Pro Medicus

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders did not always demonstrate the skills and abilities to run the service. Leaders did not operate effective processes for governance, information management and the management of risk, issues and performance. Policies were generic and did not reflect up-to-date national guidance. However, Staff were in the process of change and transition at the time of our on-site visit and they were keen to improve systems and processes. During our assessment, we found concerns which resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered managed did not demonstrate full oversight of the service provision. For instance, the registered manager did not understand the regulatory duties, did not provide statutory notifications, or ensure policies were in line with national guidance. The registered manager was unable to source relevant documentation to evidence a good governance framework, systems, and processes. The registered manager was not able to demonstrate knowledge of key performance indicators and was unable to provide information about the service's strategy or business plan. The registered manager acknowledged that the management of the service had been delegated to other staff and this had impacted on their oversight of the service. When concerns were identified during our assessment process, there was an occasion where a member of staff in a leadership position attempted to identify the members of staff involved, in order to undertake punitive action.

The service was led by the registered manager, who was an experienced ambulance technician. The registered manager had been in post since the service opened in 2004. The registered manager was supported by the medical director, and administrative staff. The registered manager regularly worked operationally. This had resulted in a lack of attention to the management of the service and to governance processes. As a result, there had been limited progress made against the concerns identified at our last inspection in 2022. There was no infection prevention and control lead within the service. This meant that the service did not have clear roles and responsibilities around infection prevention and control. There was no clear framework of accountability to help reduce risks, improve performance, and ensure compliance with regulatory frameworks. There was no clear business strategy to help the leadership outline their goals and objectives.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff acknowledged that further work was required to improve the governance and management processes in place. Staff were in the process of change and transition at the time of our on-site visit and they were keen to improve systems and processes.

The service did not operate effective processes for governance, information management and the management of risk, issues and performance. The audit process of the service was not robust enough to determine if the service was doing well and what improvements could be made. For example, staff did not carry out audits to measure the effectiveness of medicines management, monitor the environment or equipment, or hand hygiene. There were gaps in the completion of some audits and it was not always clear that actions were taken in response to concerns identified during audits. The service had not identified all relevant risks which arose from the carrying on of the regulated activity. There was no evidence that risks were regularly discussed and reviewed at management meetings. There was no evidence that any management meetings have taken place since August 2023. The management meeting minutes that were provided did not give assurance that key topics such as performance data, audit outcomes, quality metrics, and risks were covered at each meeting. We could not be assured that there was effective participation in external reviews, and that learning was shared effectively and used to make improvements. We were not provided with the report from the most recent compliance audit undertaken by the local NHS (National Health Service) ambulance trust, or any action plan linked to this. Arrangements with partners and third-party providers were not always governed and managed effectively. We were not provided with evidence of a contract, meetings or performance monitoring for the patient transport service work undertaken for a local hospital trust. Policies were generic and did not reflect up-to-date national guidance or a framework for consistent decision-making and action. There were not always effective arrangements to ensure that data or notifications were submitted to external bodies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.