as being integral to ensuring high quality care. Managers proactively supported their staff to acquire new skills and share best practice. Hazardous Area Response Team staff had protected training time. One week in seven was dedicated to training.

• Data provided by the trust showed that 96% of EUC staff had attended Mental Health Conditions training in 2015/16, which was significantly better than the trust target of 85%.

However, we also saw;

• All NHS ambulance services must respond to 75% of Category A/Red emergency calls. We found local performance data for emergency calls that were immediately life threatening showed variation across areas. Birmingham and Black Country achieved 83.5 and 81.8% respectively. However, Coventry and Warwickshire achieved 72.3%, West Mercia 69.8%, and Staffordshire 68.0%.
• Staff at PTS Stoke needed more mental health training to support patients with a mental health condition. The trust board took immediate and remedial action to address concerns raised.

Caring

• Staff across all areas staff consistently demonstrated kindness, compassion and respect towards patients, relatives and carers. All patients, relatives, and callers were treated as individuals and given support and empathy in often the most difficult circumstances.
• Staff recognised when patients required further information and support and this was provided at all times.
• Staff asked questions in a calm manner and demonstrated an empathetic approach to information gathering when communicating with patients, relatives and carers. This was observed during EUC and PTS with staff and patient interaction and in the EOC with call handlers during telephone conversations.
• Callers who were distressed and overwhelmed were well supported by staff. Staff used their initiative and skills to keep the caller calm, and provide emotional support in often highly stressful situations.
• There were systems to support patients to manage their own health and to signpost them to other services where there was access to more appropriate care and treatment. Staff involved patients in decisions about their care and treatment. When appropriate, patients were supported to manage their own health by using non-emergency services such as their GP
• Staff made sure people had understood the information given back to them by telephone advisors.
• Staff took time to interact with patients and supported them and their relatives and carers. They treated patients with dignity and respected their privacy at all times.
• Feedback from people who use the service, those who are close to them and stakeholders were consistently positive about the way staff treated people.
• There was a strong, visible person centred culture. Staff and management were fully committed to working in partnership with people and find innovative ways to make it a reality for each person using the service.
• Communication with children and young people was age appropriate and effective.
• Staff were highly motivated and inspired to offer kind and compassionate care; they displayed determination and went the extra mile to achieve this. For example, one staff member arranged for a patients’ cat to be cared for whilst the patient was in hospital, which alleviated the patient’s anxiety and they agreed to leave their home and go to hospital.

Responsive

• The trust planned and delivered services in a co-ordinated and efficient way that responded to the needs of the local population. For example, PTS had a good escalation and planning process for the next day’s journey. The plans detailed monitoring of transport times, cancellations and aborts, action they take to prevent breaches of the contract and remedial actions should they occur.

• People’s individual needs and preferences were central to the planning and delivery of tailored services. This was particularly evident within EOC and Resilience where services were flexible, provided choice and ensured continuity of care.

• We saw strong evidence of multi-disciplinary team working across all areas to support people with complex needs. For example EOC staff were trained to use type talk (which was a text relay service for patients with difficulty hearing or speaking) they could also use voice over internet protocol (VOIP) to receive 999 calls.
• We observed staff conversing with patients with mental health issues and interacting with them in a way that met their individual needs.
• Community First Responders (CFRs) within EUC services worked efficiently across the region particularly in rural areas to support ambulance staff with responding to life threatening emergencies. The trust used Rapid Response Vehicles (RRVs) effectively to ensure emergency treatment started as soon as possible.
• EUC’s ‘make ready’ team freed up ambulance staff to attend to calls throughout their shift rather than spending time preparing and cleaning vehicles.
• The trust managed and reviewed patients’ complaints appropriately and people who used services were involved with service improvements.

• Hazardous Area Response Team had been given additional staff and equipment in order to provide the trust response to bariatric patient’s needs.

  However, we also saw;

• Specialist bariatric equipment was not always readily available across all areas.
• Across EUC and PTS there were limited tools in place to assist patients with learning disabilities and people living with dementia staff felt that they would benefit from receiving training in regards to this.
• Information about how to raise concerns or make a complaint about services was limited on ambulances for EUC and we saw complaints information on most PTS vehicles. PTS Managers across some areas dealt with complaints at a local level, which meant there were missed opportunities for trust-wide learning.
• EUC staff we spoke with told us generally target response times were achievable and the only reason they would not meet some targets would be as a result of the wide geographical area. We saw these figures were being monitored internally, however more work was required to achieve the set targets so that people living in rural areas were not continually disadvantaged. For example, we observed the ambulance crew respond to a call in Rugby whilst they were in Coventry the journey time between the two areas was 35 minutes.

Well led

The overall rating for the well led domain was rated ‘good’. The ‘Good’ rating was due to overwhelming evidence during the inspection period and information supplied by the trust before and after the inspection that supported strong senior leadership of the organisation.

