ArrivaTransportSolutionsLimited ArrivaTransportSolutions- … · 2019. 4. 25. · Contents Detailedfindingsfromthisinspection Page BackgroundtoArrivaTransportSolutions-SouthWest 8

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, other information know to CQC and information given to us from patients, the public andother organisations.

Arriva Transport Solutions Limited

ArrivArrivaa TTrransportansport SolutionsSolutions --SouthSouth WestWestQuality Report

3rd FloorThe Crescent CentreTemple BackBristolBS1 6EZTel: 0191 520 4226Website:

Date of inspection visit: 19, 20, 21 July 2016Date of publication: 29/12/2016

1 Arriva Transport Solutions - South West Quality Report 29/12/2016

Letter from the Chief Inspector of Hospitals

Arriva Transport Solutions South West is part of Arriva Transport Solutions Limited, a nationwide provider ofindependent, non-emergency patient transport services. Arriva Transport Solutions Limited is part of an internationaltransport group.

We did not rate Arriva Transport Solutions - South West as they have not yet had an announced comprehensiveinspection. We carried out an unannounced focussed inspection on 19, 20 and 21 July 2016 to review the service’sarrangements for the safe transport of patients. We did this following concerns raised by a number of patientorganisations and hospital trusts after an increase in delays to travel times affecting both transport to appointmentsand return home.

Our key findings were as follows:

• We saw evidence of learning that directly benefited patients such as reviewing and developing patient feedbackprocesses. There were plans for 2016/17 to continue working with commissioners on learning from the level of harm,as well as distress, caused by incidents of delayed transport, to ensure quality improvements improved patientexperience

• Staff were aware of their responsibilities to report incidents to managers. We saw incident reporting that coveredwhat staff did to manage resuscitation if patients needed it, safeguarding regarding staff, and patients, and injuriesduring transport.

• Staff we spoke with were aware of their responsibilities regarding duty of candour and understood the importance ofbeing open and transparent with patients when things go wrong.

• Mandatory training for the coming months had been planned as mandatory training records showed that not all staffhad received the yearly training. However targets and completion of mandatory training overall was high comparedto other organisations.

• There were reliable systems, processes and practices in place to protect adults, children and young people fromavoidable harm. The patients we spoke with during this inspection told us they felt safe with the staff and in thevehicles.

• There was an infection prevention and control policy and system that described decontamination of medicaldevices, vehicles and workwear. Overall we found stations we visited to be visibly clean and tidy. We saw evidence ofwhen vehicles and equipment were last cleaned and when it was next due.

• People’s needs were assessed and transport provided to patients in line with national and local guidelines. Theeligibility criteria required call takers to ask prompted questions about the patient’s condition, health and mobilitystatus, which determined the most appropriate type of transport required.

• We saw that people were treated with kindness, dignity, respect and compassion while they received care. Wereceived positive comments about ambulance crew from patients, patient’s relatives and from staff working at localhospitals we spoke with. Crew were described as 'wonderful' and 'brilliant.' Another patient described crew as ‘lovely’and said they could not do enough to help.

• Crew encouraged patients to be as independent as possible and provided support where required. We observedcrew members enabling and encouraging patients to move independently, providing support and advice whereappropriate

• The service ensured that lessons were learnt when things went wrong and actions taken as result of complaints.Learning included, reflection on attitude even when complaints not upheld, acknowledging that increases indemand affected journeys and journey times.

Summary of findings


• There was a clear vision and credible strategy to support quality care. We saw evidence that the key to goodnon-emergency patient transport was understood by the relevant staff. There were governance frameworks in placeto support staff to know their responsibilities and that quality, performance and risks were understood and informedaction plans. However, senior managers acknowledged that there was some way to go in a number of areas. Forexample, achieving key performance indicators, reducing the number of complaints related to delays.

• Patients and others who used the service and staff were engaged and involved in several ways. Patients wereengaged in a survey run by an external company and fed back to the service. The number of returns was small andthe result of the patient feedback survey was mixed and reflected both positive and negative comments.

• Managers and others told us of a culture that encouraged candour, openness and honesty. We saw evidence of thisand senior managers spoke broadly about the duty of candour and how it applied to service delivery.

• Patient records were created at the control centre and received by ambulance crew on the electronic tabletassociated with each particular vehicle. Control staff collected relevant information during the booking process sothat they recorded the information regarding patient’s health and circumstances. Several of the provider’s ambulancecrews reported that the information provided on the patient record was sometimes incorrect, out of date or verylimited which had been raised with the organisations that had supplied the information.

However

• Staff level was at 85% for road based staff and there was a recruitment plan in place. The service used bank andvolunteer staff when necessary.

• Not all lessons were learned when things went wrong. Staff told us that it was difficult to report incidents on theelectronic system. They said they frequently experienced long waits when calling the control room to report incidentsso some potential for improvements were not identified when things went wrong.

• There was not a robust system in place to make sure defects in the vehicles were recorded and always actioned in atimely way and vehicles were not always taken off the road for repair.

• Delays and long waiting times for patient outbound journeys from clinics were a recurring theme amongst staff wespoke with at the local hospital and patients. We saw that the service had investigated all incidents or were inprocess of doing so. Themes included, the service arriving late and other organisations moving patients to a differentlocation and not letting the service know or providing incorrect mobility information.

• Staff were not supported to be able to communicate with patients who were significantly hearing or vision impaired.• Service delivery did not always meet people’s needs. We saw evidence of mixed patient experience and missed key

performance indicators in reports from external stakeholders such as Healthwatch Gloucestershire and clinicalcommissioning group reports. The service was working with stakeholders to improve the service and had recentlyundergone a management recruitment and restructure in order to deliver the requirements of their contract in 2016and beyond.

We saw several areas of outstanding practice including:

• Control and road based staff recognised where they could help patients. Staff went out of their way to assist patientswe were told by a patient of an example of staff amending their journey to help a patient who was delayed byanother provider. There were other examples that we saw in the incident recording, where staff had identified issuesthat patients needed assistance with at home and had completed tasks before leaving to ensure the patient was safeas well as emotionally supported.

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

Importantly, the location must:

• Ensure that mandatory training observations, appraisals and yearly updates for all staff are carried out and up todate including the high dependency ambulance vehicle staff.

Summary of findings


• Ensure that the process in place to record defects in vehicles was recorded and actioned in a timely way wasfollowed.

The location should:

• Ensure that the process for staff to be informed of updated policies, procedures and quality and governance updatesis followed and records kept

• Ensure that all equipment and particularly those used to take measurements of patients’ blood pressure and oxygensaturation levels are listed on equipment servicing records and serviced and maintained within specified dates.

• Ensure that systems for control to communicate between operational or road based staff enable timelycommunication via telephone calls and text messaging so that messages about patient’s condition or incidents wereable to be shared.

• Ensure that policies and procedures for disposal of clinical waste are followed.• Ensure that battery life for equipment used for text and voice communication is fit for purpose and is reliable• Ensure that the process for identifying poor performance that needed to be addressed and managed formally was

followed.

In addition the location should:

• Consider how staff receive feedback from any incidents they report.• Consider whether Mental Capacity Act 2005 and deprivation of liberty safeguards training meet staff needs.• Consider aids for staff to be able to communicate with patients with significant sight or hearing impairment are

available.• Consider reviewing the process and questions for call taking for identifying mental health and other support needs a

patient may have once scripted prompts are exhausted.• Consider carrying out a review of patients comfort in vehicles.• Consider whether electronic alerts that the planning and control room staff used on patient records that included the

word complaint complies with records keeping best practice.• Consider the method for journey time allocations and whether post code allocation is detailed enough.• Consider increasing the opportunity for road based staff and control based staff to understand each other’s role

better.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Patienttransportservices(PTS)

Our findings were as follows:

• There were reliable systems, processes andpractices in place to protect adults, children andyoung people from avoidable harm. The patientswe spoke with during this inspection told us theyfelt safe with the staff and in the vehicles.

• There was an infection prevention and controlpolicy and system that described decontaminationof medical devices, vehicles and workwear. Overallwe found stations we visited to be visibly clean andtidy. We saw evidence of when vehicles andequipment were last cleaned and when it was nextdue.

• We saw that people were treated with kindness,dignity, respect and compassion while theyreceived care. We received positive commentsabout ambulance crew from patients, patient’srelatives and from staff working at local hospitalswe spoke with. Crew were described as 'wonderful'and 'brilliant.' Another patient described crew as‘lovely’ and said they could not do enough to help.

• People who used services and those close to themwere involved by Arriva staff as partners in theircare. We heard appropriate responses given tocallers when call takers answered questions andexplained the eligibility criteria for non-emergencypatient transport. This included calls to staff oforganisations and patients

• Mandatory training for the coming months hadbeen planned as mandatory training recordsshowed that not all staff had received the yearlytraining. However targets and completion ofmandatory training overall was high compared toother organisations.

• Staff were trained to recognise and respond to theneeds of patients living with a learning disability,with mental health illness, living with dementia andbariatric patients. This was supported by theservice’s equality and diversity policy as well asequipment.

Summaryoffindings

Summary of findings


• The service ensured that lessons were learnt andactions taken as result of complaints. Patients andpeople’s complaints and concerns were listened toand used to inform action plans to improve thequality of care.

• There were governance frameworks in place tosupport staff to know their responsibilities and thatquality, performance and risks were understoodand informed action plans.

However:

• Not all lessons were learned when things wentwrong. Staff told us that it was difficult to reportincidents on the electronic system. They said theyfrequently experienced long waits when calling thecontrol room to report incidents so someimprovements were not identified when thingswent wrong.

• Mandatory training records showed that not all staffhad received the yearly mandatory training.

• There was not a robust system in place to makesure defects in the vehicles were recorded andalways actioned in a timely way and vehicles werenot always taken off the road for repair.

• Delays and long waiting times for patient outboundjourneys from clinics were a recurring themeamongst staff we spoke with at the local hospitaland patients. We saw that the service hadinvestigated all incidents or were in process ofdoing so. Themes included, the service arriving lateand other organisations moving patients to adifferent location and not letting the service knowor providing incorrect mobility information.

• Staffing was at 85% for road based stafftransporting patients.

• We did not see any aids for staff to be able tocommunicate with patients who were significantlyhearing or vision impaired.

Summaryoffindings

Summary of findings


ArrivArrivaa TTrransportansport SolutionsSolutions --SouthSouth WestWest

Detailed findings

Services we looked atPatient transport services (PTS)


Contents

PageDetailed findings from this inspectionBackground to Arriva Transport Solutions - South West 8

Our inspection team 8

How we carried out this inspection 9

Facts and data about Arriva Transport Solutions - South West 9

Action we have told the provider to take 41

Background to Arriva Transport Solutions - South West

Arriva Transport Solutions South West is part of ArrivaTransport Solutions Limited, a nationwide provider ofindependent, non-emergency patient transport services.Arriva Transport Solutions Limited is part of aninternational transport group Deutsche Bahn (DB). SinceDecember 2013 Arriva South West have providednon-emergency patient transport for Bath and North EastSomerset, Wiltshire, Gloucestershire and Swindon. Theservice covers a mix of urban and rural areas includingcities such as Bath, Salisbury and Gloucester, large townssuch as Swindon, and rural areas such as Wiltshire. Theaims and objectives of Arriva Transport Solutions Limitedis to provide Private Ambulance Services fornon-emergency patient transport on behalf of the NHS.The journey types and categories of patient theytransport include, outpatient appointments, hospitaldischarges, hospital admissions, hospital transfers, renal,oncology, palliative care, intermediate care, mentalhealth, paediatric, bariatric and transport from an acutehospital of high dependency patients who had receivedspecialist treatment such as unblocking of cardiacarteries.

We inspected the five key questions whether the servicewas safe, effective, responsive, caring and well-led. We

inspected the ambulance stations at Gloucester,Keynsham and Swindon. We inspected these locations inorder to speak to patients and staff about the ambulanceservice.

We undertook a responsive unannounced inspectionfollowing concerns raised by a number of patientorganisations and health trusts. Concerns were regardingpatient experience and safety following an increase incomplaints from service users to HealthwatchGloucestershire about delays to travel times, affectingboth pick up for transport to appointments and returnhome. There were common themes emerging frompatient and public feedback following a report fromHealthwatch Gloucestershire who received 197 pieces offeedback about Arriva Transport Solutions betweenDecember 2013 and May 2016. Delays in homeboundjourneys accounted for 28% of the feedback, 22%identified inconsistencies in eligibility criteria for patients,21% accounted for delays on outbound journeys, 11%related to the condition of the vehicles and 3% identifieddifficulties in getting through to the booking centre. Also,14% of the feedback collected accounted for themisunderstanding of Healthwatch Gloucestershire’s roleby Arriva staff and some patients.

Our inspection team

Our inspection team was led by:

Inspection Lead: Nigel Timmins, Inspection Manager,Care Quality Commission

The team included CQC inspectors and two specialistadvisors who had extensive experience and knowledge ofemergency ambulance services and non-emergencypatient transport services.

Detailed findings


How we carried out this inspection

We undertook an unannounced inspection of ArrivaTransport Solutions South West non emergency patienttransport service on 19, 20 and 21 July 2016.

We visited three of the six ambulance stations run byArriva South West in Gloucester, Keynsham and Swindon.We spoke with three patients and observed the care ofthree others. We inspected five ambulances including theHigh Dependency ambulance and an ambulance car tocheck they were clean and had been maintained andserviced.

We spoke with the head of the south region, themanaging director who was the registered manager, andthe quality and safety lead who was also the infectionprevention and control lead. We spoke with managers,deputy managers and team leads at the three ambulancestations. We also spoke with control and planning staffincluding those who spoke with members of the public,road based crews, and locality managers who worked

closely with hospitals and clinics. In total we spoke with14 staff including ambulance crews, team leaders andmanagers. We spoke with three patients who were usingthe service.

We looked at five ambulances including the HighDependency Unit ambulance and an ambulance car.

We reviewed a range of evidence from Arriva TransportSolutions South West including policies and procedures,performance and quality reports, incidents andcomplaints, safeguarding referrals, training informationand vehicle maintenance information. We also gatheredinformation from other organisations includingHealthwatch Gloucestershire, clinical commissioninggroups and three NHS Foundation Trusts and acommunity care services trust. We did not accompanypatients on journeys. We did not speak with anysub-contractors of, or volunteers for the service.

Facts and data about Arriva Transport Solutions - South West

Arriva Transport Solutions South West was part of ArrivaTransport Solutions Limited a nationwide provider ofindependent, non-emergency patient transport serviceson behalf of the NHS. Arriva Transport Solutions Limitedwas part of an international transport group. They wereregistered to provide transport services and triage andmedical advice provided remotely.

