Yorkshire Ambulance Service NHS Trust HQ NewApproachFocused Report

93 Pages·2016·0.95 MB·English

Yorkshire Ambulance Service NHS Trust
YYoorrkksshhiirree AAmmbbuullaannccee SSeerrvviiccee
NNHHSS TTrruusstt HHQQ
Quality Report
Springhill2,BrindleyWay
Wakefield41BusinessPark
Wakefield
WestYorkshire
WF20XQ Dateofinspectionvisit:13-16September2016,6
Tel:[phone] October2016
Website:www.yas.nhs.uk Dateofpublication:01/02/2017
Thisreportdescribesourjudgementofthequalityofcareatthisprovider.Itisbasedonacombinationofwhatwe
foundwhenweinspected,otherinformationknowtoCQCandinformationgiventousfrompatients,thepublicand
otherorganisations.
Ratings
Overall rating for this
Good –––
ambulance location
Emergency and urgent care services Good –––
Patient transport services (PTS) Requiresimprovement –––
Emergency operations centre Good –––
Resilience planning Good –––
1 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summary of findings
LetterfromtheChiefInspectorofHospitals
YorkshireAmbulanceServiceNHSTrust(YAS)wasformedon1July2006whenthecounty'sthreeformerservices
merged.ThetrustcoversNorthYorkshire,SouthYorkshire,WestYorkshire,HullandEastYorkshirecoveringalmost6,000
squaremilesofvariedterrain,fromisolatedmoorsanddalestourbanareas,coastlineandinnercities.Thetrust
employsover4,670staffandprovides24-houremergencyandhealthcareservicestoapopulationofmorethanfive
million.
Thetrustprovidesanaccidentandemergency(A&E)servicetorespondto999calls,anNHS111serviceforwhen
medicalhelpisneededfastbutitisnota999emergency,patienttransportservices(PTS)andemergencyoperation
centres(EOC)where999andNHS111callsarereceived,clinicaladviceisprovidedandfromwhereemergencyvehicles
aredispatchedifneeded.Thereisalsoaresilienceandhazardousarearesponseteam(HART).
Wecarriedoutafocussedfollowupinspectionofthetrustfrom13-16September2016,inresponsetoaprevious
inspectionaspartofourcomprehensiveinspectionprogrammeofYorkshireAmbulanceServiceNHSTrustinJanuary
2015.Inaddition,anannouncedcomprehensiveinspectionoftheNHS111servicewascarriedouton10-12October
2016.
Focusedinspectionsdonotlookacrossawholeservice;theyfocusontheareasdefinedbytheinformationthattriggers
theneedforthefocusedinspection.Wethereforedidnotinspectallofthefivedomains:safe,effective,caring,
responsiveandwellledforeachofthecoreservicesweinspected.
Weinspectedfivecoreservices:
• Emergencyoperationscentres
• Urgentandemergencycare
• Patienttransportservices
• ResilienceservicesincludingtheHazardousAreaResponseTeam
• NHS111services.
Overall,weratedallofthefivekeydomainsasgoodwhichmeanttheoverallratingforthetrustwasalsogood.
Ourkeyfindingswereasfollows:
• Thetrusthadundertakenanumberofinitiativestoimprovestaffengagement;thestaffforumhadbecome
embeddedsinceourpreviousinspectionandwasviewedpositivelybystaff.
• Relationshipsbetweenthetrustandtradeunionshadimprovedsincethepreviousinspectionbuttherestillmore
workforthetrusttodo.
• Staffinglevelsthroughoutthetrustwereplannedandmonitored.Thetrusthadchallengesduetonationalshortages
however;itwasaddressingthisthrougharangeofinitiatives.
• FromApril2016thetrustwasparticipatinginthenationaltrialoftheambulanceresponseprogramme(ARP)which
helpedtheservicetodispatchappropriateambulanceresources.TherewerenoperformancetargetsfortheARP
pilot.Thetrustmonitoreditsperformanceonresponsetimes.
• Atthepreviousinspectiontherehadbeenconcernsinrelationtoequipmentchecks,maintenanceofequipmentand
consumablestock.Atthisinspectionwefoundthetrusthadputinplaceasystemtoensureequipmentandstock
wassuitabletouse.
