East of England Ambulance Service NHS Trust

Our rating of the trust stayed the same. We rated it as requires improvement because:

• Well-led was rated as inadequate. We rated safe and effective as requires improvement, caring as outstanding and responsive as good.
• We rated two of the trust’s three services we inspected as requires improvement and one as good. In rating the trust, we took into account the current ratings of the core service we did not inspect.
• The services still did not have enough staff to care for patients and keep them safe despite a focus on recruitment and retention. Not all staff consistently received mandatory training and although the trust provided updated information after our inspection that demonstrated some improvements, this was a continued breach of regulations. There was a continued breach of regulations in relation to medicines being managed safely.
• Staff did not receive regular appraisals and systems in place to ensure that staff were competent for the roles continued to be inconsistently applied across services. People continued to wait too long for services and response times although improved, continued to be worse than the England average.
• The rating for well-led had declined from requires improvement to inadequate. There continued to be a mixed culture at the trust and not all staff felt that concerns were listened to. There was instability within the senior leadership team with some key leaders in interim positions. The recently implemented strategies and initiatives developed to improve performance, governance and staff welfare were yet to be embedded. Whilst the quality of services had not declined and there were signs of improvement in specific areas there were continued breaches of regulations.

However:

• The trust had continued to work with system partners to improve handover delays at hospitals. Performance in handover delays had improved since our last inspection. The trust continued to work with external partners to develop pathways of care for patients.
• Managers monitored the effectiveness of the service. Performance in some clinical quality indicators had improved since our last inspection.
• Senior leaders were aware of the challenges to providing quality sustainable care and were in the process of developing actions to address them. This was because of the significant changes that had occurred in the senior leadership team in the 12 months prior to our inspection.
• The new interim chief executive officer had been in position since November 2018 and had a positive impact in empowering staff at all levels to develop the trust strategy to drive improvements and achieve the trust’s vision.

Our rating of this service stayed the same. We rated it as requires improvement because:

• We rated safe, effective, and well led as requires improvement, responsive as good and caring as outstanding.

• Safe staffing levels were not consistently achieved across the whole service. Some areas utilised resources to ensure that patient facing hours were achieved, however some areas did not achieve the same.

• The service provided mandatory training, including safeguarding training; however, not all staff completed. This was highlighted as an area of concern at our previous inspection. Average compliance across all staff groups was 75% against a trust target of 95%.

• There continued to be inconsistent medicines management systems across the trust. There were variations of medicines management across the service. This presented a potential risk as medicines bags were often restocked at different stations to where they originated, meaning that the contents and the way the medicines were dated could be misinterpreted.

• Patient group directives, which allow paramedics to administer certain medicines to a group of patients such as paracetamol to patients experiencing pain, were mostly out of date by approximately one month at the time of our inspection. This was escalated on inspection and the service was taking measures to update these.

• Staff mainly kept vehicles, themselves and equipment clean. However, sharps bins were not always labelled when they were opened. This meant staff could not be sure how long the bins had been in use. This represented a potential infection and prevention control risk.

• Response times were consistently not met. Although the service was trying different initiatives to improve this such as increasing the number of double manned ambulances and reducing the number of rapid response cars. This meant that patients did not always receive care and treatment in a timely manner.

• Staff development and competence was inconsistent across the service. Appraisal and induction rates varied across the service, as did staff development. In some areas staff told us they had requested and been granted development training in different skills. However, in other areas staff felt frustrated at the lack of development opportunities.

• The 15-minute best practice target times for hospital handovers was not consistently achieved, with average times ranging from 18 to 33 minutes. This meant that patients being conveyed to hospital sometimes had to wait with ambulance staff for some time before having their care handed over to hospital staff.

• The service took approximately 20 additional days to investigate and close complaints than the trust’s policy on complaints management set. This meant that patients were waiting excessive times for resolutions to any complaints they had raised.

• Whilst culture and morale had improved from our previous inspection, many staff were unsure that the present changes would last. Staff also told us that whilst they felt supported and valued by their local leaders, they did not believe their opinions mattered to senior leaders.

• Whilst we saw good local oversight of performance, governance and risk management, we did not see adequate scrutiny, management and representation of these factors at corporate or senior level.