The journey types and categories of patient transportedincluded outpatient appointments, hospital discharges,hospital admissions, hospital transfers and renal,oncology, palliative care, intermediate care, mentalhealth, paediatric, bariatric and transport from an acutehospital of high dependency patients who had receivedspecialist treatment such as unblocking of cardiacarteries .

• Arriva Transport Solutions South West undertook254,920 patient journeys from June 2015 20 June 2016in the South West Region.

• The service employed 27 staff in the Bristol control, 169ambulance care assistants and 30 additional bank staffwho provided the equivalent of 27 full time staff. Theservice provided transport services 24 hours a day fromsome of their stations in the South West.

• The ambulance control operated 24 hours a day withthe Keynsham base also operating 24 hours a day.Gloucester station opened until 1am and some of therest of the stations closed before or at 11pm.

• The service had a fleet of 89 vehicles in the South West,including ambulances that could cater for stretchersand wheelchairs, patient transport cars and bariatricambulances.

Notes

1. We did not give a rating for Arriva Transport Solutions- South West as they have not yet had an announcedcomprehensive inspection

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the serviceArriva Transport Solutions South West is part of Arrivatransport solutions who are registered to provide transportservices and triage and medical advice provided remotely.Arriva Transport Solutions South West is part of ArrivaTransport Solutions Limited, a nationwide provider ofindependent, non-emergency patient transport services.Arriva Transport Solutions Limited work with clinicalcommissioning groups, hospital trusts, community healthcare trusts across Bath and North East Somerset, Wiltshire,Gloucestershire and Swindon. They provide non-urgentpatient transport between people’s homes and healthcareestablishments.

• Arriva Transport Solutions South West undertook25,4920 patient journeys between June 2015 and 2016in the South West Region.

• The service employed 27 staff in the Bristol control, 169ambulance care assistants and 30 additional bank staffwho provided the equivalent of 27 full time staff. Theservice provided transport services 24 hours a day fromsome of their stations in the South West.

• The service provides transport services 24 hours a dayfrom some of their stations in the South West. Theambulance control operates 24 hours a day with theKeynsham base also operating 24 hours a day.Gloucester station opened until 1am and the rest of thestations closed before or at 11pm.

• The service has a fleet of 89 vehicles in the South West,including ambulances that could cater for stretchersand wheelchairs, patient transport cars and bariatricambulances.

We carried out an unannounced focussed inspection on 19,20 and 21 July 2016 to review the service’s arrangements

for the safe transport of patients. We did this followingconcerns raised by a number of patient organisations andhospital trusts after an increase in delays to travel timesaffecting both transport to appointments and return home.

Patienttransportservices

Patient transport services (PTS)


Summary of findingsOur findings were as follows:

• There were reliable systems, processes and practicesin place to protect adults, children and young peoplefrom avoidable harm. The patients we spoke withduring this inspection told us they felt safe with thestaff and in the vehicles.

• Staff were trained to recognise and respond to theneeds of patients living with a learning disability,with mental health illness, living with dementia andBariatric patients. This was supported by theservice’s equality and diversity policy as well asequipment.

• We saw that people were treated with kindness,dignity, respect and compassion while they receivedcare. We received positive comments aboutambulance crew from patients, patient’s relativesand from staff working at local hospitals we spokewith. Crew were described as 'wonderful' and'brilliant.' Another patient described crew as ‘lovely’and said they could not do enough to help.

• People who used services and those close to themwere involved by Arriva staff as partners in their care.We heard appropriate responses given to callerswhen call takers answered questions and explainedthe eligibility criteria for non-emergency patienttransport. This included calls to staff of organisationsand patients

• The service ensured that lessons were learnt andactions taken as result of complaints. Patients andpeople’s complaints and concerns were listened toand used to inform action plans to improve thequality of care.

• There were governance frameworks in place tosupport staff to know their responsibilities and thatquality, performance and risks were understood andinformed action plans. However, senior managersacknowledged that there was some way to go in anumber of areas. For example, achieving keyperformance indicators, reducing the number ofcomplaints related to delays.

• There was an infection prevention and control policyand system that described decontamination of

medical devices, vehicles and workwear. Overall wefound stations we visited to be visibly clean and tidy.We saw evidence of when vehicles and equipmentwere last cleaned and when it was next due.

• Mandatory training for the coming months had beenplanned as mandatory training records showed thatnot all staff had received the yearly training. Howevertargets and completion of mandatory training overallwas high compared to other organisations.. Arrivastaff had been notified by a governance and qualitymandatory training bulletin June 2016 that requiredthem to attend either for a full one day mandatorytraining day (operational staff, including bank staff)or a half a day (control staff and non-operationalmanagers).

However:

• There was not a robust system in place to make suredefects in the vehicles were recorded and alwaysactioned in a timely way and vehicles were notalways taken off the road for repair.

• Not all lessons were learned when things wentwrong. Staff told us that it was difficult to reportincidents on the electronic system. They said theyfrequently experienced long waits when calling thecontrol room to report incidents so someimprovements were not identified when things wentwrong.

• We did not see any aids for staff to be able tocommunicate with patients who were significantlyhearing or vision impaired.

• Delays and long waiting times for patient outboundjourneys from clinics were a recurring themeamongst staff we spoke with at the local hospital andpatients. We saw that the service had investigated allincidents or were in process of doing so. Themesincluded, the service arriving late and otherorganisations moving patients to a different locationand not letting the service know or providingincorrect mobility information.




Are patient transport services safe?


• Mandatory training for the coming months had beenplanned as mandatory training records showed that notall staff had received the yearly training. However targetsand completion of mandatory training overall was highcompared to other organisations.. Arriva staff had beennotified by a governance and quality mandatory trainingbulletin June 2016 that required them to attend eitherfor a full one day mandatory training day (operationalstaff, including bank staff) or a half a day (control staffand non-operational managers).

• Evidence from the provider at the time of our inspectionshowed the compliance rates for mandatory training foreach ambulance station at June 2016. The rates ofcompletion were:▪ Gloucester 85%,▪ Lydney 90%,▪ Newport 90%,▪ Keynsham 88%,▪ Swindon 97%▪ and Salisbury 92%

• All except Swindon were below the 95% service targetcompletion rate. The target of 95% was particularly highcompared with other organisations.

• We saw evidence of learning that directly benefitedpatients such as reviewing and developing patientfeedback processes. There were also plans for 2016/17to continue working with commissioners on learningfrom the level of harm, as well as distress, caused byincidents of delayed transport, to ensure qualityimprovements improved patient experience

• Staff were aware of their responsibilities to reportincidents to managers. We saw incident reporting thatcovered what staff did to manage resuscitation,safeguarding regarding staff, patients, and injuriesduring transport.

• Staff we spoke with were aware of their responsibilitiesregarding duty of candour and understood theimportance of being open and transparent with patientswhen things go wrong.

• There were reliable systems, processes and practices inplace to protect adults, children and young people fromavoidable harm. The patients we spoke with during thisinspection told us they felt safe with the staff and in thevehicles.

• There was an infection prevention and control policyand system that described decontamination of medicaldevices, vehicles and workwear. Overall we foundstations we visited to be visibly clean and tidy. We sawevidence of when vehicles and equipment were lastcleaned and when it was next due. Vehicles werecleaned at the end of each shift vehicles we inspectedwere clean and tidy.

• The service made sure that up to date ‘do not attemptcardio pulmonary resuscitation’ (DNACPR) informationand end of life care planning was appropriatelyrecorded when patients were being transported. ArrivaTransport Solutions South West carried out acomprehensive review of DNACPR in November 2015.

• Staffing was at 85% and there was a recruitment plan inplace.

• The service had a major incident plan and was availableon the instructions of the clinical commissioning groupto provide additional transport services in the event of amajor incident. The service had taken part in onetelephone call exercise 25 August 2015.

However

• Not all lessons were learned and some potential forimprovements were not identified when things wentwrong. Some staff reported that they frequentlyexperienced long waits when calling the control room toreport incidents.

• There was not a robust system in place to make suredefects in the vehicles were recorded and alwaysactioned in a timely way and vehicles were not alwaystaken off the road for repair.

• Staff said it was a common occurrence for them not toget their breaks. They told us that this was because notenough time was allowed in the schedule for staff totake their breaks. We saw that on occasions journeyswould be booked in to start immediately after the crew’sbreak which did not allow time to travel to pick up.

• Oxygen cylinders were not stored safely and correctlyand fire and risk assessments relating to control ofsubstances hazardous to health were not completed forall stations. Action was taken to resolve the issue when itwas raised.




• Ambulance crew and other staff had not had anyspecific training in respect to major incidents and theservice had not engaged in regular table top or practiceexercises for managing major incidents in 2015/16.

Incidents

• The content of the yearly mandatory training waschanged depending on the needs of the service orincidents that had occurred. As an example, during 2015there had been increased emphasis on driver trainingbecause of an increase in minor vehicle accidents. At thetime of our inspection, the emphasis was on movingand handling. For control staff and non-operationalmanagers, a session had been developed to refresh staffon incident reporting requirements and the use ofelectronic reporting systems.

• There had been two serious incidents investigated bythe service in the year prior to our inspection; onesafeguarding event October 2015, and one patient injurySeptember 2015. The two incidents were investigatedthrough root cause analysis and both notified to CQC..

• In total 128 incidents or other occurrences not requiringa level of investigation as for serious incidents werereported by the service between October 2015 and July2016. Of those, seven were classed as transportation,admission or discharge, two were about patients homesecurity, four about medical devices, 34 about patientinjury or illness, one related to damage to a third partiesproperty, three confidentiality issues and 25 abusive,violent, or disruptive behaviour/safeguarding concern.Seventy seven recorded incidents were closed, whilst allthe rest were under investigation.

• Staff we spoke with were aware of their responsibilitiesto report incidents to managers. We saw incidentreporting that covered action staff had taken followingresuscitation, safeguarding of staff and patients, andinjuries during transport. We spoke with staff who toldus there was a policy and procedure in place forambulance crews to report incidents involving patientsand vehicles. We reviewed this policy and saw that itdescribed the arrangements for reporting, managingand learning from incidents which arose from theactivities of the service and any subcontracted oragency provider working for or on behalf of the service.It also defined the types of incidents that may occur andclarified the process of reporting and the classificationof incidents.

• We saw evidence of some learning from incidents thatdirectly improved patient care such as reviewing anddeveloping patient feedback processes. There wereplans for 2016 /17 to continue working withcommissioners on learning from incidents relating todelayed transport and the level of harm and distresscaused to ensure improvements were made.

• The incident reporting management process wassupported by an electronic system. The system allowedelectronic reporting of incidents by managers and staffin control centres on behalf of all staff, volunteers andthird party providers. Staff described what would beclassified as an incident and gave us examples ofincidents that they had raised. Staff telephoned directlyto the control room and the incident would be recordedon the electronic reporting system. Incidents wouldthen be sent directly to the manager at the appropriatebase to be dealt with. However staff told us that it wasdifficult to report incidents on the electronic system.They said they frequently experienced long waits whencalling the control room to report incidents. As aconsequence they did not always have the time toreport incidents. This may have led to some staff notreporting incidents.

• Not all lessons were learnt and improvements were notalways identified when things went wrong. Some stafftold us they did not receive feedback from incidentsthey reported.

• There was a separate incident reporting procedure forincidents involving vehicles. Paper based vehicleincident reports had to be completed within 12 hours ofthe incident occurring and the manager of the baseinformed. A set of specific criteria was used by managersto identify the severity of the incident which determinedthe investigation process. We observed an example of arecent incident involving a vehicle collision and theinvestigation process that had been followed correctly.

• We saw example from October 2015 of when staff hadreported a range of incidents including injuries topatients that had happened when patients were notunder the care of the service, safeguarding concerns,and communication issues between control and staffwho booked transport which had resulted in incorrectbooking information being given. We reviewed onerecord of an incident which involved incompleteinformation being handed over to Arriva staff regardingthe resuscitation status of the patient. The service had




not always had relevant information passed to them bythe organisations that booked the transport. Wheneverthis occurred local managers worked with providers totry to prevent a reoccurrence.

• The incident reporting procedure was laminated andwas available in a box which the crew took with them atthe start of every shift.

Duty of Candour

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014, was introducedin November 2014. This Regulation requiresorganisations to be open and transparent with a patientwhen things go wrong in relation to their care and thepatient suffers harm or could suffer harm which falls intodefined thresholds.

• Staff we spoke with were aware of their responsibilitiesregarding duty of candour. They were aware of theregulation and when to use it and understood theimportance of being open and transparent with patientswhen things go wrong. We asked one senior manager ifduty of candour had been used and were told that itwas mainly done at the time of the incident, patientswere apologised to. We did not see evidence of lettersmeeting duty of candour.

Mandatory training

• Mandatory training included a safeguarding update(including deprivation of liberty safeguards and theMental Capacity Act 2005), basic life support and oxygentherapy update, vehicle cleaning and infection control,patient handling update and practical, incidentmanagement, operational updates, informationgovernance updates and fire safety update. The contentof the yearly mandatory training was changeddepending on the needs of the service or incidents thathad occurred. As an example, during 2015 there hadbeen increased emphasis on driver training because ofan increase in minor vehicle accidents. At the time ofour inspection, the emphasis was on moving andhandling. For control staff and non-operationalmanagers, a session had been developed to refresh staffon incident reporting requirements and the use ofelectronic reporting systems.

• Mandatory training records showed that not all staff hadreceived their yearly mandatory training. Howevertargets and completion of mandatory training overallwas high compared to other organisations.. At the time

of our inspection, 25 (8.4%) ambulance staff wereoverdue on their yearly mandatory training updates. Forsome of the 25 staff, the last time they completedmandatory training was in 2014. Documents requestedfrom the provider at the time of our inspection showedthe compliance rates for mandatory training for eachambulance station at June 2016. The rates ofcompletion were:▪ Gloucester 85%,▪ Lydney 90%,▪ Newport 90%,▪ Keynsham 88%,▪ Swindon 97%▪ and Salisbury 92%

• All except Swindon were below the 95% service targetcompletion rate. The target of 95% was particularly highcompared with other organisations. We saw records ofdates planned and named staff for training later in theyear for those who were not up to date with mandatorytraining. Staff were aware of the dates.

• The training records showed not all staff had notreceived first aid at work training or infection controltraining for the previous year.

• Staff were not required to attend mandatory training ifthey had attended a full induction course in the lastyear.

• Service managers had action plans in place to monitorattendance rates throughout the rest of 2016 to ensureall staff received the correct mandatory training byMarch 2017.

