Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Human Touch Ambulance Ltd 111-113 Spalding Road, Deeping St James, PE6 8SD Date of Inspection: 12 June 2014 Date of Publication: July 2014 We inspected the following standards in response to concerns that standards weren't being met. This is what we found: Management of medicines Safety and suitability of premises Safety, availability and suitability of equipment Supporting workers Met this standard Met this standard Met this standard Met this standard Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 1
Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activities Human Touch Ambulance Ltd Mrs Anita Human Human Touch Ambulance Limited is an independent ambulance service registered to provide transport services, remote triage and medical advice, and treatment required by the patients who use their services. Ambulance service Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Management of medicines 6 Safety and suitability of premises 8 Safety, availability and suitability of equipment 10 Supporting workers 12 About CQC Inspections 14 How we define our judgements 15 Glossary of terms we use in this report 17 Contact us 19 Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met. This was an unannounced inspection. How we carried out this inspection We carried out a visit on 12 June 2014, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services. We talked with commissioners of services. During this inspection we viewed provider's records and viewed ambulances., What people told us and what we found We undertook this review because of concerns alerted to us. The concerns related to drug management, the poor repair of some vehicles, lack of servicing on equipment used and lack of support for staff. We spoke with the managing director of the company, the general manager, the clinical lead and ten members of office and operational staff. In addition we spoke with the commissioners of the provider's services. Below is a summary of what we found when three inspectors visited Human Touch Ambulance Limited on 12 June 2014. The summary is based on our observations during the inspection and speaking with staff. We also looked at documentation. If you want to see the evidence supporting our summary please read the full report. We ask five key questions of services we inspect. Are they safe, are they effective, are they responsive, are they caring, are they well-led? Because this inspection was as a result of specific concerns we focused on two of those five questions; are they safe and are they effective? Is the service safe? The provider had a medicine management policy in place which followed NHS national prescribing legislation relating to possession, administration and supply of medicines. Medicines were stored securely and records were comprehensive. However, we found the access key to paramedic drugs was also stored with the same key for the ambulance technicians to gain access to ambulance technician drugs. This meant ambulance technicians had access to paramedic drugs. Following our visit we received confirmation a key press system was now in place to ensure access to paramedic drugs was limited to Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 4
that staff group. Drugs were disposed of appropriately and record keeping was comprehensive, which meant staff followed the provider's medicine policies and procedures. We saw there were systems in place where staff could identify any faults with vehicles. All paperwork relating to each vehicle was kept in separate folders. Some staff we spoke to felt faults were not always attended to quickly. Specific staff were employed to undertake deep cleaning of vehicles on a regular basis; they were trained to use the chemicals supplied to them for such purposes and followed the provider's policies and procedures.. We looked at four vehicles during our visit, one of which had ripped seats. This had been reported previously and the vehicle was awaiting repair. We spoke with a representative of the East of England Ambulance Service; this service uses the company to support their work. Between May 2013 and March 2014 there had been five incidents relating to vehicle defects which had been resolved satisfactorily. We looked at equipment on the four vehicles we saw during our visit. Some of it had not been serviced within the last twelve months as required; the provider rectified this within twenty-four hours; the provider responded to this within 24 hours. We saw supplies of consumable and non-consumable equipment was available and stored securely. Is the service effective? Staff received a comprehensive induction and on-going training to ensure patients who used the service received effective care. We saw appraisal and clinical supervision systems were in place for staff although 39 appraisals were overdue. The provider acknowledged this and responded to our findings by setting dates for overdue appraisals within two weeks of the inspection. Relations between some staff and senior management required attention. You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 5
Our judgements for each standard inspected Management of medicines Met this standard People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Reasons for our judgement We inspected the arrangements for the safe management and administration of medicines. The service had a medicine management policy in place which was current and followed NHS national prescribing legislation relating to possession, administration and supply of medicines. We saw a local pharmacy officer and representatives from both ambulance trusts, which commissioned services from the provider, had recently inspected the provider's medicine management and had been satisfied with their processes. We looked at the medicine records and saw that the service kept comprehensive records which included: the non-controlled drugs medicine batch number, the first expiry date of each medicine, supplier, delivery date, total stock held and when it was issued or disposed of. We saw recorded evidence of where medication was purchased, how and by whom. We found the controlled drugs did not have the drug batch number recorded within individual controlled drug record books which would facilitate good practice with audit purposes. We told the provider about this and received information from them that a system for ensuring drug batch numbers was recorded would be in place by 20 June 2014. Medicines were stored securely and appropriately within a locked cabinet in a locked room. However, the access key to paramedic drugs was also stored with the same key for the ambulance technicians to gain access to ambulance technician drugs. This meant those staff had access to paramedic drugs. Following our visit we received confirmation a key press system was now in place to ensure access to paramedic drugs was limited to that staff group. All medicines were within date and seals were intact. We saw a coloured tag system in use which identified using the colours red, amber and green against drug bags to easily Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 6