However:

• Throughout our inspection we saw several examples of positive change being trialled and in some cases freshly implemented. These changes were implemented after the appointment of the trust’s interim chief executive officer approximately six months prior to our inspection. Examples of these changes include a restructure of the local leadership roles and responsibilities, the introduction of the people and vehicle support hub which improved late finishes for crews, and the introduction of safety huddles for all staff on every shift.

• Whilst the majority of service changes were yet to be fully embedded, the service was actively monitoring performance and initial results showed improvements in relation to many aspects such as staff morale, visibility and support of local leaders, and a reduction in the number and length of late finishes for crews.

• Whilst safeguarding training rates were not meeting trust target. We found an improvement in awareness of safeguarding concerns and recognising abuse.

• National guidelines and trust guidelines continued to be used in aspects of patient care and patient care records were consistently well managed.

• The service performed the same as or better than the England average for many recorded patient outcomes. There were examples of effective multidisciplinary working with both internal and external partners in care. Staff understood the principles of consent.

• Staff consistently provided care and treatment for patients in a way that was compassionate, supportive, informative, respectful, maintained their dignity and involved them in their own care.

• Oversight of the service demand and capacity was present at both senior and local levels. The service planned resources in advance and worked with other professionals such as private ambulance services and community first responders to cover both rural and urban areas.

• A recent leadership restructure had led to local leaders being more visible and supportive to their staff, and staff told us they felt well respected and supported by their local leaders.

• Culture and morale amongst staff was improved from our previous inspection, although staff were concerned that the temporary nature of the leadership team could impact on progress in this area.

• Local leaders had good oversight of their teams’ performance, wellbeing, and local service risks.

Our rating of this service stayed the same. We rated it as requires improvement because:

We rated safe, effective and well-led as requires improvement. We rated responsive and caring as good.

• Mandatory and safeguarding training rates still remained significantly below the trust targets. Compliance rates varied across regions and ranged from 26% to 76%.

• Appraisal rates and access to comprehensive frontline induction continued to be inconsistent across the service.

• The service took approximately 22 additional days to investigate and close complaints than the trust’s policy on complaints management set. This meant that patients were waiting excessive times for resolutions to any complaints they had raised.

• Whilst culture and morale had improved from our previous inspection, many staff were unsure that the present changes would last. Staff also told us that whilst they felt supported and valued by their local leaders, they did not believe their opinions mattered to senior leaders within PTS.

• Whilst we saw good local oversight of performance, governance and risk management, we did not see adequate scrutiny, management and representation of these factors at corporate or senior level.

• Whilst performance for collection and drop-off times for patients had improved since our last inspection, the service was still not meeting performance standards set by their commissioners.

However,

• Staff knowledge of safeguarding and incidents

• Infection prevention and control was well understood, complied to and audited throughout the service. Ambulances, cars and ambulance stations were well equipped and properly maintained. The design, maintenance, and use of facilities, premises, and equipment kept people safe.

• Staff understood consent and we saw examples of staff ensuring they gained consent throughout patient journeys by informing them and respecting their choices.

• Staff consistently provided care and treatment for patients in a way that was compassionate, supportive, informative, respectful, maintained their dignity and involved them in their own care.

• Oversight of the service demand and capacity was present at both senior and local levels. The service planned resources in advance and worked with other professionals such as private ambulance services and volunteers to cover all geographic areas they were commissioned for.

This is our first time inspecting the core service and rating this service. We rated it as good because:

We rated safe, effective, responsive as good and well led as outstanding. Due to the nature of the service we did not see any patient care and have not rated caring on this occasion.

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment to patients and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients.
• We did not rate ‘caring’ as we were unable to observe caring interactions between staff and patients and gather enough evidence to make a judgement. Although we were able to review a number of extremely positive feedback comments from patients and external partners.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported all staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Leaders were visible, all staff felt respected, supported and valued. They were focused on the needs of patients receiving high quality standards of care. Staff were clear about their roles and accountabilities. The service engaged well with patients, external agencies and the community to plan and manage services. All staff were committed to improving services continually.

However:

• The service did not receive feedback from the trust electronic patient records audit.