British Emergency Ambulance Response Service (BEARS) was founded in 2009 and is an independent ambulance service providing a range of patient transport services across London. This includes the transfer of high dependency and critical care patients, bariatric patient and paediatric patients. It also includes secure transfers of mental health patients.

The service has contracted work with three NHS trusts in London and also provides ad-hoc work for other NHS and independent hospitals. Journeys are made to various locations within London and longer journeys occurred on a regular basis. The service has vehicles operated by paramedics, ambulance and emergency care assistants and emergency medical technicians.

We previously inspected this service in October 2017 and identified some concerns regarding the use of restraint. We asked the service to make some improvements, which included:

• The secure services division was occasionally using mechanical restraint without appropriate consideration of the mental health act code of practice.

• Ensure they consider the Mental Health Act (1983) Code of Practice in their policies and procedures around secure patient transfers.

• Not use mechanical restraints on patients in a way that deprives their liberty.

• Ensure use of mechanical restraints is appropriately risk assessed and the least restrictive option.

• Ensure patient record forms include all key information around the secure services patient transfer. This should include detailed information of the decision to restrain patients including any risk assessments.

• Ensure patients who are sedated are accompanied by a qualified mental health profession.

Our key findings from this inspection were as follows:

• The service ensured they considered the mental health act code of practice within the secure services division.

• In the records we reviewed the service was not using restraint in a way that deprived patients of their liberty.

• The service conducted risk assessments for patients where any form of restraint might be used, including the Cat B secure cell in the vehicle (this is a secure cell within the back of the vehicle). The service also recorded details of professionals who were involved in these decisions.

• Patient record forms included all key information around secure service patients’ transfers. This included detailed information about the patients’ behaviour and mood, any risks and de-escalation methods used.

• The service recorded whether patients were sedated and accompanied by mental health professionals.

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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

British Emergency Ambulance Response Service (BEARS) was founded in 2009 and is an independent ambulance service providing a range of patient transport services across London. This includes the transfer of high dependency and critical care patients, bariatric patient and paediatric patients. It also includes secure transfers of mental health patients.The service has contracted work with two NHS trusts in London and also provides ad-hoc work for other NHS and independent hospitals. In addition, the service are providing a step in arrangement for a trust in North West London. Journeys are made to various locations within London and longer journeys occurred on a regular basis. The service has vehicles operated by paramedics, ambulance and emergency care assistants and emergency medical technicians.

We carried out this inspection in response to some concerns we received in September 2017. We responded to these concerns by carrying out an unannounced inspection on the 24 and 25 October 2017. The inspection we carried out was a comprehensive inspection covering all five domains.

We had not previously inspected this service under the current methodology. However, the service had previously been inspected in December 2012.

At the time of the inspection the registered manager was Claire Olohan-Bramley.

Summary of the information triggering the responsive inspection:

In September 2017, we identified some concerns about aspects of care one of the patient transport services was providing. BEARS subcontracted work out to the service. We also received some enquiries regarding BEARS. These concerns were about:

• Staff recruitment including reference and disclosure barring services (DBS) checks.

• Staff blue light training.

• Subcontracts in place and audits of subcontracted work.

• Subcontracted services registration.

• Allocation of jobs to other patient transport service.

Inspection findings

We identified areas of poor practice where the service needs to make improvements:

• The safeguarding lead was not trained to the recommended level of safeguarding training.

• Patient group directions (PGDs) were not being appropriately used.

• Information governance training was not part of mandatory training as per national guidance.

• The secure services division was occasionally using mechanical restraint without appropriate consideration of the mental health act code of practice.

• Subcontracts with other patient transport services were not signed off at the time of the inspection. However, audits of the services had begun.

• A number of policies were currently under review.

• Staff had not had appraisals at the time of the inspection.

However, there were also areas of good practice including:

• The service had an incident log and learning from incidents was shared with staff.

• Staff adhered to good Infection prevention and control practice.

• Vehicles were maintained to a high level of cleanliness.

• There were good systems in place for checking controlled drugs and drugs on ambulances.

• We saw staff treating and caring for patients with compassion and respect.

• The service had good performance against Key performance Indicators (KPIs) and regular communication with providers.

• Staff felt valued and enjoyed working for the service.

• The new management team was taking steps to improve the service and changes were apparent during the inspection. This included ensuring all staff had DBS checks.

• The service had developed a mobile phone application which promoted good information sharing with staff.

Importantly the provider must:

• Ensure they consider the Mental Health Act (1983) Code of Practice in their policies and procedures around secure patient transfers.

• Not use mechanical restraints on patients in a way that deprives their liberty.

• Ensure use of mechanical restraints must be appropriately risk assessed and the least restrictive option.

• Ensure patient record forms include all key information around the secure services patient transfer. This should include detailed information of the decision to restrain patients including any risk assessments.

• Ensure patients who are sedated are accompanied by a qualified mental health profession.

• Not use patient group directions for care assistants and technicians.

• Ensure all staff must receive information governance training.

• Ensure all staff must receive training on duty of candour and understand their role with regards to the regulation. The duty of candour policy should be up to date and incorporated into the serious incident policy.

In addition, the provider should:

• Train the safeguarding lead to the appropriate level of safeguarding training.

• Make sure staff are competent and appropriately qualified.

• Improve completion of mental capacity and mental health training to support staff when they are making mental health transfers.

• Have service level agreement in place with all services BEARS subcontracts work too. The service should audit these services to ensure they are safe and providing good care and treatment.

• Continue to update all out of date policies and procedures.

The above list is not exhaustive and the service should examine the report in detail to identify all opportunities for improvement and determining its improvement plan.

Amanda Stanford

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