• Arriva staff had been notified by a governance andquality mandatory training bulletin in June 2016 thatthey were required to attend either a one daymandatory training update (all operational road basedstaff, including bank staff) or a half day mandatorytraining update (control staff and non-operationalmanagers).

• The control room staff were due to have mandatoryannual training, but the training records were blank forthis group of staff. It was not clear when this training hadlast occurred.

Safeguarding

• There were reliable systems, processes and practices inplace to protect adults, children and young people fromavoidable harm. Staff had received training in thesafeguarding of adults and children but not all hadreceived updates. Staff understood the different forms




of abuse and could recognise the potential signs ofabuse. Staff we spoke with knew how to reportsafeguarding concerns and where to seek additionaladvice when necessary.

• We saw evidence from incident reporting ofsafeguarding alerts raised about staff, otherorganisations and home circumstances. The patients wespoke with during this inspection told us they felt safewith the staff and in the vehicles.

• We saw in the Gloucester and Swindon stations, contactdetails for the local safeguarding team were on displayfor staff to use if necessary. The information was also inthe box assigned to the vehicle taken by road staff onevery journey.

• Disclosure and barring service (DBS) checks for all staffwere carried out including taxi drivers and staff fromother independent ambulance services used by ArrivaTransport Solutions South West. The service had apolicy and checklist to complete for ensuring staff hadup to date DBS. Other providers used were expected tocarry out their own checks on staff before they wereused and they were then entered onto Arriva’s approvedlist. Additionally independent hire drivers had to havehad a current DBS through their local authority as partof the licensing programme. For volunteer drivers, theservice conducted the DBS checks in the same way asfor Arriva Transport Solutions South West employees.When agency staff were used, the service would alsocheck that the agency had completed the relevantemployment checks.

• The majority of staff had received ‘prevent’ training.Prevent training is the counter-terrorist programmewhich aimed to stop people being drawn intoterrorist-related activity.

• Volunteers and third party transport were issuedsafeguarding flowcharts and policies. If they wereengaged on patient journeys with Arriva TransportSolutions South West they were required to report allincidents including any safeguarding referrals theymade through the Arriva control room and thisinformation was managed through the electronicreporting system.

• The head of quality was the safeguarding lead for theservice and had access to external support and advice ifneeded through local authority safeguarding contacts.

Cleanliness, infection control and hygiene

• There was an infection prevention and control policyand system that addressed all relevant aspectsincluding decontamination of medical devices, vehiclesand workwear.

• The Swindon, Gloucester and Keynsham bases hadcleaning products and disposable mop heads availableat bases to support staff with this task. Staff had accessto cleaning sprays, cloths, wipes and disposable gloves.These could all be replenished at the bases whenrequired. Cleaning products on ambulances were keptin an overhead storage locker. We saw there was asystem of using colour coded mops with differentcleaning products to avoid cross-contamination. Safetyinformation and instructions for use of the cleaningproducts were on display to ensure staff safety whenusing the products. Sluice areas at stations were cleanand tidy. Vehicles contaminated beyond crews ability toclean it between patients or when needing equipmentnot routinely available on return to station would becleaned by an external company. We saw audit ofvehicle cleaning completed 12 July 2016 whichdemonstrated that the service had achieved 95%although the sample was small (20% of vehicles) .

• Overall, we found stations we visited to be visibly cleanand tidy. However, in one corner of Gloucester station inthe garage we found bags of salt for use in icyconditions. These bags were stacked on a woodenpallet and on the floor. It appeared that some of thebags had spilt out onto the floor and had not beencleaned up.

• Clinical waste bins were present at stations we visited. InGloucester this was in the garage for staff to dispose ofany soiled waste. The bin was kept locked. We saw thatat Gloucester staff did not always dispose of clinicalwaste appropriately. It should be put in a bag and tiedbefore being put into the clinical waste bin. We saw thatitems had been put into the bin without being put into abag first. This resulted in a possible risk of crossinfection. We raised this during inspection.

• We inspected five vehicles and found them to be visiblyclean and tidy. Clean linen was available for patients.

• We saw evidence of when vehicles and equipment werelast cleaned and when cleaning was next due.

• Staff were regularly audited for infection prevention andcontrol awareness and practice. Both audit achieved100% although the sample size was small for both (30%




and 5%). This was due to availability of staff on stationand staff to carry out audit. We saw staff use personalprotective equipment appropriately including glovesand aprons.

• The head of quality was the infection control andprevention lead for Arriva Transport Solutions SouthWest. We saw evidence of national guidance followed bythe lead in infection prevention and control policy.

Environment and equipment

• There was not a robust system in place to make suredefects in the vehicles were recorded and actioned in atimely way. Daily vehicle safety checks were carried outby operational road staff who used electronic tabletsassigned to each individual vehicle to record them. Anew electronic format had been introduced in April 2016which some staff were still getting used to. Informationwas recorded and individually stored for each vehicle ona database. Managers would check this daily to identifyany issues with vehicles which required repair andaction this as appropriate. There was still work to bedone around the use of the electronic system aroundimproving the order of the vehicle check requests forexample, from the front to the back of the vehicle tomake the process more streamlined and efficient.

• We saw that one vehicle had not been taken off the roadfor repair despite the repair being highlighted severaltimes. We looked at the checklists for June 2016 for allvehicles and cross checked this against maintenancerecords. We found on one vehicle, staff had reportedthat the emergency doors did not open from the insidewhich posed a risk to patients and staff in the event ofan accident. Staff documented this issue on thechecklist on the 30 June 2016 and again on the 19 July2016. This issue had not been picked up or actioned forrepair. We raised this with a manager during ourinspection and they were unsure as to why it had beenmissed. The vehicle was taken off the road and bookedin for repair once we had raised this with a manager.

• We asked how staff kept track of vehicles when theywere due for a service and we were shown a boardindicating the service date for each vehicle. Duringinspection we were told that there was no centralrecording and that staff relied on the individual serviceindicators in each vehicle displaying when a service wasdue. We were also told that records were held centrallyfollowing inspection. We looked at the board with thevehicle servicing dates and found it to be inaccurate. As

an example, one ambulance showed that it was lastserviced on the 30 December 2014 when the fleetdepartment confirmed it was serviced on the 2 March2016. This meant that it was not clear to all staff when allvehicles had been serviced and so the staff couldn’t beassured if the information was correct.

• We reviewed records of equipment and maintenanceschedules including vehicles and medical devices. Thefleet at the Gloucester station consisted of 25 vehicles.At the time of our inspection, five of these vehicles werenot in use because they were being repaired. We lookedat five vehicles and found that they had been servicedaccording to manufacturer’s instructions. The first aid kitand fire extinguishers were all in date. Equipment suchas wheelchairs, ramps, carry chair and stretchers had allbe serviced appropriately.

• Arriva Transport Solutions South West could not assurethemselves that equipment on their high dependencyunit vehicle was maintained. One ambulance at theGloucester station was used as a High Dependency Unitvehicle to transport patients with heart problemsbetween the Gloucester and Cheltenham acutehospitals. The ambulance was equipped with additionalequipment such as a defibrillator and machines fortaking blood pressure and monitoring oxygen levels inthe patient’s body. The majority of equipment carriedon this ambulance had been serviced regularly andstickers were in place to confirm the next service. Otherequipment such as the first aid kit and fire extinguisherswere all in date. The exception was that the bloodpressure machine and the machine for recording oxygenlevels. Both of these pieces of equipment did not haveany information as to when they were last serviced andcalibrated; this was normally undertaken by a third partyprovider. Neither of these pieces of equipment werelisted on the service’s equipment servicing records for2015 or 2016. We raised this with managers during theinspection who said they would address it.

• Car seats were available for children using patienttransport at each base although staff told us thatparents usually brought their own child’s car seat. Arrivastaff told us that staff should carry out a visual check ofthe seat and ensure it is safe and securely fitted into thevehicle. If there were any doubts over the safety orcondition of the child seat staff were aware they shouldnot complete the journey.

• Each ambulance was fitted with a tracking system whichperformed several different functions. When staff logged




in, the system enabled managers at the bases and thedispatch team to view the status of the ambulance forexample location, whether they were driving orstationary so could allocate work more efficiently it alsomonitored the performance of the driver. Each Arrivastaff member had their own fob to enable them accessto the system, with spare fobs for agency staff who hadto sign the fobs in and out for their shifts.

• There was a system in place to ensure stock on theambulances could be replenished at the start or end ofa shift. There was a store at each base which held itemssuch as personal protective equipment, for exampleaprons, gloves, hand gel and other items such asdisposable blankets, disposable sheets for stretchersand water that may be required during a journey. Asystem with staff signing out stock items that had beentaken to replenish vehicles was in use. This helpedmanagers to identify current stock levels and when newstock needed ordering.

• There were 92 vehicles based in the south west a mix ofstretcher, seated and high dependency ambulances(three). The service had vehicles and equipment forbariatric patients. The Keynsham base had one bariatricvehicle, a stretcher and two wheelchairs toaccommodate bariatric patients. The vehicles metpatient’s needs.

• Electronic tablets used to send and receive patientinformation were reliable in sending and receivinginformation. The battery life on the tablets wasconsidered poor by ambulance crew. They reported thatusing the tablet and making telephone calls drained thebattery very quickly. Charging the device was slow dueto having to do this on board the ambulance. We werenot aware of any patient harm from this and battery lifehad been reported

Medicines

• No emergency medication was carried on theambulances and staff did not administer medication.Staff would ensure that any medicines provided topatient by the hospital to take home arrived safely withthe patient.

• Each ambulance was equipped with oxygen which staffwere able to administer to patients if it had alreadybeen prescribed by a doctor. Staff were not allowed toalter the flow rate of the oxygen.

• Staff working on the high dependency unit ambulancehad received additional training in oxygen therapy inrelation to resuscitation.

• We looked at where the oxygen cylinders were stored inthe Gloucester and Swindon stations. When we startedour inspection, the cylinders in Gloucester were storedin a corner of the garage, however, on the third day ofthe inspection they had been moved into a store roomand another locked metal cabinet. The Health andSafety Executive (Oxygen use in the workplace, INDG459)states that ‘oxygen cylinders should be stored in awell-ventilated storage area or compound, away fromcombustible materials’. The metal cabinets did notappear to be ventilated and they were stored next tocombustible materials and chemicals. The cabinetswere provided by a third party for the service’s use. Weasked if a risk assessment had been carried out for thestorage of the oxygen cylinders but the managers wereunaware if one had ever been completed. We sawmanagers begin enquiries about whether cabinets weresafe to use or not and we were given assurance that allissues were resolved following inspection.

• In Swindon, the storage of oxygen cylinders was in astore room. The cylinders were immediately adjacent tocombustible materials including paper and flammableliquids and cleaning products hazardous to health. Thedoor was not a fire door. There were no door signs toidentify the room contents for example compressed gas.We saw that seven full cylinders were restrained with athin nylon strap in racking that staff had to bend forwardto manoeuvre the cylinders. One empty cylinder wasfree standing close to the door. The empty cylinder wasa hazard and could cause harm to staff if it fell. Theempty cylinder was not stored with a clear divisionbetween it and full cylinders. We brought these issues tothe attention of the station manager. We also askedthem for the latest risk assessment for medical gasstorage and one for the control of substances hazardousto health. The risk assessments provided were genericand did not address the specific issues we identified.The general manager responded by instigating a riskassessment for medical gas storage and one for controlof substances hazardous to health and informed seniormanagement of the issues immediately and we weregiven assurance that all issues were resolved followinginspection. The issue was also entered onto the riskregister.




• Oxygen was appropriately stored on the ambulances.Each ambulance carried one large oxygen cylinder andone portable cylinder which was secured appropriatelyon the vehicle. An electronic system using barcode onoxygen cylinders was used to monitor stock. This wasreplaced frequently by the medical gas company.

Records

• Patient records were created at the control centre andreceived by ambulance crew on the electronic tabletassociated with each particular vehicle. Control staffcollected relevant information during the bookingprocess so that they recorded the information regardingpatient’s health and circumstances. For example anyinformation regarding access to property or illnessissues. The process ensured crews were informed aboutany needs or requirements the patient may have duringtheir journey.

• Several ambulance crews reported that the informationprovided on the patient record was sometimesincorrect, out of date or very limited. Crews reportedthat information regarding patients’ mobility status wassometimes not updated or incorrect from organisationsbooking transport and information regarding access to aproperty was often inaccurate. We saw evidence of thisin minutes and incident reports. There had been 11incidents where issues of incorrect or missinginformation had occurred in the previous six months.These occurrences had been raised with theorganisations that had supplied the information.

• The service made sure that up to date ‘do not attemptcardio pulmonary resuscitation’ (DNACPR) informationand end of life care planning was appropriatelyrecorded when patients were being transported.

Assessing and responding to patient risk

• Risks to people who used services were assessed, andtheir safety was monitored and maintained. All staffworking on the ambulances had been trained in basicfirst aid which gave them initial skills to notice if apatient was deteriorating and when to call emergencyhelp. Training records showed that subsequently not allstaff had had refresher training for basic first aid.

• There was a standard operating procedure for roadbased staff to follow in the event of a patientdeteriorating during a journey. Staff we spoke withreported that they would pull over and stop the vehicle,and safely call 999 to request the emergency services.

They would then inform managers at their base of thesituation, in line with the procedure and would supportthe patient as best they could until help arrived. Wewere told that this situation had not arisen recently.

• Risk assessments were carried out by team leaders andmanagers when required. If control staff identified a riskto crew and patients due to poor access at a property,managers would visit the property to assess this risk. Wewere provided with an example where a risk assessmentaround access to a property had been carried outrecently. The information was then fed back to controland added to the patient record. Managers were able tospeak with road crew directly if necessary to providefurther advice and information.

• Policies and procedures were in place to manage violentor aggressive patients but not all staff felt they weretrained and equipped to deal with aggressive patients.We did not see any evidence of ‘breakaway training’ orhow to escape someone’s grip. Staff we spoke with saida small part of the training programme focused on adiscussion around the management of aggressive andviolent patients. Newer members of staff reported thatthis was helpful but felt that they learnt on the job abouthow to manage these situations. Staff reported that inthese cases, they tried hard to listen to and talk to thepatient to try and diffuse any escalating situation.

Staffing

• Arriva Transport Solutions South West had a recruitmentplan in place and had employed a recruitingcoordinator to fill vacancies.

• We reviewed the services human resources dashboard,which showed us that for the service the full staffingestablishment was 198 whole time equivalent (WTE)posts. At the time of our inspection there were only169.6 WTE of actual staff in post or 85%. The vacancyrate had remained reasonably consistent since January2016 ranging from 15% to 11%. Control staff movedvehicles and staff as necessary between ambulancestations when shifts were unfulfilled due to staffabsence. In addition they would also use extravolunteers and taxi services if needed.