• Inmostofthecoreserviceswefoundinfectioncontrolprocedureswerefollowedandtheambulancestationsand
vehiclesweobservedweregenerallyclean.Howevertherewerestillinconsistenciesinthewaystaffmaintained
vehiclecleanlinessacrossthePTSservice.
2 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summary of findings
• Thereweresystemsinplacetosharelearningfromincidentsandadverseevents.Moststaffwespokewithconfirmed
theyreceivedfeedbackbyemailafterreportinganincident.Asafetybulletinwasproducedandsharedacrossthe
trusttosharelessonslearnt.
• Therewerehighlevelsofcompliancewithsafeguardingtrainingatlevelsoneandtwoandallstaffwhowere
determinedbythetrusttorequirelevelthreetraininginrelationtotheirrole,hadreceivedthis.
• FromApril2016thetrusthadcommencedalocalreviewofmortalityandmorbidity,supportedbylocalauditslinked
tothetrust’scommissioningforqualityandinnovation(CQUIN)targetstoexplorealldeathsinthecareofthetrust,
whereRecognitionofLifeExtinct(ROLE)hadbeeninvokedbyYASparamedics.
• WithintheNHS111service,callabandonmentratewas2%,comparedtothenationalaverageof3%.Wesawthat
89%ofcallswereansweredwithin60seconds,comparedtothenationalaverageof87%.
• WithinthePTSservicetherewasaclearlackofmanagementoversightandlackofownershipofrolesand
responsibilities,andgovernancesystemswerenotfullyembeddedthroughouttheservice.
Wesawseveralareasofoutstandingpracticeincluding:
• Theredarrestteamprovidedclinicalleadershipintheresponsetocardiacarrestpatients,whichhadimprovedthe
successrateinthereturnofspontaneouscirculation(ROSC).
• TherestartaheartteamwascommendedforitsCPRworkwithschoolchildren.Morethan31,000childrenwere
trainedinhands-onlyCPRinconjunctionwiththeBritishHeartFoundation.
• Communityfirstrespondersweretrainedvolunteerswhowereavailabletoattendemergencycallsandtoprovide
initialcarebeforethearrivalofanambulance.Morethan300communityfirstresponderschemesworkedclosely
withtheambulanceservice.
• Theservicesupported670publicaccessdefibrillatorsacrosstheYorkshireregionwhichwereavailableforuseby
membersofthepublic.Theschemeparticularlyhelpedpeopletoaccessdefibrillatorsinremotevillages.
• AmemberoftheairambulancecrewhadcompletedtraininginCrewResourceManagement(CRM).Thequalification
enabledthememberofstafftoundertakecritiqueandfeedbackofincidentswhilsttakingaccountofhumanfactors.
• HARTstaffpresentedevidenceonthebenefitsofearlyantibioticadministrationinopenfractures.Thistreatment
nowhasbecomestandardpracticewithinYAS.
• Thetrustwaspartoftheurgentandemergencycarevanguardprogramme,tosupportthedevelopmentofnew
approachestotheprovisionofurgentandemergencycare.TheWestYorkshireurgentandemergencycarenetwork
aimedtodevelopanintegratedurgentcaremodelfortheregion,buildingontheservicesprovidedbyexistingurgent
careservices.
• ThetrusthadcontributedtothedevelopmentofaPharmacyUrgentRepeatMedicationScheme(PURM)acrossthe
localitywhichenabledpatientstoaccessessentialmedicinesfromparticipatingpharmacistsoutofhours.This
schemehadwona‘PharmacyInnovation’award.
• TheNHS111servicehadimplementedaccesstopalliativecarenursesonweekendsandbankholidays,whowere
abletoprovidesupporttopatientsapproachingtheendoflife.
• Thetrusthadmadeuseofacomprehensiveworkforcemanagementtooltoforecastanticipatedcalllevelsand
deploystaffaccordingly.Thedevelopmentofthistoolandthetransformationofplanningwithintheorganisation
wasrecognisedbyaNationalPlanningAwardfromtheProfessionalPlanningForum.
However,therewerealsoareasofpoorpracticewherethetrustneedstomakeimprovements.
Importantly,thetrustmust:
• Thetrustmustensureatalltimestherearesufficientnumbersofsuitablyskilled,qualifiedandexperiencedstaff.