• Staff were aware of the robust five-year strategic plan and the trust’s vision and values were well in-bedded across all areas.
• Operational staff demonstrated passion and commitment to provide high-quality care and they ‘lived’ the strategy daily.
• Clinical governance, risk and quality management were effective. We were confident that the governance, risk and quality boards influenced and impacted services at an operational level.
• The trust was focused on achieving response time performance targets, and this was reflected in the governance framework used to monitor performance.
• Through staff interviews and observations we saw that there was a high standard of leadership at the trust, with strong leadership from the CEO. All the executive directors were well engaged and interacted with each other appropriately.
• The vast geographical area covered by the trust, meant it was not always practical for the CEO and other executives to meet frontline staff on a regular basis. We saw that the leadership team recognised this and encouraged staff to engage with them in other ways such as direct email.
• The trust was actively involved in effective public engagement to recruit staff from Black and Minority Ethnicity (BME) population.
• There was a mostly positive, open and honest culture among all staff groups. In the main, managers supported staff well and staff told us they felt listened to.
• There were high levels of staff satisfaction across EOC, PTS and Resilience and staff were proud of being a part of the trust and their role within it.
• Staff at all levels were actively encouraged and supported to explore innovative ways of working with a common focus on improving quality of care and people’s experiences.
• Across all areas staff gave examples of how they had worked together to support each other. They told us that they talked openly with each other and their managers and their managers were open and honest with them.
• Managers were extremely proud of the calibre and commitment of staff on the HART team. Managers were clear that they believed the success of the HART team rested with the ability of staff to perform professionally in extraordinary circumstances and situations, and their role was to provide them with the facilities and training to enable them to do so.

• The trust provided a counselling and support service for staff who required support following attendance at traumatic or upsetting calls. There was a 24-hour helpline, staffed by volunteers from within the service. All volunteers were trained before joining the team.

However, we also saw;

• A governance framework supported the delivery of the strategy and good quality care. However, we found this was not always effective or consistent across all areas. For example, there were instances in Coventry and Warwickshire and throughout West Mercia where staff were unclear of who had responsibility for tasks such as the checking of defibrillator test cables and auditing prescription only medicines management. Once escalated to the trust, remedial action was quickly taken and staff were advised accordingly.

• Risk registers did not always reflect each hub’s risks. For example, there were insufficient middle managers across EUC to ensure staff were fully supported. We saw the impact of this as not all managers had the time to respond to their staff’s concerns. This was particularly evident in the Worcestershire hub where the area manager was responsible for 196 staff and this was against the operating model of one manager to 100 staff-.This risk was placed on the risk register, however, there were no actions to reduce this risk.

• In West Mercia there were five area managers, two on sick leave and a third on annual leave with acting area managers in place. Bromsgrove hub also struggled to provide adequate managerial staff support and Lichfield hub had one area manager and no area support manager (ASO). Thismeant that the area manager was managing over 100 staff. This was a similar picture at the Donnington hub. Managing this large number of staff meant they were unlikely to be able to provide sufficient staff oversight and appropriate supervision.

We saw several areas of outstanding practice including:

• The trust was shortlisted in 2015 for two national awards including; Enhancing Care by Sharing Data and Information and Improving Outcomes through Learning and Development.

• HALO’s across all divisions had developed innovative and forward thinking ideas to reduce hospital admissions and ambulance call-outs which proved to be very effective. HALOs work in partnership with the Emergency Department practitioners to support the effective and efficient management of patient streams, particularly patient handover and ambulance turnaround times within the department, helping emergency crews to become available earlier to respond to the next incident.
• The trust encouraged online engagements with patients and provided patients with clear and concise tools to self-care and recognise life-threatening conditions.
• Paramedic availability throughout the service, and plans to increase this further meant that highly qualified staff could provide emergency care to patients.

• The functions within the Regional Co-ordination Centre provided effective support for complex incidents within the trust’s geographical region and externally through the Midlands Critical Care Network.

• The trust looked at innovative ways of engaging with the local population, for example, the Youth Council Strategy and the Youth Cadet scheme.

• All operational staff on the HART team were required to be qualified paramedics and to maintain their accreditation which was in line with NARU best practice. Not all trusts followed this guidance.

• The only exception to protected training was if the team was required to deploy to a major incident to support the duty team [this is another area of best practice in the UK

• Compliance with NARU and Joint Emergency Services Interoperability Programme JESIP guidance was seen to be very strong and reflected industry best practice.

• During 2015 the MERIT team were peer reviewed by the Trauma Network; and they were graded as providing recognised best practice in nine out of ten criteria, which is a recognition of best practice.
• The NHS England Core Standards return for 2015/16 was 100%, which is an area of outstanding practice.

• The sharing of the trust forward planning for New Year’s Eve represented an area of outstanding practice.

• WMAS was an integral part of the Emergency Response Management Arrangements (ERMA) and acted as the host and regional ‘GOLD’ - control centre for all Emergency Service providers during the first hour of any large-scale emergency incident. Gold Control plans were in place to assist in coordinating any such response. This is unique in an ambulance service and represents an area of best practice nationally.
• The trust provided staff with major incident aide memoire cards and were in the process of developing electronic versions. The aim was to increase efficiency and confidence of staff when dealing with major incidents.
• The HART staff were committed to improve their personal skills and provide a comprehensive service to exceed normal working practices in support of casualties.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Improve staff attendance at mandatory training ensuring it is monitored and actively supported.

• Safely store all medication on high dependency vehicles.

Professor Sir Mike Richards

Chief Inspector of Hospitals