• The service employed 27 staff in the Bristol control, 169ambulance care assistants and 30 additional bank staffwho provided the equivalent of 27 full time staff.

• Some of the staff covered shifts throughout a 24 hourperiod. Staff working out of normal office hours weresupported through the control centre. Staff never




worked alone at night. The ambulance control operated24 hours a day with the Keynsham base also operating24 hours a day. Gloucester station opened until 1amand the rest of the stations closed before or at 11pm.

• We saw recruitment records for July 2016 includingnumbers of staff leaving and the reasons for this. Forexample some recruits had not met the requirements ofthe probation period. We saw forward planning for aspecific need to increase staffing levels for a part of theservice due to a third party provider discontinuing withthe service.

• We saw evidence that staff sickness rate hadsignificantly reduced to one of the lowest level seen bythe service. A process was in place with managerreviews and occupational health referrals whereappropriate.

• Station managers at local level managed anticipatedresource risks by scheduling rotas in advance andmanaging pre-planned holidays and other leave. Staffsaid the resource planning to take booked holidays intoaccount had significantly improved. Staff were able totake holidays or days off at short notice if theynegotiated this with colleagues or other staff whereavailable. Those staff we met said they were able to takeunplanned time off (such as for funerals or medicalappointments) and the managers were helpful andsympathetic towards this. We saw action plans thatcovered a range of response to this for example theimplementation of electronic assisted planning anddespatch.

Anticipated resource and capacity risks

• There was good joint working between the service andlocal hospitals. There were daily conference calls andother calls between the locality manager and hospitals.This allowed issues to be picked up in each area toassist planning for the day and be escalated to seniormanagers as necessary. For example areas ofparticularly high demand or a shortfall in vehicles due tomaintenance. The calls enabled staff to contact hospitaland other organisations if they needed to highlightdifficulty in meeting appointment times.

• Staff planned journeys around roadworks however therewas sometimes a lack of information on current trafficalerts. Major road works were noted, but we did not seethat daily traffic alerts were communicated to staff on aconsistent basis. This would have allowed the journeyplanners or the road staff themselves to avoid road

closures, accidents or road works to reduce any possibledelays. It was expected that staff rely on their own localknowledge to avoid traffic congestion although centralplanning did not necessarily have local knowledge.

• Staff said it was a common occurrence for them not toget their breaks. They told us that this was because notenough time was allowed in the schedule for staff totake their breaks. We saw that on occasions journeyswould be booked in immediately after the crew’s breakwhich meant they then had to drive during their break.This issue was on the risk register where it was recordedas an issue from a staff survey, but not recorded as oneof the top five negative issues in the most recent staffsurvey we saw from 2015.

• There was an electronic system that was used to givestaff up to the moment overview of staff driving style,duration and breaks which would provide evidence tomanagers of who was unable to take a break and thisinformation could be used to inform discussions withshort notice planning of journeys. There had beenchanges made in the electronic planning system toenable planned meal breaks. Opportunities to takebreaks had been agreed and the situation was beingmonitored by control managers.

• Other companies were used on a sub-contract basis bythe provider. These companies ranged from otherindependent ambulance companies to independenttaxi companies. We saw evidence of Sub-contractorstatus and a monitoring spreadsheet, so staff usingthem could see who was approved for use or not.However, the record did not have a date of review or lastediting or who had amended it.

• Some risks to the service were not always anticipatedand planned for in advance. There was a major incidentpolicy that had guidance for staff to follow in the eventof changes in demand, seasonal or weather changes,loss of services or infrastructure, disruption to staffinglevels or disruptions to hospitals receiving patients. Wedid not see any evidence of Arriva Transport SolutionsSouth West conducting internal business continuitytesting for example, a process for managing extremenumbers of staff sickness or vehicles beingunserviceable due to contaminated fuel.

Response to major incidents

• As an independent ambulance service, the provider wasnot part of the NHS major incident planning. However,the provider had a major incident plan in place and they




were available on the instructions of the clinicalcommissioning group to provide additional transportservices in the event of a major incident. Staffunderstood their role in major incidents was to transfersuitable patients from and between hospitals to makecapacity available for emergencies.

• Arriva Transport Solutions South West’s policy statedthey would be expected to join a healthcareteleconference and during that call it would becomeclear whether the service had a role to play or not. Therequest for support would come from the local involvedambulance trust and would require approval from localcommissioner.

• The managers of the service were aware that anyinvolvement in supporting a major incident would havea direct impact on their routine, core business – andmight affect patients belonging to another clinicalcommissioning group which was otherwise unaffected.For this reason Arriva Transport Solutions South Westpolicy stated, communication and commissionerapproval was an important first step.

• The service had taken part in one telephone callexercise 25 August 2015.

• Ambulance crew and other staff had not had anyspecific training in respect to major incidents and theservice had not engaged in regular table top or practiceexercises for managing major incidents in 2015/16.

Are patient transport services effective?

Our findings were:

• Performance in achieving targets for pick up, drop offand journey time on vehicle was mixed. However, theservice was working with commissioning groups andother organisations to address this and meet theincrease in demand and to operate as efficiently aspossible to ensure patient safety and comfort.

• Delays and long waiting times for patient outboundjourneys from clinics were a recurring theme amongststaff we spoke with at the local hospital and patients.Hospital staff provided us with examples when patientshad still been waiting for transport to take them homefrom clinic appointments long after the clinic hadclosed. Staff recalled incidents where members of staffhad waited with patients after their shift finishing timesuntil transport arrived to collect the patient.

• Arriva Transport Solutions South West took over 61% ofpatient transport booking over the telephone which wasabove the target figure of 40%. This had an effect oncontrol staff not being able to answer telephoneseffectively at all times. Although work was beingundertaken to work with stakeholders on this.

• The service received 25% of ‘on the day bookings’compared to its target of 10%. This indicator was notwithin the service’s control. Locality managers had seenvarying engagement between the different hospitalsand clinics within the locality on these issues.

• Staff told us they had received training in the MentalCapacity Act 2005. The training took approximately 20minutes to complete. Staff told us that the training hadbeen useful but had not given them enough informationfor them to judge people’s capacity to give consent. Staffwe spoke with did not have the confidence to undertakebasic mental capacity assessments.

However,

• People’s needs were assessed and appropriatetransport provided to patients in line with national andlocal guidelines.

• Risk assessments were completed for complex patientsor patients with body weight or bariatric needs.

• There were arrangements in place to have something todrink for those patients that were on a vehicle for a longperiod of time. Water was available at each ambulancestation for the crews to take on the ambulances andbottles were carried on ambulances and could beprovided if required on long journeys or hot days.

• We were told the planning system was set to includetime for comfort breaks and take account of patientneeds for meals.

Evidence-based care and treatment

• People’s needs were assessed and transport provided topatients in line with national and local guidelines. Thishappened through eligibility criteria assessedelectronically using a specific set of questions based onDoH guidelines. Patients had to confirm they wereregistered under a GP in the commissioning area andthat they required transport to or between NHS fundedproviders before the call takers continued to assess theeligibility of the patient to use the service.Commissioners of the service had decided that all




patients attending dialysis or chemotherapyappointments were eligible to use the patient transportservice. Dialysis transport represented 41% of ArrivaTransport Solutions South West’s total activity.

• We saw two different sets of eligibility questions used bythe call takers. One for adults over 18 years of age andone for children up to 18 years of age. The questionsasked, helped to determine the most appropriate typeof vehicle required for the individual.

Assessment and planning of care

• Control staff followed scripted prompts to understand apatient’s condition in order to plan transportappropriately. The eligibility criteria required call takersto ask prompted questions about the patient’scondition, health and mobility status, which determinedthe most appropriate type of transport required. Therewere stretcher vehicles, wheelchair assisted vehicles,seated ambulances, bariatric vehicles, taxis andvolunteer car drivers available depending upon thepatients individual need.

• Risk assessments were completed for complex patientsor patients with bariatric needs. The World HealthOrganisation describes people who have a body massindex greater than 30 as obese, and those having a bodymass index greater than 40 as severely obese (WHO,2000). Bariatric needs are those that make supportingpatient’s mobility, moving and handling needshazardous to staff and to patients due to the patientsweight Risk assessments were recorded on paper at thecontrol centre and contained important informationabout complex access issues, mobility issues and anyissues with bariatric patients that may pose a risk tostaff or the patient. The assessment would then bepassed on to the manager at the appropriate base tocarry out a more detailed assessment. This was thenshared with the crew via the manager and also reportedback to control to store on the patients record. Crew hadaccess to this information via their electronic tabletscarried on each vehicle during each shift.

• Staff generally identified any mental health needs ofpatients but this was dependent on the call takersexperience. The booking form prompted the call taker toask if the patient had any mental health problems, butdid not prompt staff to request any further detail. Staffwere taught during the call taker training programme tofollow up, independently of the scripted questioning, onany mental health issues a patient may have to support

them as much as they could. There was also theopportunity for callers to provide other informationwhen prompted to do so by the call takers at the end ofthe prompts. However this relied on staff experienceand knowing when to move away from the scriptedprompts in order to gain all relevant information.

• New mobility codes were introduced by Arriva TransportSolutions South West developed in conjunction withorganisations that used the service. This enabled theservice to plan better and those booking transport toenable a better understanding, assessment and plan forpatient care. In February 2016, the mobility code list hadincreased to 21 codes. The codes enabled the call takersto gain a better understanding of the mobility status of apatient with 21 categories under four general headings,whilst enabling the planners and dispatchers to allocatethe most appropriate resource and crew to the job. Calltakers, planners and dispatchers we spoke with felt thecodes had improved their ability to provide a morethorough assessments and effective use of resources.Staff of other organisations were also able tounderstand the best response to give when bookingtransport.

• Pre-booked transport was planned and arranged aminimum of one day in advance. The planning teamused an electronic system to plan and allocate the mostappropriate resources to the patient identified, by thebooking information collected by the call takers. Theassisted planning and dispatch system introduced inAugust 2015 had key performance indicators for theservice embedded into the assisted planning system toensure that journeys planned met expected targets.Planners felt that the system was effective whenorganising and planning shorter journeys althoughthere were still problems in delayed journeys both toand from appointments. We saw that some journeys stillhad to be planned manually.

• The service aimed to provide continuity for patientsmaking regular weekly journeys to the hospital fordialysis. It was a challenge to arrange the same crew totransport patients regularly due to a rotating rotaallocating different shift patterns. However, plannerswere able to initiate a ‘carry by’ or named a driver orcrew status on the system for dialysis patients attendingregular weekly appointments, to enable them to




continually travel on the same transport and wherepossible, with the same patients to and from theirdialysis appointment. However, there were stillproblems in achieving this at time of our inspection.

Nutrition and hydration

• There were arrangements in place to provide drinks forthose patients that were on a vehicle for a long period oftime. Water was available at each ambulance station forthe crews to take on the ambulances and bottles werecarried on ambulances and could be provided ifrequired on long journeys or hot days. Water bottlescould be replenished at each of the bases.

• No food was carried on board the ambulances forpatients. We were told the planning system was set toinclude time for breaks and take account of patientneeds for meals. Some complaints to Arriva TransportSolutions South West and others received were aboutmissed meals due to overly long journeys resulting inpatients not being able to have something to eat duringthis time.

Patient outcomes

• The service’s performance in achieving their targets wasmixed. However, they were working with commissioninggroups and other organisations to address this andmeet the increase in demand and to operate asefficiently as possible to ensure patient safety andcomfort.

• Delays and long waiting times for patients returninghome from clinic journeys were a recurring themeamongst staff we spoke with at the local hospital andpatients. Hospital staff provided us with examples whenpatients had still been waiting for transport to take themhome from clinic appointments long after clinic hadclosed. Staff recalled incidents where members of staffhad waited with patients after their shift finishing timesuntil transport arrived to collect the patient. Theseincidents were reported on the electronic reportingsystem and given to the service locality manager at thehospital to investigate. We saw that Arriva TransportSolutions South West had investigated all incidents orwere in process of doing so. Themes included, Arrivatransport arriving late and organisations movingpatients to a different location and not letting Arrivaknow and incorrect mobility information.

• In Arriva Transport Solutions South West’s most recentcombined performance report for June 2016:

▪ Arriva achieved their target for patients travelling lessthan 10 miles not spending more than 60 minutes onthe vehicle on either an outward or return journey forsix of the 12 months to June 2015/16. This meantthat for 50% of journeys, patients were not on thevehicles for over the locally agreed length of time

▪ The service achieved the target for patients travellingmore than 10 miles and less than 35 miles and notspending more than 90 minutes on the vehicle oneither an outward or return journey all 12 months toJune 2016.

▪ The service achieved their target for patientstravelling more than 35 miles and less than 50 milesand not spending more than two hours on thevehicle on either an outward or return journey for the12 months to June 2016.

▪ Arriva Transport Solutions South West did notachieve the target for all 12 months to June 2016.Forpatients dropped off between 45 minutes earlierthan booked arrival time and 15 minutes later thanbooked arrival time,

▪ For, patients picked up within 1 hour of being‘booked ready’ for collection, the service did notachieve the target for all 12 months to June 2016.There was a commissioning for quality andinnovation target set for the indicator to providefurther incentive to improve.

▪ For patients picked up within 4 hours of being‘booked ready’ for collection, Arriva TransportSolutions South West achieved their target forDecember 2015, and January and March 2016. Therewas a commissioning for quality and innovationtarget set for the indicator to provide furtherincentive to improve. The service also had an end oflife target for pick-up of patients within two hours ofbeing ‘booked ready’ for collection. In Arriva’scombined report June 2016 for this performanceindicator, the service had achieved their target forDecember 2015 only. However for six other monthsthey were over 70% and five months over 60% withan overall target of 85%.

• Data from the performance dashboard for theGloucestershire dialysis units from July 2015 to June2016 showed that on average, 3,515 patients wereconveyed every month to the dialysis units. TheGloucestershire clinical commissioning group had setfour key performance indicator (KPI) targets in relationto the dialysis units. These were :




▪ Journey arrival time (target 95%).The service wasfalling below the 95% target of ensuring patientswere arriving 45 minutes before or 15 minutes aftertheir designated arrival time for their inboundjourney. Between July 2015 and May 2016, theservice was achieving between 82% and 87% ofinbound journeys arriving within the allocated timecompared to its target. However, 5% of patients inApril 2016 and 4% of patients in May 2016 arrived 30minutes prior to the specified 45 minute arrival timeone hour and 15 minutes before their appointmentleaving patients waiting for long period of time priorto their appointment.