identify if the drug bag was fully stocked, required additional stock or the red tag identified that the bag should not be used. We inspected two medication packs which contained medicines that were authorised for paramedics and ambulance technicians to administer. All medications were within date and seals were intact. When a medication was administered this was recorded on the patient clinical record form with the authorised staff member's signature against each medicine that was administered. We saw that when necessary medicines were disposed of appropriately and arrangements were in place to witness and record the methods of disposal. All disposal records we looked at were up to date. This meant the provider followed their medicine management policies and procedures appropriately. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 7
Safety and suitability of premises Met this standard People should be cared for in safe and accessible surroundings that support their health and welfare Our judgement The provider was meeting this standard. People were protected against the risks associated with unsafe or unsuitable vehicles because they were maintained appropriately and identified faults rectified. Reasons for our judgement From the information at the provider's offices we saw the provider had 34 ambulances and six cars used for taking patients to out-patient appointments. Four of those vehicles were being used for transporting patients in the Norwich area; the vehicles used in Norwich were rotated depending on the servicing needs of the vehicles and the provider's responsibility to the commissioners of their services. Five of the ambulances were rented. The general manager informed us each vehicle undertook approximately 80,000 miles a year. The vehicles ranged from between five and nine years old. We were informed that because of the prohibitive cost of purchasing new vehicles, the provider had short, medium and long-term plans for replacing their fleet of vehicles. Three new hire vehicles were due to arrive on 27 June 2014 to undertake patient transport service duties. 21 vehicles were high dependency vehicles, four were rapid response vehicles and 17 were patient transport vehicles. During our visit four of the vehicles were awaiting disposal and five were not in service due to mechanical faults; these had been booked into the workshop and were awaiting the relevant parts to be fitted. The provider employed three full-time mechanics to service and repair the vehicles. Sometimes vehicles were required to be repaired by external workshops. We saw there were systems in place where staff could identify any faults with the vehicles, for example a light not working. There was a clear audit trail which identified who had repaired the fault and when. We saw all paperwork relating to each vehicle was kept in separate folders, for example repair work carried out, servicing history and MOT certificate. Following our visit we spoke with five members of staff who used the vehicles to transport and treat patients. We asked them about repairing faults on vehicles. One member of staff told us, "The driving seats have collapsed on a lot of the vehicles. These were reported a few months ago but nothing has been done yet." We spoke with the general manager about this who informed us only one issue with a seat had been reported. The seat had been replaced and they were awaiting the return of the newly upholstered seat. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 8
Another member of staff told us, "Some of the vehicles have mechanical issues that crop up quite regularly." A third member of staff informed us they had to use a faulty vehicle on two or three occasions in the previous 18 months. The provider may wish to note that all reported faults should be attended to in a timely manner to ensure staff and patient safety. The provider employed people called 'make ready operatives' to ensure vehicles were ready to be used. We looked at the area used for deep-cleaning vehicles and found all vehicles were deep cleaned on a monthly basis. All cleaning materials used under Control of Substances Hazardous to Health (COSHH) regulations were stored appropriately and safely. Employees who used them were trained to use them and there was a clear system of work in place. This meant staff followed infection prevention and control procedures appropriately. We looked at four vehicles during our visit. We found one of the vehicles had ripped seats. We brought this to the attention of the general manager. This had been reported previously and the vehicle was awaiting repair. Two days after our visit we received confirmation this had been rectified. We asked the two main commissioners of the provider's services about their opinions of the service provision. East Midland's Ambulance Service (EMAS) told us they had no concerns. East of England Ambulance Service (EEAS) gave us a number of documents related to the service and we saw between May 2013 and March 2014 there had been five incidents which related to vehicle defects which had all been resolved satisfactorily. We were informed by senior management and staff alike it was the crew's responsibility to ensure the vehicles were fit to be used before they left the depots. We saw the comprehensive check lists that were used for this purpose for four vehicles picked at random. A member of senior management informed us they had changed the system recently to ensure staff only signed for items they had personally checked. This meant the provider had a robust audit system in place to ensure vehicles were able to be used safely. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 9
Safety, availability and suitability of equipment Met this standard People should be safe from harm from unsafe or unsuitable equipment Our judgement The provider was meeting this standard. People were protected against the risks associated with unsafe equipment because generally it was stored and maintained appropriately. Any identified unsafe equipment was removed from use. Reasons for our judgement We looked at equipment on the four vehicles we saw during our visit. We saw five items had not been serviced within the last year, for example a carry chair had last been serviced in November 2011 and a suction unit's service had been due in June 2013. The rest of the equipment we saw had been serviced within the last twelve months as required. We saw some intravenous fluids were not stored securely on one vehicle and on another alcohol hand gel was not available. The provider informed us the vehicles had not undergone their pre-shift checks when these issues would have been identified. On a third vehicle we found electrocardiograph (ECG) electrodes stored in the open air which can affect the quality of an ECG trace. The provider may wish to note ECG electrodes should be stored in an air tight container when the pack has been opened. We looked at equipment grab bags for paramedics. The provider had a system whereby bags were securely tagged and checked by an operations manager, the crew then signed out the bags and signed them back in on return. We opened one bag and found that the sphygmomanometer (blood pressure machine) had not been serviced; it had expired in August 2013 and was therefore not calibrated. This meant that blood pressure readings could be incorrect. We told the provider about our findings who immediately took action to rectify the issues. Four days after our visit we spoke with the company who serviced the equipment. They informed us they had visited the day after our inspection to repair and service items. We had seen the report from the company dated 21 October 2013 which identified almost 200 pieces of equipment that had been serviced satisfactorily. The company representative informed us they had to visit the provider's premises on a number of different days to ensure they completed their work because of the availability of the vehicles. We saw items of equipment requiring repair were identified and placed in a specific area stating they were not to be used. This meant staff were following the provider's policies and procedures for identifying faulty equipment. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 10