• Withinpatienttransportservices(PTS)thetrustmustensurethatallambulancesandequipmentareappropriately
cleanedandinfectioncontrolproceduresarefollowed.
• Thetrustmustensuresecureseatingforchildrenisroutinelyavailableinambulancevehicles.
Inadditionthetrustshould:
3 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summary of findings
• ThetrustshouldreviewthetrainingrequirementsforoperationalstaffinthePTSserviceforvulnerablegroupssuch
aspatientslivingwithdementiaandpatientsexperiencingmentalhealthconcerns.
• Thetrustshouldreviewthearrangementsforoperationalstafftochecktheirvehicleandequipmentatthestartof
theshifttoensuretheyhavesufficienttimetocompletethechecks.
• Thetrustshouldreviewtheauditproceduresforreviewingtherecordingofcontrolledmedicines.
• Thetrustshouldcontinuetoensurethatequipmentandmedicalsuppliesarecheckedandarefitforpurpose.
ProfessorSirMikeRichards
ChiefInspectorofHospitals
4 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
Ourjudgementsabouteachofthemainservices
Service Rating Why have we given this rating?
Emergency AtourpreviousinspectioninJanuary2015,the
Good –––
and urgent servicewasratedasRequiresImprovementoverall.
care InSeptember2016weratedthiscoreserviceas
services Goodbecause:
• Thetrusthadputinplaceprocessesforrisk
managementandclinicalgovernanceofthe
service.Riskswereratedandareviewdate
specifiedwhichshowedeachriskwasrecently
reviewed.
• Positivechangestotheexecutiveleadershipof
theservicewererecognisedandappreciatedby
staff;thechiefexecutivewasseenas
approachable.
• Thetrustwasparticipatinginthenationaltrial
oftheambulanceresponseproject(ARP)which
helpedtheservicetodispatchappropriate
ambulanceresourcestopatients.
• Outcomesforpatientshadimproved;for
examplepracticetosupportthereturnof
spontaneouscirculation(ROSC)and
involvementwithregionalandnationalsepsis
networkshadstrengthenedthesepsispathways
andimprovedclinicalqualityoutcomes.
• Staffworkedcloselywithhospitalprovidersof
emergencyandotherprovidersofservices
includingfireandrescueandcommunity
responderstocoordinateappropriatepathways
ofcareforpatients.
• Staffwereabletoreportincidentsreadilyand
learningfromtheinvestigationofincidentswas
shared.
• Infectioncontrolprocedureswerefollowedand
ambulancestationsandvehicleswereclean.A
vehicle“makeready”servicehadbeen
introducedinsomestations.Therewereplans
tointroducethisacrosstheservice.
• Equipmentandconsumablesupplieswere
readilyavailableandarrangementsfor
disposingofoutofdateitemswereinplace.
• Theworkforceplandevelopedduring2016-17
reflecteddemandprofilesforeachareaand
5 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
plannedworkforcenumbersandrecruitment
weremonitoredweekly.Theworkforceplanwas
communicatedandunderstoodbystaffwhich
helpedtosupportretention.
• Recordscontainedappropriateandsufficient
informationaboutthepatientandtheir
conditionandwerefullymaintainedand
audited.
• Patientswithdeterioratingconditionswere
identifiedpromptlyandescalatedfor
appropriatetreatment.Pathwaysforassessing
andrespondingtopatientswhoexperienced
trauma,sufferedfromchestpainorexperienced
asuspectedstrokewerefollowed.
• Medicineswerestoredsecurelyand
administeredsafely.Oxygenandanalgesic
gasesweresecuredsecurelyandwereindate.
Securestorageformedicineswasalso
maintainedinacutehospitals.Wesaw
medicinescabinetsweresecurelylockedwith
accessonlypermissiblebyambulanceservice
crews.Controlledmedicineswerestoredin
ambulancestationsinalockedroomwithina
lockedsafeandtheroomwasalarmed.
• Thelearninganddevelopmentofstaffwas
supported.Allstaffnewtotheservicereceived
thoroughinductionandtrainingandtheservice
wastakingstepstoensurestaffreceivedan
annualappraisalandclinicalsupervision.Most
staffhadcompletedtheirmandatorytraining.