▪ Pre-planned outward pick up times (target 85%).Performance was worse than the target of 85% forthe majority of months between June 2015 and May2016 for pre-planned pick up for patients to bereturned home. The service aimed to pick patientsup within 60 minutes from their ‘booked ready’ time(the time they were deemed to be ready to becollected and returned home). The service met itstarget of 85% in November and December 2015 andJanuary 2016. The dialysis units logged whenpatients were supposed to be picked up againstwhen they were actually picked up. This showedexamples of where patients waited a long time to bepicked up. In one example, we saw the patient wasdue to be picked up from home at 8am for theirdialysis appointment. The patient was picked up fivehours later. In another example, the patient had adelay of four hours waiting for transport. Whilst theselengthy delays were exceptions, the log showedpatients regularly waiting in excess of an hour fortheir transport. The log recorded 107 patientjourneys of which 53 (49.53%) waited in excess of onehour to be collected.

▪ On the day outward pick up times (target 85%) Theservice demonstrated a varying ability to meet its85% target of picking up patients within four hourswhen transport was booked on the day of travelbetween June 2015 and May 2016. In November2015, December 2015 and February 2016, the servicemet its target, however fell below its target for theother months. The contract expected that less than20% of bookings would be made by telephone. Theservice took over 25% of patient transport bookingover the telephone which was above the target figureof 10%. This had an effect on control staff to able to

answer telephones effectively at all times. Thisindicator was not totally in control of the service whohad supported education of call handlers to changethis. They were also working on a draft proposalrequested by a commissioning group that could beused with other stakeholders to reduce telephonebookings.

▪ Number of calls answered within 30 seconds (target85%). Arriva had a target of answering 85% of all callswithin 30 seconds. The ability of call takers to answercalls following an automated introductory messagewithin 30 seconds was inconsistent. Between July2015 and January 2016 the service at its worst waswell below the target. In August 2015, only answering39.6% of calls in 30 seconds, compared to January2016 where they were performing above their targetand answering 88% of calls within the allocated timeframe. During our inspection, on 18 July 2016, therate of call answering within 30 seconds was 24.88%and for the month previous 50.62%. The percentageswere displayed on a board in the control room sothat staff could see how they were performing. Thecall takers we spoke with confirmed that this datawas reviewed daily by the team lead and discussedinformally with them on a daily basis where they fellshort of targets.

• For journey arrival times, the service had failed to meetits target every month during this reporting period. Forthe other two KPI’s, pre-planned outward pick up timesand on the day outward pick up times, these wereconsistently met and exceeded the targets for everymonth during the reporting period.

• The service received 25% of ‘on the day bookings’compared to its target of 10%. This indicator was not inthe service’s control. Locality managers had seenvarying engagement between the different hospitalsand clinics within the locality on these issues. Theservice relied on posters and reinforcing online bookingand working with stakeholders to increase onlinebooking.

• Locality managers for the service had been working withstaff at the local hospitals on a ‘train the trainer’ schemein order to increase the ability of hospital staff to use theonline booking system. The aim was to train onemember of staff in each department who would be ableto train other members of staff at the local hospitals.Local hospitals favoured using the telephone booking




system over the online booking system. We were toldthis was partly down to staff possibly not having toremember passwords or take time to access a computerterminal that was free.

• Arriva managers provided data to a range ofstakeholders and we saw evidence of discussionbetween parties to improve efficiency of patienttransport.

• Overall Arriva managers action plans to addressperformance issues were outlined in the risk registerand involved, increasing control staff so the servicecould answer phones more responsively, maintainingrecruitment for road based staff and working with otherstakeholders to ensure that non-emergency patienttransport was as efficient as possible.

Competent staff

• There was a framework to support staff to have theskills, knowledge and experience to deliver effectivecare. All crews that worked on the ambulances weresupposed to have six monthly observations by a mentor,team leader or manager. We were told and sawevidence that at the Gloucester station, 70% of staff hadnot received an observation of their care. At theSwindon station 17% of staff had not received anobservation.

• Staff at the Keynsham station had not carried outobserved practice for most ambulance crew fromJanuary 2016 to June 2016. Three had been completedout of 43 staff during this time period. The targets hadnot been met due to having to cover for absence. Wewere told the service was trying to improve compliancewith this and showed us rotas for August 2016 withallocated times for observed practice for the ambulancecrew. Staff had received mentor training and the teamlead had also been recruited to support with the drive toachieve compliance with observed practice.

• At the Gloucester station, five members of staff hadreceived additional training to become mentors. Thismeant they would be able to mentor other staff andundertake the six monthly observations of other staffincluding those outstanding before March 2017

• The personal development review documentation wascomprehensive. Staff self-assessed themselves againstthe target expected by the provider. The assessmentwas then agreed between the manager and member ofstaff. The review covered various topics such as health

and safety, attitude and conduct, vehicle maintenance,patient care, quality, service improvement andsafeguarding and information governance. Futuredevelopment needs were discussed.

• Staff competence of delivering patient care wasmonitored and assessed several ways. The driving ofeach ambulance was constantly monitoredelectronically. This took account of the speed travelled,cornering, late breaking or quick acceleration. Theseaspects of driving had a direct impact on patientcomfort during the journey. Each driver received scoreswhich could be accessed at any time by the teamleaders or managers. These scores were then rated asgreen, amber or red. We were told the scores weresometimes discussed with each driver at the end of theirshift or during their performance meetings. This helpedto make sure the patients were being driven safely andas comfortably as possible to their destination.

• When we inspected Swindon station there was a drivingassessor waiting to go out with a crew member who hadrecently had a road traffic collision and was going toreassess the crew member’s driving.

• A training programme was provided for new staff. Thecourse lasted two weeks and incorporated drivertraining, mandatory training, manual handling and twodays of being an observer member of staff on a vehiclewith the crew. New employees were assigned a mentorwho had received a one-day mentoring training course.Seven shifts were completed with a mentor present anda ‘new employee’ booklet provided and completedonce the new member of crew had completed a tasksuccessfully. The mentor programme could be extendedif required if a new member of crew needed extrasupport and was decided by the manager and mentor inconjunction with the new member of staff. A newemployee we spoke with praised the quality and depthof information provided during training. Following thisnew staff had three and six monthly probationaryreviews with their mentors. At these reviews, theindividual staff performance was discussed alongsidehealth and safety and flexibility of working practice.

• Assistant general managers were responsible forcarrying out the appraisals for all staff they managed.Not all appraisals were up to date. We asked if teamleaders were able to undertake staff appraisals and wewere informed they were allowed during periods ofmanager absence, but not otherwise. This meant that69 staff (41%) in Gloucester had not received their




annual appraisal or a six monthly review at the time ofour inspection. At the Swindon station, 19% of staff hadnot received their annual appraisal and 9.7% of staff hadnot received a six month review. There was an actionplan in place to address this, by March 2017.

• Staff who worked on the High Dependency Unit (HDU)ambulance were required to have additional training inairway management, suctioning, use of the defibrillatorand use of a bag and mask in a resuscitation situation.Some of the staff we spoke with told us that they shouldreceive yearly updates for this training, but had not hadany. We looked at the training records and asked for alist of staff suitably qualified to work on the HDUambulance. This showed that 32 staff were trained towork on the ambulance, however, 21 (65.62%) had notreceived training since July to September 2014. We alsofound that the training matrix had not been updated ina timely way. Staff who had received HDU ambulancetraining in March 2016 were shown on the trainingmatrix as not having received the training.

• There was no structured approach to regularly monitorthe call takers competence with call handling andpatient assessment. The call taker team lead wouldlisten into a live call and assessed competence to takeand manage calls only when a call taker haddemonstrated poor performance identified through acomplaint or had not met key performance indicators.We observed completed call monitoring checklists.Actions were identified and discussed with the call takerin order to improve practice. There was no follow up andreassessment to ensure actions were carried out andimplemented into practice

• One to one supervision sessions between call takers andthe team leader were inconsistent and did notdemonstrate quality. There was no formal system orplan in place to ensure call takers were getting regularsupervision sessions. However, there was a frameworkfor discussions held during one to one sessions lookingat any issues raised, attendance, performance, conductand complaints and compliments. We saw examples oftwo records from one to one sessions. The form lackeddetail and some boxes were incomplete. The team leadsaim was to provide consistent, monthly one to onesessions for all call taking staff.

• There were no specific triggers to identify when poorperformance needed to be addressed and managedformally for call takers. Formal management of poorperformance was at the discretion of the call taker team

lead. At the time of our inspection, none of the calltakers were under formal management for poorperformance. We were told that informal discussionsaround performance were not documented and therewas no formal framework available if formalperformance management situations arose. We wereshown an example of one word processed paragraphdocumenting a conversation between a team lead andthe call taker who had been under review for poorperformance. The document contained no action plansto work on improving performance.

• The service was not assured that all front line staff wereaware of changes to policy and procedure that hadbeen made following patient safety and other alerts.Staff were expected to sign a form once they had readthe information however; the form demonstrated 50%compliance. Information about changes to policies andprocedures for reporting incidents was available on thestaff notice board at bases we visited. Staff had accessto paper copies of updated policies and procedures aswell as access to these electronically on the staffintranet. Quality and governance updates were alsoavailable for staff in the staff room and on notice boards.

Coordination with other providers

• Arriva Transport Solutions South West sharedcomprehensive information with other agenciesregarding their mobility coding and changes as well aswhat influenced booking procedure and times. Thisoccurred through meetings such as ambulanceoperating groups which involved hospital trusts.

• Service locality managers were part of a dailyconference call with the local hospital and communityservices. The call aimed to ensure clear communicationand pressures faced by each service so that everyonewas aware of the current status of services and impactthis may have on the transport service. We saw emailsfrom locality managers that shared resource anddemand information for the service and suggestions totrusts about planning when they could not meetdemand.

• We saw minutes of performance meetings that Arrivamanagers attended for the trusts they transportedpatients to and from .The minutes and other evidenceshowed when the service met its key performanceindicators and when it didn’t.

• The service had developed an action plan with a localdialysis unit to improve patient experience. There were




21 actions, including work specifically to improvejourney quality by taking data that Arriva TransportSolutions South West held and sharing it with the unitso that they could allocate patients better and reducepatient delays. The managers of the local dialysis unitstold us that they had regular meetings with the serviceto improve the service to its patients.

• We saw the daily summary about capacity provided tolocal hospitals to keep them informed of the service’sstatus and ability to provide transport within targets.The summary was shared with each of the four localcommissioned areas which was sent to seniormanagers, locality hospital managers, dispatch teamand the operations team. The information providedsummarised recent key performance indicators, currentwork with any significant work that may affect capacityand the contact details of the dispatch team on shift andcontact telephone numbers. Arriva locality hospitalmanagers took this information to daily escalationmeeting at local hospitals to keep them aware of theservice’s status. There had been positive feedback aboutthis addition to the daily summary from partners. Therewas ongoing work to support local hospital staff toprovide better risk assessments and information aboutaccess to patient property. The service locality managerfor a local hospital had worked closely withphysiotherapists and occupational therapists fromhospitals to provide a set of criteria that staff could useto provide a comprehensive overview of the access to apatients property to enable the service to plan moreeffectively for journeys. We saw the checklist, howeverat the time of our inspection there was no date forimplementation of this tool to improve communicationand information provided to the service by the hospitalstaff booking transport.

• Locality managers were working closely with localhospitals and community clinics and trusts to buildrelationships and improve communication in order toimprove the quality of the service provided. Educationand training had been provided to different locations toensure an understanding around the service's targetsand challenges. Senior managers acknowledgedturnover of staff and long term unplanned absence haddisrupted communications and their efforts to workbetter with other organisations. They knew it hadaffected other organisations quality of service as well astheir own. We also saw evidence that some recentmeetings with other organisations had been cancelled

preventing them working together as efficiently aspossible to solve problems with service delivery thataffected patients. Arriva were clear as to why there hadbeen some disruption in attending meetings, but werealso being as flexible as possible to meet with others.

• We saw evidence of joint training plans with some truststhe service had worked with in 2015. Training includedimproving online booking by trusts. There were alsoindividual action plans for the service, improving theirdata quality and sharing with others and issuing a singlepoint of access telephone number for the key role oflocality manager for better access to communicate withthe service.

Multidisciplinary working

• We observed a good level of communication among thecall takers and dispatchers in the control centre. Weobserved the call takers frequently going to discussissues and clarify information with the dispatch team.We received positive feedback from staff in the controlcentre about the how well the wider team workedtogether.

• Staff felt supported by their team leader and theircolleagues in the call taking team and their manager.Staff told us that they often discussed things with eachother and felt supported by their team.

• There was a lack of communication at times betweenthe control room and the road based staff. Many of thecrew stated that when they sent a text message to thecontrol centre, it was rarely acknowledged andresponded to. The control centre informed us that therewere service issues with the text message service, butthat the systems team were aware and trying to find theroot cause of the problem. The crews seemed unawareof this problem, however, the control centre had sentthe crew a text message to make them aware of theproblem.

• Staff and stakeholders told us how difficult it was to getthrough on the telephone to the control room. Onestakeholder showed us their own log which indicatedthey were on hold for the control room for 15 minuteswhilst trying to find out when a patient was beingcollected.

• Staff we spoke with said they faced challenges to speakdirectly to a member of staff at the control centre. Arrivastaff told us that they regularly encountered waitingtime between 30 and 40 minutes to speak to a memberof the control team. Road based staff consistently told




us that text messages were rarely acknowledged oranswered. This posed a risk to staff if they needed tospeak to control urgently. This was being monitored andwas on the risk register.

Access to information

• There were information and record systems thatsupported delivery of effective care.

• Each vehicle had an allocated electronic tablet that wascarried by the crew during each shift. The tablet enabledcrew to see the patient record, provide information todispatch as to their status during their shift, for exampleif they were mobile or waiting to pick up a patient. Thecrew could also use the tablet to telephone and sendtext messages to the control centre.

• The service made sure that up to date ‘do not attemptcardio pulmonary resuscitation’ (DNACPR) informationand end of life care planning was appropriatelyrecorded when patients were being transported. Thestaff confirmed they would ask for the original copy ofthe DNACPR documentation from ward staff or hospitalstaff would show documentation and the crew signed tosay they had seen the original forms. This paperworkthen accompanied the patient. Information regarding apatient’s DNACPR status would also be recorded on thepatient’s electronic record by control staff when takingdetails for bookings and was available to crew via theelectronic tablet. Forms were disposed of in confidentialwaste and this was managed by an external company.

• The electronic system used by the service allowed textmessages to be sent to crews. The system could sendalerts to crews only in one part of the region or acrossthe whole region depending on the nature of themessage. This system was used to alert staff toimportant information such as road closures that couldaffect their journeys or a major incident at a local acutehospital.