We spoke to five members of operational staff. One of them told us, "I have got no issues with the equipment." Another told us "I never have to work with equipment that doesn't work properly." We were informed by senior management and staff alike that it was the crew's responsibility to ensure there was sufficient equipment for the shift on the vehicles before they left the depots. We saw supplies of consumable and non-consumable equipment in a lockable store cupboard. This meant the provider had processes in place to ensure vehicles were adequately equipped. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 11
Supporting workers Met this standard Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. Staff were supported to deliver care and treatment to people safely and to an appropriate standard. Communication and relations between some members of staff and senior management required attention. Reasons for our judgement We looked at documentation, training schedules and appraisal rates for staff employed by the service. We also spoke with staff and the provider. The company employed 162 members of staff. Some people were employed on a full-time permanent basis, whilst the majority of staff undertook bank work. Bank workers undertook shifts on an occasional basis. We saw the provider's staff handbook issued in November 2013. It was a comprehensive document and covered such issues as code of conduct, health and safety and the company's whistle-blowing policy. All new employees took part in a five day induction. Staff working on patient transport service vehicles (PTS staff) undertook a three day first aid at work or first person on scene course; this meant they were able to care for people who required first aid. An additional two days included the company's appraisal system, occupational health screening, health and safety, infection prevention and moving and handling. We saw further training was available including supervised practice sessions. The paramedics employed by the provider joined the company as fully qualified personnel. If the company required staff with additional training, courses were paid for. If staff wished to further their own career or undertake continuing professional development, individuals paid their own course fees. Staff employment contracts provided clear information about continuing responsibility of training fees. The provider arranged mandatory training for all members of staff on an annual basis. Additionally monthly training sessions were provided for staff who wished to attend; courses included safeguarding vulnerable people, resuscitation and spinal board immobilisation. We were given information about 14 members of staff who had been able to progress in the company over the previous eighteen months and were able to work on high dependency vehicles instead of patient transport service vehicles. The company had Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 12
funded the courses and the employees had attended in their own time. The appraisal system and the system used for undertaking clinical supervision for staff were satisfactory. However, we saw that 39 members of staff required an annual appraisal. Of those, some had not had an appraisal since they had commenced their employment. We told the provider about our findings. They told us they knew appraisals required attention. Three days following our visit we were informed of the dates of staff appraisals that were overdue; the majority were within the following two weeks. Other staff members had been emailed for available dates. Since our visit the provider has informed us appraisals are compulsory for all members of staff. When we spoke with staff about their line manager, one person said, "I think it is (name of the person) but not sure, have very little contact with head office, not spoken to them." Another person told us, "I think (name of the person) but I do not know. They have never introduced themselves to me." A third member of staff knew who their line manager was. We saw the providers newsletter dated 28 January 2014 which had been emailed to all staff. It clearly explained who the staff's line manager was. The provider informed us line managers were identified to new employees during their induction. We also asked five members of staff if they felt well supported by the senior management of the company? One person said, "Yes, I am not somebody who has issues." Another person said," No I don't. I do not feel supported or valued." A third person told us they felt well supported. We discussed the differing staff opinions with the provider. They informed us they were aware of the negative feelings among a small number of of staff. They had asked those staff for their help to address the issues but they had declined. We discussed staff meetings with senior management. They informed us it had been difficult to encourage staff to attend meetings but they had recently set up a staff forum using elected representatives. We saw the minutes from the first two meetings in March and April 2014. Items included business re-organisation, contract changes for the provider, moving and handling issues and continuing professional development. The date of the next meeting had been arranged. We were informed by some staff there were no minutes of the meeting for them to see. However the provider told us they were available for all staff to view on staff notice boards but that in future the minutes would be emailed to staff following each meeting. One member of staff told us, "The rep we voted for left and then management told us who our rep was. We therefore do not have any confidence that our issues are going to be addressed properly." When we spoke with the provider about this they informed us the representative was the member of staff who had received the second largest number of votes. The provider may wish to note that further efforts are needed to ensure open communication channels and meaningful dialogue exists between management and operational staff. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 13
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 14
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 15
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 16
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 17
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 18
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Human Touch Ambulance Ltd July 2014 www.cqc.org.uk 19