Yormed Ambulance Station

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

On CQC’s last inspection in November 2023, it rated Effective as RI. On this inspection Effective was rated Good. Staff delivered good care and treatment following evidence-based practice and people had good outcomes. They followed and adhered to best practice guidance and standards. Staff coordinated, collaborated and shared information about patients with partner organisations where appropriate. The service had systems in place to monitor clinical outcomes for patients. PTS staff gained and fully recorded all patient’s consent to care and treatment.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Office staff assessed patient’s needs on the transfer booking form. PTS staff then verified these to identify any further requirements.

The service had a booking system in place. Providers contacted office staff to book transfers. Staff assessed patients to confirm if they needed any specialist equipment such as a bariatric stretcher.

CQC reviewed the service’s monthly management meeting minutes for February 2024. These minutes stated staff had completed 415 jobs during the month. These were mostly patient transport service (PTS) for the service’s contracted regional NHS ambulance service. The service completed five PTS transfer jobs in July 2024 which met their key performance indicators (KPIs). All were clear and on time. However, PTS work had reduced. Staff only completed three PTS jobs in September and one in October 2024. PTS staff often received carry chair jobs with discharged patients from contracted NHS ambulance services. Managers reviewed all related case notes from their carry chair jobs to ensure best practice in accordance with equipment manufacturers.

On CQC’s last inspection in November 2023 the service failed to demonstrate there were systems in place to evidence how they monitored the effectiveness of the service. On this inspection CQC found the service better monitored their effectiveness through audits, patient assessments, and performance compliance reports from contractors. PTS staff used and completed patient decision aids (PDAs) for their regional NHS ambulance service jobs as per NICE guidance.

Staff fed back positively about how appraisals were scheduled. The registered manager confirmed the staff policy on how staff were assigned shifts. The registered manager considered PTS staff welfare. For example, they advised and encouraged drivers not to work second jobs and to rest in between shifts which could run over time. This complied with their service’s health and safety policy. Most PTS staff were on the bank and did not work full time.

The service worked with partner providers to ensure PTS staff clearly recorded, assessed and monitored all patient’s needs. Office staff noted all relevant details when referred patients from contractors to ensure they were fully supported with an effective transition. The CQC published their last report in February 2024 with an inadequate rating overall. Managers initiated calls with all commissioners also rated inadequate or ‘requires improvement’. They offered to suspend services. One organisation rated ‘requires improvement’ at the time did suspend their working. However, a regional NHS foundation trust (FT) confirmed since February 2024 they had used the service’s PTS 12 times, most recently on 29 August 2024. Managers sent providers a copy of their action plan for assurance the service had addressed all breaches. Managers and staff had forged good relations with commissioners. They hoped to resume and increase regulated activity under PTS once re-rated.

All staff were competent and completed training relevant to the patient cohorts they cared for. For example, staff completed modules on mental health awareness, dementia, autism and learning disabilities (Oliver McGowan) through e-learning for healthcare (eFH). PTS crews were trained in manual handling and experienced in dealing with patients with intensive support.

All PTS staff had appraisals. Managers explained how their appraisals process had become more comprehensive to cover absence, training and learning needs, staff’s own assessment of their skills, knowledge and statements of understanding, achievements, improvements, objectives setting to support areas of focus, and a declaration. Managers reviewed how many shifts staff had covered. CQC reviewed all six PTS staff’s annual appraisals and competency assessments. All followed the same format, were in date and order. The service had an assessment of competence form with a competency profile for all PTS staff detailing essential and desirable criteria. Poor performance was assessed and acted upon. Manager followed guidance in the initial process as per their disciplinary policy. Managers spoke to staff, investigated any issues, and where relevant assigned themself on shifts with the staff member to address any operational shortfalls directly. At the time of CQC’s assessment the registered manager was the only PTS driver.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service undertook performance audits and implemented actions from the results to ensure staff met their contractual obligations. For example, the service’s office staff had undertaken a monthly data analysis audit. The audit analysed the efficiency, effectiveness and overall performance of services. It also ensured response times were kept to a minimum. The audit covered all their PTS jobs for the seven months from 1 November 2023 to 31 May 2024. During this period, they completed 2,709 patient journeys. Only four of these journeys did not meet their contractual obligations. Three were ward cancellations beyond the service’s control. The audit’s action plan implemented a procedure for staff to call the ward pre-arrival to ensure patients were ready to leave. Results were relayed to ambulance crews. The service completed 786 transfers during their busiest month of the last year in November 2023. The service had a data analysis plan for 2024. The plan’s objective was to identify any areas for monthly improvement with their main commissioner; a regional NHS ambulance service. The plan had seven key lines of enquiry (KLOEs). Results overall achieved 100% or outstanding in six of these, and 96% in training, health and safety. This NHS ambulance service contractor sent the service copies of reports with their response times until their contract ended in February 2024. CQC reviewed the last report from April to September 2024. This had an overall initial red, amber, green (RAG) rating of Good or outstanding with 99% compliance.

The service completed 293 PTS journeys in the five months from 1 February to 30 June 2024. Journeys reduced in the few months before CQC’s assessment. This meant their sample for monitoring and improving outcomes was limited. Managers reviewed and ensured the service met all their key performance indicators (KPIs) and targets. Wherever possible managers sought their contractor’s performance data to monitor and improve patient outcomes. Driver staff received their dashboard driving summary upon logging into their smartcam. Managers received monthly driving performance reports, with top ten scoreboards based on yesterday, last week and last month. This helped managers address driving non-compliance immediately.

Managers and staff considered and recorded consent at all stages of the patient pathway. Staff recorded patient’s written consent on all paperwork and internal forms. They sought patient’s verbal consent before giving any care and treatment.