• Each vehicle had its own individual information boxwhich was carried by the crew during each shift. The boxcontained information that crews may have neededwhen out on the road for example how to reportincidents, information about translation services andvehicle incident reporting forms.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Patient’s consent to care and treatment was sought inline with legislation and guidance. Staff understood the

need to have valid consent when supporting patients.Examples included staff asking patients for their consentto be moved, placed into a wheelchair or a stretcher.The ambulance care assistants said they also knew theycould not expect a patient to do anything against theirwill. If they were supporting a patient who they felt didnot have the mental capacity to make their owndecisions, they would support them as much aspossible. Staff said, they would act in the patient’s bestinterests and would not expect a patient to comply withanything they clearly did not want to do. We were givenan example when a patient who appeared confused andanxious refused to board a vehicle at the hospital. Theambulance care assistants took the decision to returnthe patient to the hospital where they could be caredfor. They requested the control team to rebook thejourney for later that day when the patient was thenable to travel without anxiety.

• Staff told us they had received training in the MentalCapacity Act 2005. The training took approximately 20minutes to complete. Staff told us that the training hadbeen useful but had not given them enough informationfor them to judge people’s capacity to give consent. Staffwe spoke with did not have the confidence to undertakebasic mental capacity assessments. Where staff hadconcerns, they said they were able to phone the controlroom for advice. The control room staff however did nothave any additional training to be able to advise crews.

• We found that staff we spoke with had no workingknowledge of the Deprivation of Liberty Safeguards(DoLS) or how they applied it in practice. There was notraining for staff in understanding the way in which DoLSmight relate to their services. For example an awarenessof the implications of transporting or transferringpatients who lack capacity to make specific decisionabout their care and where it is delivered.

Are patient transport services caring?

Our findings were:

• We saw that people were treated with kindness, dignity,respect and compassion while they received care. Wereceived positive comments about ambulance crewfrom patients, patient’s relatives and from staff working




at local hospitals we spoke with. Crew were described as'wonderful' and 'brilliant.' Another patient describedcrew as ‘lovely’ and said they could not do enough tohelp.

• Some of the organisations we requested informationfrom about also told us that ambulance crews werethought of highly by patients and staff.

• Staff knew of and responded to patients needs whilstbeing transported. Staff displayed care for patient’swellbeing during the journeys “Fantastic staff, very kindand friendly with a smile on their face.”

• Staff told us they were aware that some patients,particularly elderly and frail patients and patients withback problems sometimes found the journeysuncomfortable and bumpy.

• People who used services and those close to them wereinvolved by staff as partners in their care. We heardappropriate responses given to callers when call takersanswered questions and explained the eligibility criteriafor non-emergency patient transport.

• Patients who used services and those close to themreceived the support they needed to cope emotionallywith their care. For example two patients said “the crewalways look after me, they are brilliant and I can’t faultthem.”

• Crews encouraged patients to be as independent aspossible and provided support where required. Weobserved crew members enabling and encouragingpatients to move independently, providing support andadvice where appropriate

However

• The result of a patient survey was mixed and reflectedboth positive and negative comments. For example forthose patients very satisfied patients said the crews arewonderful, helpful, very polite and professional andmake you feel safe, Good service all round. Howeverthose who answered dissatisfied or very dissatisfied inthe patient survey described a range of issues includingdelays and cancellations.

Compassionate care

• We saw that people were treated with kindness, dignity,respect and compassion while they received care. Wereceived positive comments about ambulance crewfrom patients, patient’s relatives and from staff working

at local hospitals we spoke with. Crew were described as'wonderful' and 'brilliant.' Another patient describedcrew as ‘lovely’ and said they could not do enough tohelp.

• Some of the organisations we requested informationfrom about Arriva Transport Solutions South West’sperformance also told us that ambulance crews werethought of highly by patients and staff.

• Staff ensured dignity was maintained travelling to andfrom their vehicle. We observed crew providingcompassionate care towards the patients they wereassisting off and onto vehicles. Crew explained clearly topatients what they were going to do and did not rushpatients to get on and off the vehicles.Patients wereclothed and covered appropriately.

• Staff knew of and responded to patients needs whilstbeing transported. Staff displayed care for patient’swellbeing during the journeys, “Fantastic staff, very kindand friendly with a smile on their face.” Staff told us theywere aware that some patients, particularly elderly andfrail patients and patients with back problemssometimes found the journeys uncomfortable andbumpy. This was due to the nature of the route or attimes due to the ongoing problem with the feel of somevehicle suspension which was reported by severalcrews. The staff we spoke with explained how they triedto make patients as comfortable as possible byproviding pillows for extra support and drove as slowlyas possible to ensure that patients did not becomeuncomfortable or distressed during the journey.

• The managers of one of the dialysis units told us thatthe staff were excellent, very helpful and supportive tothe patients they looked after and had a great rapportwith patients

• When Arriva Transport Solutions South West plannerswere allocating work, they tried wherever possible toensure patients went with drivers they knew howeverthis was sometimes difficult to achieve. They had a‘carry by’ section on the planning system for thispurpose. We saw evidence of some patient’s complaintswhere this was not possible.

• Staff encouraged and ensured that patients respectedother patients where they could. We saw evidence ofstaff having intervened and then recordedcircumstances as an incident when patients complainedabout the behaviour of another or when they thoughtpatients had been spoken to rudely by other patients.




Understanding and involvement of patients and thoseclose to them

• People who used services and those close to them wereinvolved by Arriva staff as partners in their care. Weheard appropriate responses given to callers when calltakers answered questions and explained the eligibilitycriteria for non-emergency patient transport. Thisincluded calls to staff of organisations and patients.

• Language line was available for staff to use but aids forpatients with significant sight or hearing impairmentswere not available.

Emotional support

• Patients who used services and those close to themreceived the support they needed to cope emotionallywith their care. We spoke with two patients who hadbeen transported to a local outpatients department.Both patients were very positive about the staff they hadmet. Their comments included, “the crew always lookafter me, they are brilliant and I can’t fault them.”

• Staff told us how they might support other patients ifsomeone died whilst in their care. The ambulance crewwould contact their office to alert their manager andwould then be given time, to support the family untilother people arrived to help. Staff knew where to accessthe bereavement policy.

• Staff recognised where they could help patients. As anexample, a patient we spoke with said how the crewwho were taking them home saw a patient whoappeared frail and who was waiting for transport whichthey found out would be some time in arriving. The staffcontacted the control team who arranged to transfer thepatient onto their vehicle. The patient was then takenhome much earlier than they would have been. Thepatient said they had been asked if it was okay ifanother patient joined the journey they said they wereonly too happy to have seen this patient helped. Therewere other examples that we saw in the incidentrecording where staff had identified issues that patientsneeded assistance with at home and had competedtasks before leaving to ensure the patient was safe aswell as emotionally supported.

Supporting people to manage their own health

• Crew encouraged patients to be as independent aspossible and provided support where required. Weobserved crew members enabling and encouraging

patients to move independently, providing support andadvice where appropriate, to help patients to completethe transfer from the wheelchair as independently andsafely as possible

• Pathways were used by Arriva staff to signpost callers toother transport services. This included referral to patientadvocacy and liaison services or Healthwatch teams.However Healthwatch Gloucestershire had recorded anumber of incidents where Arriva staff had given theimpression that Healthwatch booked alternativetransport when people were told they were not eligibleby Arriva Transport Solutions South West. It was clearfrom reading the feedback and complaints that theseevents caused significant frustration and distress topatients.

• Referrals occurred when patients did not meet eligibilitycriteria used in assessment for transport. Patients had toconfirm they were registered under a GP in thecommissioning area and that they required transport toor between NHS funded providers before the call takerscontinued to assess the eligibility of the patient to usethe service.

Are patient transport services responsiveto people’s needs?(for example, to feedback?)


• The service aimed to take account of the needs ofdifferent people, including those in vulnerablecircumstances and an equality and diversity policy wasin place.

• The needs of patients living with a learning disability ordementia those with a mental health illness andbariatric patients were identified in training andsupported by the service’s equality and diversity policyas well as equipment. For example, the service hadvehicles and equipment for bariatric patients.

• For those patients whose first language was not English,language cards were available on each ambulance forpatients to identify the language spoken. A telephoneinterpreting service was then available when staffneeded to communicate further with a patient.




• The service ensured that lessons were learnt andactions taken as result of complaints. Learning included,reflection on attitude even when complaints were notupheld.

• Patients and people’s complaints and concerns werelistened to and used to inform action plans to improvethe quality of care. The main source of complaintscontinued to be related to pick and drop off and journeytimes both inward and outward which the service werehoping would be addressed by action plans in place.

• commissioners had asked the service to assess bookingbehaviour and to assist in promoting a reduction insame-day bookings. Arriva Transport Solutions SouthWest accepted that there was a responsibility on themto lead good booking behaviour. However, they werealso clear that they were looking to commissioners tosupport behavioural change across other NHS providerorganisations.

However

• Patients could access care and treatment, but therewere delays. For example some patients who were prebooked were sometime displaced by bookings thatwere requested by trusts and others on the day. Delayswere a common feature of complaints to ArrivaTransport Solutions South West and organisations suchas Healthwatch. Delays also featured as an issue forhealthcare trusts when we asked them for theirexperiences of the service.

• There were times when the planning team and systemdid not take sufficient account of local geographyincluding temporary traffic disruption. Crews we spokewith said that often journey time allocations wereunrealistic and unachievable.

• The systems used to enhance planning were stilldeveloping and this included an assisted planning tool,an assisted despatch tool supported by manual journeymanagement.

• For patients who were had a learning disability or weresignificantly hearing or vision impaired staff were notsupported with devices or aids to be able tocommunicate with them. For example the service didnot have any information in Braille. The service’sinduction training did not include enhancedcommunication methods or options.

• There were common themes emerging from patient andpublic feedback following a report from stakeholderswhich included homebound journeys, inconsistencies ineligibility criteria for patients, and difficulties in gettingthrough to the booking centre.

Service planning and delivery to meet the needs oflocal people

• Services planned were aimed to meet the needs ofpeople. The journey types and categories of patient theservice had been contracted to carry out included,outpatient appointments, hospital discharges, hospitaladmissions, hospital transfers, renal, oncology, palliativecare, intermediate care, mental health, paediatric,bariatric and transport from an acute hospital of highdependency patients who had received treatment suchas unblocking of cardiac arteries .

• Service delivery did not always meet people’s needs. Wesaw evidence of mixed patient experience and missedkey performance indicators in Arriva, HealthwatchGloucestershire and clinical commissioning groupreports. The service was working with stakeholders toimprove the service and had recently undergone amanagement recruitment and restructure in order todeliver the requirements of their contract in 2016 andbeyond.

• We saw recruitment records and forward planning for aspecific need to increase staffing levels for a part of theservice due to a third party provider discontinuing withthe service.

• Staff were trained to recognise and respond to theneeds of patients living with a learning disability, withmental health illness, patients living with dementia andbariatric patients. This was supported by the service’sequality and diversity policy as well as equipmentprovision. There were 92 vehicles based in the southwest a mix of stretcher, seated and high dependencyambulances (three). The service had vehicles andequipment for bariatric patients. The Keynsham basehad one bariatric vehicle, a stretcher and twowheelchairs to accommodate bariatric patients. Thevehicles met patient’s needs. Risk assessments werecompleted for complex patients or patients withbariatric needs.

• During induction staff received a presentation ‘the bigpicture’ which put into context how the patienttransport service fitted into the rest of Arriva’s corporatebusiness and structure of the parent company. Senior




managers were open when talking about deployment ofvehicles and staff to meet patient need. Regularmeetings and engagement took place to ensure keyperformance indicator data was accurate whichsupported the planning of services.

• Arriva Transport Solutions South West had twocommissioning for quality and innovation targets(CQuIN) for 2016/17 agreed with commissioners ofservices April May 2016:▪ The aim of the first CQuIN was intended to improve

patient experience and engagement with acutetrusts. It was to be achieved through improvedexperience of patients through working together withpatients who use the patient transport service andorganisations that booked it. The service hadachieved the target April September 2016.

▪ The aim of the second CQUIN was to improve Arriva’sperformance against the key performance indicatorsPTS05 and PTS06. This would improve timeliness ofservice and contribute to a better patient experience.This target had been partially achieved.

• Previous CQuIN for 2015/16 were:▪ CQuIN 1 – Improving performance measures for

performance improvement. This included PTS05:which required 85% or more pre-planned outboundpatients should be collected within 60 minutes of the‘ready’ time and PTS06: which required 85% or morepatients booked on the same day of travel should becollected within 240 minutes of the ‘ready’ time.

▪ CQuIN 2 – Improving patient experience and CQuIN 3– Reducing on-day bookings.

▪ For CQuIN 3, commissioners asked the service toassess booking behaviour and to promote areduction in same-day bookings. Whilst the corenon-emergency patient transport service contractprovided for journeys which were booked on the dayof travel, there was recognition that the volume ofthis part of the workload exceeded a sustainablelevel.

▪ Arriva Transport Solutions South West accepted thatthere was a responsibility on them to lead goodbooking behaviour. However, they were also clearthat they were looking to commissioners to supportbehavioural change across other NHS providerorganisations.

• We saw evidence of regular engagement with clinicalcommissioning groups and other organisations to try toimprove the service provided by Arriva Transport

Solutions South West. This was done through meetingsin person as well as telephone conferences. Someprogress was evident for example work on jointperformance indicators between trusts and the service.

• There were times when the planning team and systemdid not take sufficient account of local geographyincluding temporary traffic disruption. Crews we spokewith said that often journey time allocations wereunrealistic and unachievable. Staff felt that control staffdid not understand the geography of the area theycovered and the challenges the crews faced. It was feltthat journeys were based on the time taken to getbetween postcode to postcode on a clear run. Crewstold us that they were able to predict when their shiftstarted at what point they were going to face achallenge with meeting planned journey times whichwould then create a knock on effect for the remainder ofthe day making them late for subsequent jobs.

• We saw examples where times given to crews to pick apatient or a number of patients up and drop them to acommunity or acute hospital were not achievable. Stafffelt the times given to complete these journeys did nottake into account the frailty or mobility of the patientand the time that was needed for them to board theambulance.

• The systems used to enhance planning were stilldeveloping. These included an assisted planning tool,an assisted despatch tool supported by manual journeymanagement.

• We saw evidence on the service risk register of the needto change shift patterns to meet operational demand.The management team were in consultation withunions to change working patterns so the service couldimprove by meeting the demand.

• The planners used volunteer drivers and local taxicompanies routinely and when bookings exceededplanned vehicle availability. The use of taxis as analternative when demand exceeded capacity was beingreduced due to cost and extra staff were being recruited.