• Thecultureoftheservicehadimproved.Public
engagementfortheservicehaddevelopedand
includedroadshowsandcommunity
partnershipevents.Localengagementevents
hadattractedmorethan3,000membersofthe
public.Consultationarrangementswithstaff
includedanewlyestablishedmultiunion
partnershipandthestaffforumwasembedded.
• Staffknewhowtodealwithcomplaintsthey
received,complaintswereinvestigatedandwe
foundsomeevidencethatlearningwasshared
withstaff.Forthe12monthspriortoour
inspectiontheservicehadmetagreeddue
datesin96%ofcasesandhasachievedan
6 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
averageresponsetimeof21workingdaysforall
services.Theservicehadastandardof85%for
qualityauditoutcomes,andwasachieving86%
atthetimeofourvisit.
• Innovationwasencouragedthroughsupportfor
nationalinitiativesandlocallybasedresearch
projects.
However:
• Theallocatedtimeofsixminutesforcrewsto
checktheirvehicleandequipmentatthestart
oftheirshiftwasinsufficientforallessential
equipmenttobechecked.
• Therecordingofmedicinesadministration
containedsomediscrepancieswhichwerenot
alwaysidentifiedthroughauditprocedures.At
anemergencydepartmentwevisited,whenwe
checkedthestockofcontrolledmedicines,we
foundtheitemsissuedhadbeenaudited
incorrectly,sothatoneitemwasshown
incorrectlyasinsurplus.Theserviceaddressed
thisissueatthetimeofourvisit.
• Recordswerenotalwayssecurelystoredon
ambulancevehicles.Weraisedthiswiththe
trustduringourvisitandatourunannounced
inspectionwefoundthatprocedureshadbeen
changedtoprotectthesecurityofrecords.
• Itwasnotalwayspossibleforambulancecrews
toaccesssecurevehicleseatingforchildren.
• Disposalofclinicalwasteandsharpswas
variableinaminorityofvehiclesand
ambulancestations.
• Furtherworkwasneededtoensureatarget
numberofstaff(atleast85%)receivedan
annualappraisal.Theservicehadinplacea
recoveryplantoachieve90%appraisalratesby
2017-18.
• Specialisedequipmenttosupportbariatric
patientsneededtobemadeavailableand
accessibletoallemergencyambulancecrews.
• Frontlinestaffwespokewithcouldnot
articulatethevisionandstrategyfortheservice.
7 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
Patient Weundertookacomprehensiveinspectionofthe
Requiresimprovement –––
transport YorkshireAmbulanceService(YAS)inJanuary2015.
services Atthistime,weratedPatientTransportServicesas
(PTS) RequiringImprovementinthedomainsofsafe,
effective,responsiveandwell-led.Weratedthe
caringdomainasGood.
• Therehadbeensomeimprovementstoincident
reportingandtherewerealsosomesystemsin
placetomonitorrisks.However,therewasa
lackofrobustprocessesandmanagement
oversighttoensurestaffhadlearnedfrom
incidentsorcomplaints.
• Therewereidentifiedrisksmissingfromtherisk
register,soitwasunclearwhatactionshad
beentakentomitigatetheserisks.
• Therehadbeensomeimprovementsinthe
maintenanceandcleaningofvehiclesandthe
replenishmentofequipmentvehicles.However,
therewasinconsistencyinwhatwasstoredon
vehiclesandwhereitwasstored.Storageof
someequipmentwasnotsafeandposedarisk
topatients.Therewerealsounsafevehiclesin
useandfaultreportingwasnotrobust.
• Insomelocalitieswefoundvehiclesecurityto
bepoorwhichwasarisktotheservice.
• Thereweresystemstomonitorqualityand
performance.Therehadbeensome
improvementsintheservice’sperformance
againstsomeofthekeyperformanceindicators.
However,concernsremainedregardingthe
performancetargetsnotbeingmetforsome
renaldialysispatientsandwithinthe
communicationsandcontrolcentre.
• Therecontinuedtobestaffingvacanciesinthe
communicationsandcontrolcentre.Thishada
negativeimpactonpatientexperienceand
otherstakeholderscontactingtheservice.This
alsohadanimpactontheplanningand
schedulingofpatients’returnjourneys.