Meeting people’s individual needs

• The service aimed to take account of the needs ofdifferent people, including those in vulnerablecircumstances. Arriva Transport Solutions South Westhad an equality and diversity policy. The aim of thepolicy was to define and promote all the company’semployees approach to equality and diversity, and toensure there were defined guidelines for employees to




follow. It stated the company is committed to equality ofopportunity for all regardless of race, gender, genderidentity, religion, belief, sexual orientation, age,physical/mental capability or offending background.The service recognised that promoting equality anddiversity was essential to deliver quality, culturallyappropriate ambulance and support services to allsections of the communities that they served. The policyclearly described that the approach in the policyapplied to staff and to users of their service.

• Control staff tried to ensure that journeys were plannedto account for comfort breaks, feeding and hydration ifjourneys were long for example in rural areas. Howeverwe saw evidence of complaints regarding journeysbeing too long and people missing meals. Clinics thatpatients went to that might offer drinks and snacks suchas tea or biscuits could not always plan ahead to ensurepatients had eaten, if they did not get enough notice oflengthy journeys delays.

• The needs of patients living with a Learning disability,with mental health illness, living with dementia andbariatric patients were identified in training andsupported by the equality and diversity policy as well asequipment. For example, the service had vehicles andequipment for bariatric patients. The Keynsham basehad one bariatric vehicle, a stretcher and twowheelchairs to accommodate bariatric patients.However, for those patients who were significantlyhearing or visually impaired, we did not see any aids forstaff to be able to communicate with them. Forexample, the service did not have any information inBraille, a system of reading and writing using raiseddots. We did not see any enhanced communication aidseither, for example, for those with a learning disabilitythat require additional support for example ‘easy read’guides. The service’s induction training did not includeenhanced communication methods or options.

• For those patients whose first language was not English,language cards were available on each ambulance forpatients to identify the language spoken. A telephoneinterpreting service was then available when staffneeded to communicate further with a patient.

Access and flow

• Patients could access care and treatment but there weredelays. The computer and paper based system forbookings allowed for staff to book different priority forpatients. For example, some patients who were pre

booked were sometime displaced by bookings thatwere requested on the day. The planners andcontrollers tried to ensure that all vehicles and staffwhere in the place they needed to be when they neededto be there. This did not always happen. Delays were acommon feature of complaints to the service andHealthwatch Gloucestershire. Delays also featured as anissue for healthcare trusts when we asked them for theirexperiences of the service. Locality managers workedwith organisations to address reasons for delay wherethey could and feedback to Arriva managers about anyproblems not immediately fixed.

• There was a system to support booking and plan wherevehicles needed to be at the correct time to ensure keyperformance indicators were achieved. The assistedplanning and dispatch system had the organisations keyperformance indicators embedded which supportedplanners and dispatchers to plan journeys to achieverequired targets. The planning and dispatch team aimedto make the best use of resources available to them,whilst being mindful to leave some gaps to manage onthe day bookings.

• An issue for the service was delayed journeys due to latepick-ups. If crew were running late or delayed to a clinicthey would contact either control or the clinic directly toinform them of this delay. We observed the dispatchteam managing several calls of this nature and callingdirectly to clinics to ensure that the clinic could have anopportunity to alter the appointment time of the patientwhen clinically appropriate so that they did not misstheir appointment completely. However, crews statedthat getting through to speak to staff at control orgaining a response via text message was challenging.

• Another issue was that all outbound patients leavingclinics and hospitals needed to be ‘booked ready’ forcollection before Arriva Transport Solutions South Westwould start the journey. However, patients not beingready when Arriva staff arrived was a frequent problem.An analysis of April 2016, data indicated that over 110hours of Arriva staff time was wasted waiting for patientswho were not ready on arrival at one trust’s wards anddepartments.▪ For journeys cancelled by Arriva Transport Solutions

South West. The highest rate of cancellations were inDecember 2015 (0.4%) or 118 patients.




▪ There was no report/data in Arriva TransportSolutions South West’s combined report June 2016for non-aborted journeys for which no collection ismade.

• For call answer times the service achieved the target forDecember 2015 and January 2016 only.

Learning from complaints and concerns

• The service ensured that lessons were learnt andactions taken as result of complaints. Learning includedreflection on attitude of staff even when complaintswere not upheld. The service had developed an actionplan with a local dialysis unit to improve patientexperience. There were 21 actions, including workspecifically to improve journey quality by taking datathat Arriva Transport Solutions South West held andsharing it with the unit so that they could allocatepatients better and reduce patient delays.

• One manager told us that when they got things wrongfor the same patient a number of times, a flag wasadded to their patient record. We were told this flagalerted the planning and control room staff in anattempt to reduce the transport problems experiencedby the patient.

• Patients and people’s complaints and concerns werelistened to and used to inform action plans to improvethe quality of care. The service acknowledged in May2016, that complaints figures had reduced in Bath,North East Somerset and Gloucester. However, they hadseen an increase in Wiltshire and a small rise inSwindon. The main source of complaints continued tobe related to pick and drop off and journey times bothinward and outward which the service expected wouldbe addressed by performance action plans in place.Service managers recognised that some complaintswere received as a result of incidents.

• We saw examples where staff had apologised to apatient if they arrived late and explain the reasons why.Following any incidents, the managers would make afollow-up call to the patient the next day to apologiseand to check on the patient’s welfare. We saw evidenceof written apologies and communication aboutcomplaints with detailed explanations of where thingshad gone wrong and detailed actions to try to ensure itdid not happen again. We saw evidence that staff hadcalled patients relatives within 20 minutes of incidentssuch as disruption to transport arrangements topersonally discuss issues raised.

• The locality managers for each area managed thecomplaints process. If information provided about thecomplaint was limited, the complainant was called inorder to get a clearer picture of the issue. We sawevidence of how a complaint was dealt with through theprocess where a letter was sent to the complainant oncean investigation had been carried out. If thecomplainant was not satisfied with the response, thecomplaint would be escalated and dealt with by themanagement team. There were two complaints duringthe time of our inspection that had been escalated tomanagement to deal with. Staff were clear that peoplewho complained could appeal any outcome toParliamentary Health Service Ombudsman.

• All complaints were logged within the electronicreporting system so linking could take place betweenincidents and complaints. The process for dealing withcomplaints was detailed within the servicemanagement of complaints policy.

• Staff said they provided information to patients thatwished to complain. Information on how to raiseconcerns or complaints was available in leaflets on eachambulance. Although it was above and behind patientswho were travelling on a stretcher so may not have beenseen by all patients. This might have made it difficult forsome people to start a discussion about complaining.Staff told us that they would try and resolve anyconcerns at the time. Where they were unable to resolvethem they would give the patient details of the patientexperience team who would assist with their complaint.A large sticker in the vehicle provided patients withtelephone numbers and an address of where they canmake a complaint..

• We saw patient information leaflets that had beenrevised with the assistance of HealthwatchGloucestershire following an increase in inappropriatetransport request calls to them. Initially, callers hadbeen redirected to Healthwatch Gloucestershire byArriva staff under the misapprehension that they wouldarrange to provide a transport service. Healthwatch arean independent champion for consumers and users ofhealth and social care in England and they ensure thepatients' voice is heard by those who make thedecisions.

• There were common themes emerging from patient andpublic feedback following a report from HealthwatchGloucestershire who had received 197 pieces offeedback about Arriva from December 2013 to May 2016.




Delays in homebound journeys accounted for 28% ofthe feedback, 22% identified inconsistencies in eligibilitycriteria for patients, 21% accounted for delays onoutbound journeys, 11% related to the condition of thevehicles and 3% identified difficulties in getting throughto the booking centre. Also, 14% of the feedbackcollected accounted for the misunderstanding ofHealthwatch’s role by Arriva staff and some patients.Although the service managers had spoken withHealthwatch Gloucestershire to address the problem.Part of the solution was correcting patient informationleaflets and training call handlers better.

Are patient transport services well-led?

Our findings were:

• There was a clear vision and credible strategy to supportquality care. We saw evidence that the key to goodnon-emergency patient transport was understood bythe relevant staff.

• The leadership team and culture of senior managersreflected the vision and values of the organisation.

• Senior and other managers encouraged openness andtransparency. We saw this in responses to complaints aswell as engagement with others sharing keyperformance indicator data. Leaders encouragedappreciative, supportive relationships among staff.

• Senior leaders were visible and approachable within thecontrol room. Control room staff described theirmanagers and team leaders as visible, approachableand supportive. Staff told us that managers were verysupportive and they felt valued and respected.Operational role staff were able to see their manager ona daily basis at their base station.

• All staff groups or roles described the importance ofapology and honesty regarding reporting incidents butwere sometimes frustrated in reporting when they couldnot contact control quickly before having to continue onwith their scheduled work.

• Staff were engaged with the vision and strategy throughseveral ways. During induction staff received apresentation ‘the big picture’ which put into contexthow the patient transport service fitted into the rest ofArriva’s corporate business and structure of the parent

company. Senior managers were open when talkingabout deployment of vehicles and staff to meet patientneed. Regular meetings and engagement took place toensure key performance indicator data was accurate.

However

• There were governance frameworks in place to supportstaff to know their responsibilities and that quality,performance and risks were understood and informedaction plans. However, senior managers acknowledgedthat there was some way to go in a number of areas. Forexample, achieving key performance indicators andreducing the number of complaints related to delaysand developing supporting and monitoring staffthrough appraisal and one to one.

• There were no specific triggers to identify when poorperformance needed to be addressed and managedformally for call takers. Formal management of poorperformance was at the discretion of the call taker teamlead. At the time of our inspection, there was no formalframework available if formal performancemanagement situations arose.

• Patients and others who used the service and staff wereengaged and involved through a survey. Patientresponses to an external survey was poor with a 5%return rate.

Vision and strategy for this service

• There was a clear vision and credible strategy to supportgood quality care. The vision was to provide safe,compliant and high quality service to customers and toaccept and embrace personal accountability for work.The strategy was to acknowledge change as apermanent feature of work and recognise that changebrings opportunities. The managers that we spoke withwere clear of the overall objectives for the patienttransport service. The objectives were to provide aneffective and safe service with consistent quality. Seniormanagers acknowledged that there was some way to goin a number of areas. For example, key performanceindicators and creating an environment with others toinfluence change. We saw evidence that the vision andstrategy was understood by the relevant staff.

• Staff were engaged with the vision and strategy throughseveral ways. During induction staff received apresentation ‘the big picture’ this put into context howthe patient transport service fitted into the rest of thecorporate Arriva Transport Solutions South West’s




business and structure of the parent company. Staffwere also aware of the vision which had been reinforcedin a booklet given to all staff detailing their role inachieving the service’s set aims and objectives. All staffwe spoke with wanted to provide the best possibleservice to patients.

• Senior and other managers were aware what the risks,plans, goals and pressures for the service were. Thesewere summarised in the quality account for 2015/16 asaiming to provide a safe, compliant and high qualityservice to our customers; Achieve continuousoperational improvement in call centres, control roomsand on the front line; Accept and embrace personalaccountability for our work; Build a sustainable businessthat consistently delivers value for money.

Governance, risk management and qualitymeasurement

• There were governance frameworks in place developedby the registered manager and other managers in theSouth to support staff to know their responsibilities.Quality, performance and risks were understood andinformed action plans, however, some were noteffective. The service was managed by a head ofnon-emergency patient transport for the south regionwho was previously the companies’ director ofgovernance and quality. They reported to the managingdirector who was the registered manager. They weresupported by a head of quality and standards, head ofoperations and heads of control and planning. Anumber of general managers, assistant generalmanagers and locality managers were responsible forvarious bases in the region. The governance proceduresin place were regularly reviewed, and somedemonstrated change and learning.

• Systems were in place to notify staff of changes topolicies, although the systems did not provideassurance that all staff were aware of changes at thesame time. Governance and Quality notices were sharedwith staff through the managers to all staff. We saw inthe Gloucester station that these were displayed in thecrew room along with signature sheets for the crew tosign once they had been read. The manager told us thatthey followed the issue of notices up with all staff whohad not signed to make sure that all staff would beaware of change.

• There were no specific triggers to identify when poorperformance needed to be addressed and managed

formally for call takers. Formal management of poorperformance was at the discretion of the call taker teamlead. At the time of our inspection, none of the calltakers were under formal management for poorperformance but there was no formal frameworkavailable if formal performance management situationsarose. We were shown an example of one wordprocessed paragraph documenting a conversationbetween a member of staff who has been under reviewfor poor performance and their line manager Thedocument contained no action plans to work onimproving performance.

• A system called ‘checkpoint’ was used for each memberof staff at the end of their shift. This meant that moststaff had conversations with their managers on a dailybasis, most on the day they ended the shift. Thecheckpoint forms were provided at the start of each shiftand used to confirm vehicle checks were made, thecrews driving scores were recorded and any issues thatthey had encountered during their shift could be shared.

• There was a systematic programme of audit to monitorand manage quality and ensure performance data wasaccurate, valid and relevant. The service was workingwith one local trust to review validity of delay data. Wesaw evidence of the monthly review of a range ofperformance and risk indicators.

• Following the appointment of a new head of southregion at end of May 2016, a review of operations hadoccurred. This included a review of all aspects ofoperational performance and quality particularly theperformance improvement plans currently in place inrecognition that some plans had not produced the levelof improved performance.

• Progress with addressing the vacancy rate across thearea had been taking place since the appointment of adedicated recruiter for the service. The staff needed forthe area had been reviewed to match current levels bystation and compared with revised service demanddata. This had led to Salisbury and Keynsham basesbeing the focus for recruitment.

• Performance was discussed regularly at the operationalquality performance group. This group hadrepresentatives from all the service’s areas. This groupreported to the senior management team. Locally,monthly policy performance and senior managementmeetings took place. A trading review meeting took




place each month. The trading review looked atcomplaints, performance and any action plans. The riskregister was also discussed and fed through to theoverall provider’s risk register.

• We reviewed the risk-register for non-emergency patienttransport services. It reflected most of the risks voicedby staff and by outside organisations. For example, theissue of long waits for staff to speak to a member ofcontrol staff, staff claiming they did not get meal breaksand the potential for damage to Arriva TransportSolutions South West’s funding from reduced incomedue to not meeting key performance indicators. Threerisks of the 17 had been escalated to the corporate riskregister, not meeting key performance indicators andthe two most recent identified by CQC regarding oxygenstorage and related fire risks. The risk register wasupdated. Action was being taken on all issues that werestill open.

Leadership of service

• The senior leadership team consisted of a managingdirector who was the registered manager, a newlyappointed head of south region, head of operations,head of planning and control . The senior managersreflected the vision and values of the organisation.Senior and other managers encouraged openness andtransparency. We saw this in responses to complaints aswell as engagement with others sharing keyperformance indicator data. They had a clear aim toprovide and promote good quality care regardless of theissues they were dealing with. For example, the increasein demand and some performance indicators beingoutside of their control such as ‘on the day bookings’.

• The service was managed by a head of non-emergencypatient transport for the south region who waspreviously the companies’ director of governance andquality. They reported to the managing director whowas the registered manager. They were supported by ahead of quality and standards, head of operations andheads of control and planning. A number of generalmanagers, assistant general managers and localitymanagers were responsible for various bases in theregion.

• We spoke with the head of the south region, themanaging director who was the registered manager, andthe quality and safety lead who was also the infectionprevention and control lead. They understood thechallenges within the service and could produce actions

which had been implemented to deliver some changeand improvement. However, crucial information did notalways get shared in a timely way to all people in theorganisation. We spoke with some key staff memberswho were not aware of a Healthwatch Gloucestershirereport received by Arriva Transport Solutions SouthWest regarding delays and other transport issues. Theywere surprised that it existed but said that they wouldread the report as soon as was possible.

• Leaders encouraged appreciative, supportiverelationships among staff. Senior leaders were visibleand approachable within control. Control room staffdescribed their managers and team leaders as visible,approachable and supportive. Staff told us thatmanagers were very supportive and they felt valued andrespected. Operational role staff were able to see theirmanager on a daily basis at their base station. Seniormanagers were available when needed in the SouthWest. The team leaders, managers and senior managersthat we spoke with told us how proud they were of theirteams and the care they provided to their patients.

• The service supported staff to develop by encouragingfurther education and training. A member of staff hadbeen enabled to undertake a leadership course tosupport development and increase ability to lead. Staffhad commented on how support and leadership for theorganisation had improved.

Culture within the service

• Managers and others told us of a culture thatencouraged candour, openness and honesty. We sawevidence of this and senior managers spoke broadlyabout the duty of candour and being open generallyand how it applied to service delivery. All staff groups orroles described the importance of apology and honestyregarding reporting incidents but were sometimesfrustrated in reporting when they could not contactcontrol quickly before having to continue on with theirscheduled work.

• We observed that support was available to staff. Thisincluded occupational health, discussions with amanager or team leader and the availability ofcounselling should the member of staff need it.

• Senior managers were open when talking aboutdeployment of vehicles and staff to meet patient need.




They were clear that they had to meet targets set bycommissioners but were clear that ultimately they werein response to meet patient need and so were one andthe same.

• Staff we spoke with felt respected and valued. Staff toldus that it was a great and positive organisation to workfor and felt well supported. They said they were able toput forward ideas and that they were listened to.Managers told us that the provider was progressive andadaptive to change despite operating in a difficultenvironment. During our inspection, it was evident fromstaff that they were very patient focused and wanting toprovide every patient with a good experience.

• Some staff told us that they wished the company lookedafter them better. When we explored this further, itseemed to be in relation to pay rates. An employeesatisfaction survey was carried out in 2015/16.Out of 291employees, there were 155 responses (53% responserate).

• We saw evidence of action taken to address behaviourand performance below the expected standardsalthough processes for monitoring the performance ofcontrol staff were informal and not all staff were up todate with appraisal and one to one meetings.

• There was a perceived lack of understanding around thechallenges faced by different teams, between thecontrol centre and ambulance road crew and base staff.The relationship between the ambulance road crew andcontrol room team was disjointed. There was aperception from ambulance crews that the dispatch andplanning team did not understand the challenges oftheir role and vice versa. Both sides felt that it would bebeneficial for each side to spend a day with the oppositeteam in order to gain more of an understanding of eachother’s role and the pressures they were under. Thedispatch manager informed us that where possible theytried to accommodate this but this had beenchallenging recently due to demand and staffing levels.

Public engagement

• Patients, staff and others who used the service wereengaged and involved. Patients were engaged in asurvey run by an external company and fed back in adocument called Arriva Patient Transport Survey SouthRegion. Data was gathered from February 2016 to April2016. There were 3306 questionnaires distributed and159 (5%) returned. The total return for ambulance basesin the South West was as follows. Of the 457

questionnaires distributed, there were 48 returned fromSwindon (11%), of the 990 questionnaires distributed 53were returned from Gloucester (5%), of the 134questionnaires distributed there were 7 returned fromNewport (5%). None were returned from Lydney (500questionnaires distributed).

• The result of the patient feedback survey was mixed andreflected both positive and negative comments. Forexample, a sample of comments from those whoanswered very satisfied in the patient survey describeda range of issues, the crews are wonderful, helpful, verypolite and professional and make you feel safe, Goodservice all round. The driver was very caring andconsiderate during our journey to the RUH. Althoughcomments of those very satisfied in Gloucester didfeature a theme of delays.

• A sample of comments from those who answereddissatisfied or very dissatisfied in the patient surveydescribed a range of issues. On two occasions - failed toarrive. Previously faultless performance. Two hours late,I was late for my appointment, the department stayedopen until I got there

• Arriva Transport Solutions South West promotedHealthwatch Gloucestershire as a contact in informationleaflets as well as patient advocacy and liaison services.

Staff engagement

• Staff felt safe to raise concerns and leaders understoodthe value of staff raising concerns. Staff felt engagedwith their employer in planning and delivery of theirservice. An employee satisfaction survey was carried outin 2015/16.Out of 291 employees, there were 155responses (53% response rate). The response rate forArriva Transport Solutions, which was the nationalorganisation, was 56%. Arriva Transport Solutions SouthWest had a 3.1 rating out of a total of 5 on an employeesatisfaction index, the national rating was 3.2.

• Key positive responses were:▪ that staff understood what they could do to help

deliver an excellent service 89%,▪ my responsibilities suit my personal skills and

expertise 86%,▪ I can rely on my colleagues when I need support

84%,▪ I work beyond what is required to help the company

succeed 78%▪ I enjoy my work 76%.

• However, the five lowest rated question responses were:




▪ My pay is appropriate 20%,▪ I am satisfied with the additional benefits I am

offered 24%,▪ there are good opportunities for career development

here 23%,▪ employees interests are taken into account in

important decisions at the company 22%,▪ I feel I am part of an international group 22%

• Staff team meetings were held monthly at theKeynsham base at 6.30pm and staff were paid if theyattended outside of their shift. Attendance was low dueto staff not being able to get back to base due to workdemands, with just 10 out of the 43 staff attending themeeting in June 2016. We reviewed minutes of the teammeeting, the discussions held and the action plan.Action plans from the meeting had already beencompleted by the station manager.

• Checkpoint was a newly introduced method of enablingambulance crew to provide daily feedback. Checkpointwas introduced in March 2016 and enabled crew toprovide feedback about different aspects of their day.Feedback included vehicle issues, analysis of latejourneys, patient feedback and other issues raised bystaff. There was a varied response to the new systemwith some crew feeling that parts of the checkpointwere a duplication of the vehicle checks completed atthe start of each shift.

Innovation, improvement and sustainability

• We saw evidence of plans to promote the continuousimprovement and sustainability of the non-emergencypatient transport service. However there were manyfactors being considered as to why the improvementdesired had not been seen across all plans for all keyperformance indicators. Plans had been affected byinability to recruit new and turnover of experienced staff.Also, Arriva staff were still learning the limitations ofimplementing the electronic systems that assistedplanning and despatch.

• The effectiveness of the service delivered by ArrivaTransport Solutions South West was not completelywithin their direct control. Factors included theproportion of on the day bookings, avoidable abortedjourneys by other organisations and someorganisation’s reluctance to use online booking. . ArrivaTransport Solutions South West was working withstakeholders to improve the service and had recently

undergone a management recruitment and restructurein order to deliver the requirements of their contract in2016 and beyond. Managers were confident they couldaddress all these issues and work with partners to meetthe demands

• A significant issue was the service depended uponaccurate information at the point of booking. Inaccuratemobility information could lead to an aborted journey,delay for the patient, inconvenience for acute trust staffand a waste of the service’s resource. The use of newmobility codes was intended to address this. Also, areview of mobility re-grading trends across all treatmentlocations showed that on some occasions the originalmobility type was incorrect. The analysis was beingintroduced into planned transport working group (TWG)meetings. Locality managers would also address theissues as they arose as well as report to the TWG.

• The impact on quality and sustainability was measuredthrough key performance indicators. The service wascontinuously learning and trying to improve with someinnovation, for example, systems to monitor drivingstyle as well as automated planning and despatchsystems.

• There had been a recent implementation of a staffbonus scheme to try to affect the key performanceindicator PTS04 or the percentage of patients arriving 45minutes earlier to 15 minutes after that scheduledappointment time. Road based staff were encouragedto collect better data and commence journey from basestation more promptly.

• The service implemented new software at the end of2015, which assisted in planning journeys at the control.Over time, it was expected that this would be fullyautomated and more efficient so that patient journeyswere as short as possible. This would give call centrestaff the time to make more calls should they need to intimes of high demand. The software was a learningpiece of software that we were told would take time tofully take on the thousands of journeys that wereplanned successfully each day.

• Each ambulance was fitted with a tracking system whichperformed several different functions. When staff loggedin the system enabled managers at the bases and thedispatch team to view the status of the ambulance forexample whether and how they were driving or whetherthey were stopped. The system also monitored thedriver’s performance which was reviewed by managers.




• We saw recruitment records and forward planning for aspecific need to increase staffing levels for a part of theservice due to a third party provider discontinuing withthe service.

• Arriva Transport Solutions South West carried out acomprehensive review of do not attempt cardio

pulmonary resuscitation procedures in November 2015.This was done with the support of qualitycommissioners in another area of the country; however,the new process had been applied across all of thecontracts nationally.




Outstanding practice

We saw several areas of outstanding practice including:

• Control and road based staff recognised where theycould help patients. Staff went out of their way toassist patients we were told by a patient of an exampleof staff amending their journey to help a patient whowas delayed by another provider. There were otherexamples that we saw in the incident recording, where

staff had identified issues that patients neededassistance with at home and had completed tasksbefore leaving to ensure the patient was safe as well asemotionally supported.

However, there were also areas of poor practice wherethe location needs to make improvements.

Areas for improvement

Action the hospital MUST take to improveImportantly, the location must:

• Ensure that mandatory training observations,appraisals and yearly updates for all staff is carried outand up to date including the high dependencyambulance vehicle staff.

• Ensure that the process in place to record defects invehicles was recorded and actioned in a timely waywas followed.

Action the hospital SHOULD take to improve

• Ensure that the process for staff to be informed ofupdated policies, procedures and quality andgovernance updates is followed and records kept

• Ensure that all equipment and particularly those usedto take measurements of patients’ blood pressure andoxygen saturation levels are listed on equipmentservicing records and serviced and maintained withinspecified dates.

• Ensure that systems for control to communicatebetween operational or road based staff enable timelycommunication via telephone calls and textmessaging so that messages about patient’s conditionor incidents were able to be shared.

• Ensure that policies and procedures for disposal ofclinical waste are followed.

• ensure that battery life for equipment used for text andvoice communication is fit for purpose and is reliable

• Ensure that the process for identifying poorperformance that needed to be addressed andmanaged formally was followed.

In addition the location should:

• Consider how staff receive feedback from anyincidents they report.

• Consider whether Mental Capacity Act 2005 anddeprivation of liberty safeguards training meet staffneeds.

• Consider aids for staff to be able to communicate withpatients with significant sight or hearing impairmentare available.

• Consider reviewing the process and questions for calltaking for identifying mental health and other supportneeds a patient may have once scripted prompts areexhausted.

• Consider carrying out a review of patients comfort invehicles.

• Consider whether electronic alerts that the planningand control room staff used on patient records thatincluded the word complaint complies with recordskeeping best practice.

• Consider the method for journey time allocations andwhether post code allocation is detailed enough.

• Consider increasing the opportunity for road basedstaff and control based staff to understand eachother’s role better.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Transport services, triage and medical advice providedremotely

Regulation 18 HSCA (RA) Regulations 2014 Staffing

18. (1) Sufficient numbers of suitably qualified,competent, skilled and experienced persons must bedeployed in order to meet the requirements of

this Part.

(2) Persons employed by the service provider in theprovision of a regulated activity must—

(a) receive such appropriate support, training,professional development, supervision and appraisal asis necessary to enable them to carry out the duties theyare employed to perform,

• 25 (8.4%) staff were overdue on their yearly updates.For several of those 25 staff, the last time theycompleted mandatory training was in 2014. The controlroom staff were also due to have annual refreshertraining, but the training records were blank for thisgroup of staff. The training records also showed a largenumber of staff had not received first aid at worktraining or infection control training.

• Not all appraisals were up to date. 69 or 41% of the staffin Gloucester had not received their annual appraisal ora six monthly review at the time of our inspection. Atthe Swindon station, 19% of staff had not received theirannual appraisal and 9.7% of staff had not received asix month review.

• Staff who worked on the High Dependency (HDU)ambulance were required to have additional training inairway management, suctioning, use of the defibrillatorand use of a bag and mask in a resuscitation situation.We looked at the training records a list of staff suitablyqualified to work on the HDU ambulance. 32 staff weretrained to work on the ambulance, however, 21(65.62%) had not received training since July toSeptember 2014. We also found that the training matrixhad not been updated.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


• At the Gloucester station 70% of staff had not receivedan observation of their care. At the Swindon station17% of staff had not received an observation. TheKeynsham based had not carried out observed practicefor ambulance crew from January to June 2016.

• Staff had access to paper copies of updated policy andprocedures as well as access to these electronically onthe staff intranet. Quality and governance updates werealso available for staff in the staff room. Staff wereexpected to sign a form once they had read theinformation however, the form demonstrated that onlyaround half the staff had signed.

There was no structured approach to regularly monitorthe call takers competence with call handling andpatient assessment.

Regulated activity

Transport services, triage and medical advice providedremotely

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

12. (1) Care and treatment must be provided in a safeway for service users.

(2) Without limiting paragraph (1), the things which aregistered person must do to comply with thatparagraph include:

2) (e) ensuring that the equipment used by the serviceprovider for providing care or treatment to a service useris safe for such use and is used in a

safe way;

• Decisions were not always made to take a vehicle offthe road when defects were identified and reported.We found on one vehicle, staff had reported that theemergency doors did not open from the inside whichposed a risk to patients and staff in the event of anaccident. Staff documented this issue on the checkliston the 30 June 2016 and again on the 19 July 2016

Both the machine for recording a patient’s bloodpressure and the machine for recording oxygen levels did

Regulation




not have any information on them as to when they werelast serviced and calibrated. Neither of these pieces ofequipment were listed on Arriva Transport SolutionsSouth West’s equipment servicing records for 2015/16.