• Thebusinesscontinuityplansforthe
communicationandcontrolcentrewerenot
welldevelopeddespiteactionsbeingidentified
fromatabletopexerciseinOctober2015.
However:
8 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
• Moststafftoldustheyfeltproudtoworkforthe
trust.Patienttransportservice(PTS)stafffelt
theirimmediateoperationalmanagers
supportedthemintheirrole,althoughthere
weresomereportsofadisconnectionbetween
staffandseniormanagers.
• Therewererobustplansinplacefor
fluctuationsindemand,staffingshortagesand
foradverseweatherconditions.
• Thecomplianceratesformandatorytraining
andstaffappraisalsshowedasignificant
improvementfromourlastinspection.
• Duringthecourseofourinspection,wesaw
examplesofstaffdemonstratingacaringand
compassionateapproachtosupporting
patients.Weobservedpatientsdignitybeing
maintainedandpatientbeingtreatedina
respectfulway.Wealsoreceivedsomevery
positivefeedbackfrompatientsandtheircarers
regardingthePTSstaffwhodemonstratedareal
commitmenttodeliveringagoodservice.
Emergency Overall,theservicewasratedasGood.Thiswas
Good –––
operations because:
centre
• Theemergencyoperationcentre(EOC)usedan
evidencebasedclinicaltriagesystemtoassess
patients.
• Theyhadaccesstoalanguageinterpreter
serviceandtextrelayserviceforpatientswith
impairedhearing.
• Paramedicandmentalhealthsupportand
advicewereavailable.
• Staffknewhowtoreportsafeguarding
concerns.Safeguardingreferralscouldbemade
24hoursadaythroughtheclinicalhub
• Staffinglevelswerescheduledandplannedon
anelectronicsystem,whichtookintoaccount
previousdemanddataandforthcomingevents.
• Governanceprocesseswereinplaceandthere
werecleargovernancestructures.Riskregisters
werereviewedandmanagementwereableto
describethecurrentriskstotheEOC.
• Thecultureoftheservicewasopenand
transparentandstafftoldustheyreceivedgood
supportfromtheirteamleadersandduty
managers.
9 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017
Summaryoffindings
Summary of findings
• Thetrusthadbeeninvolvedinanumberof
initiatives,suchas‘TheBlueLight’programme.
Theaimoftheprogrammewastoimprovethe
mentalhealthofstaffworkinginemergency
servicebyhaving‘BlueLightChampions’toact
assupporttostaff.
• Theservicewasoneoftheleading
organisationsinthepilotingoftheAmbulance
ResponseProgramme(ARP)introducedinApril
2016.ARPaimedtoimproveresponsetimesto
criticallyillpatientsbyensuringanappropriate
responsetopatientsfirsttime.
• Incidentswerereported,investigatedand
lessonslearntsharedwithstaffacrossthe
organisation.Althoughthemajorityofstaff
receivedfeedbackfromincidents,therewere
inconsistenciesassomestaffhadnotalways
receivedindividualfeedback.Thiswasalsothe
findingsatthepreviousinspection.
Howeverwealsofound:
• Notallstaffusingtheevidencebasedclinical
triagesystemwereuptodatewithbasiclife
support(BLS)training.Uptodatetrainingwasa
requisiteforalicenceintheuseofthesystem.
Followingtheinspectionthetrustwroteand
assuredCQCthatbythe1December201685%
oftheEOCstaffwouldhaveBLStraining.They
alsoinformedusthattheyhadrecentlybeen
re-accreditedbytheInternationalAcademyand
givencentreofexcellencestatus.Trainingon
BLSinstructionswithinthedispatcherrolewas
partofthecriteriaforre-accreditation.
• Notallnursingstaffwereuptodatewith
safeguardingtraining.
Resilience OverallweratedresilienceatYASasGood.Safeand
Good –––
planning well-ledwasratedasGoodandeffectivewasrated
asOutstanding.
• Wefoundgoodevidenceoflearningbothin
localandwiderresilienceteams.Thiswas
supportedbygoodsystemsforreporting
incidentsanddebriefs.
10 Yorkshire Ambulance Service NHS Trust HQ Quality Report 01/02/2017