Yormed Ambulance Station

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

On CQC’s last inspection in November 2023, it rated Safe as Inadequate. On this inspection Safe was rated Good. Managers encouraged staff to raise concerns when things went wrong. Staff provided continuity of safe care and treatment to patients of all ages. Staff fulfilled and understood safeguarding requirements appropriate for their role and responsibilities. Staff managed and involved patients in discussions around risks, including clinical, to review and assess them. The service had staffing levels to meet the needs of their patients. The premises and equipment were appropriate for the service being delivered. All service areas were clean, monitored and audited for cleanliness. All staff were appropriately trained in medical gases administration.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff had achieved the service’s statutory and mandatory training (SMT) target of 100% during CQC’s assessment. SMT consisted of basic life support, data security awareness, handling information, infection prevention and control, information governance and data protection, resuscitation for adults, paediatric and newborn patients. Staff complied with the service’s mandatory training development policy. CQC reviewed all SMT certificates for PTS staff. SMT was audited monthly; CQC saw this had been done for every month in 2024. PTS staff also completed and refreshed all their care certificate training (CCT) standards every three years and were reminded before any expired. Managers ensured the training was relevant to staff’s needs. They had added the Oliver McGowan learning disabilities and autism training module. Managers identified any training needs their staff had and gave them time and opportunity The service’s governance and compliance lead was patient safety incident report framework (PSIRF) and incident investigation trained with an external training company. The governance and FTSU leads had set up separate private companies for investigating incident reports. They worked as a contractor with other NHS and IH ambulance providers to share wider learning from incidents and complaints. Examples include always having drinks onboard as patients could often be dehydrated (waiting long periods in a discharge lounge). Managers shared learning with their staff about incidents that happened elsewhere. For example, at external and contracted partner organisations. Their biggest learning had been shared with regional NHS ambulance services. This followed an incident where an elderly frail patient removed their safety belt before the vehicle had stopped. The service adopted learning to change their process in response to a similar incident at another service which resulted in death. This was covered on staff induction as learning from an incident.

The service had an incident reporting policy. The policy outlined incident reporting procedures, levels and timescales of investigation. There was a risk assessment matrix staff followed which determined risk score grades of low, moderate, high or extreme for each incident. Incidents scored as 8 or above were investigated by an external governance provider and the registered manager. The service was involved in one incident in the 12 months since CQC’s last inspection in November 2023. CQC reviewed this incident report from January 2024. This resulted in severe clinical harm to a cyclist hit by a car. Patient transport service (PTS) crew were flagged down and provided care and reassurance whilst awaiting an ambulance. The crew completed all necessary actions until handover to emergency paramedics. In response, managers gave other staff feedback on attending an incident in a supportive capacity. Staff reported incidents promptly to managers and relevant external bodies. Staff carried hard copy incident report forms on PTS vehicles for any which occurred in the field. Managers ensured staff had protected time to complete forms as soon as possible after a reportable incident. PTS staff complied with the service’s driving policy by promptly reporting any driving incidents to managers which could appear on their licence or disclosure and barring service (DBS). Managers would follow the disciplinary process if staff failed to do so. All incidents were discussed at the monthly management meeting. These minutes were used to track actions. Managers discussed and documented themes and trends, as well as any actions taken to reduce incidents in the future. They decided upon the organisational learning to share with staff at this meeting. Investigation leads ensured the staff member who raised the incident was given relevant feedback. Managers also discussed incidents which had occurred in other private ambulance services and NHS ambulance trusts with relevant learning.

Managers and office staff monitored all drivers through a road safety app. This displayed various dashboard metrics such as harsh braking, and a 10% threshold for speeding (as speedometers were not calibrated). The app recorded any idling time over three minutes. This helped drivers be more fuel efficient, as fuel was the service’s second biggest expense. Managers tracked all vehicles using a telemetric system based on virtual desk infrastructure (VDI) from the road safety manager app. This was a camera-based tool which scored staff’s driving. The app listed all vehicle-specific metrics including consumables in date. The app worked by geofencing so would not allow crew staff to progress to the next pre-shift checks until they had physically moved around the vehicle. Drivers could photograph any vehicle defects. Managers could replay all video events to determine the cause of any accident or incident. They explained the app helped improve road-related safety and reduce any incidents.

PTS staff kept patient records secure and up to date. They used transfer report forms (TRFs) for most contracted transport jobs.

At the last inspection in November 2023, CQC's lead inspector could not evidence the service's designated safeguarding lead had received the correct level of training with the service. However, externally they were trained to safeguarding level 5. At this inspection the designated safegaurding and governance lead and Freedom to Speak up Guardian (FTSUG) were both trained to level 5. As they were external to the service, the senior administrator had been trained to safeguarding level 4. Staff could directly access these individuals, for support and advice on any safeguarding matters. The registered manager and other PTS staff were level 2 trained in safeguarding adults and children as part of their induction and statutory and mandatory training. CQC reviewed a safeguarding report form from October 2023. PTS staff reported this on the Matrix reporting system. They followed the service’s safeguarding policy and recorded any foreseen associated risks. For example, they liaised with their regional NHS ambulance service contractor to organise a care package for a patient with mobility issues and no social worker.

The service had well established partner working and contacts around safeguarding with their contractors and local authorities. Most of their safeguarding cases were passed onto the relevant teams of their contracted NHS ambulance trusts. This meant often staff did not directly report to the local authority.

The service required staff to complete the full care certificate which covered MCA and DoLS modules. Staff had not carried out any capacity assessments since February 2024 when transferring patients from the regional NHS ambulance service. Office staff flagged any capacity needs for patients at the booking stage. The service’s office contained information to advise staff who to contact with safeguarding concerns. Staff followed a safeguarding flowchart for action regarding children and vulnerable adults if they had concerns about their welfare. This included relevant local authority contacts, including out of hours. For out of area safeguarding concerns, staff referred to the NHS safeguarding app available on their devices. Staff had protected time to complete safeguarding referral information.

The service did not transport any high-risk patients at the time of CQC’s assessment. Staff used a dynamic risk assessment for any patients with specialist needs. For example, in the past staff had transported patients with mental health needs, dementia, autism and learning disabilities. They ensured at least one parent, carer or chaperone accompanied the patient during transfer. Staff had the knowledge and skills to safely and supportively meet the needs of patients. In the past they had transported a young patient with highly complex needs who required specialist equipment and emergency medication. PTS staff facilitated their relative administering a suction unit onboard. CQC were assured staff could manage risk and emergencies. They could recognise and respond to patients at risk of deterioration during transit. Staff could accommodate bariatric patients under the maximum limit of their heavily weighted stretcher. They could assign an extra crew member, or a second crew to these jobs if needed. The service had also previously transferred some end-of-life care (EOLC) paediatric patients from a regional acute trust’s children’s hospital to hospice or home.

PTS staff completed basic life support and resuscitation for adults, paediatric and newborn patient modules as part of their statutory and mandatory training. All staff were red flag sepsis trained to recognise and identify symptoms. Transfer report forms (TRFs) were initially completed by office staff over the phone. They gained as much information as possible to risk assess patients. Staff always included the date and time the booking was made on the TRF and considered medicines under ‘other information’. The registered manager then completed the form as an ambulance crew member. Staff followed the service’s health and safety policy which outlined the risk assessment process, including manual handling. Office staff would call the hospital for longer distance jobs to confirm medications were ready for the patient upon the PTS vehicle’s arrival. Staff added all relevant information to TRFs to ensure patients were promptly returned to their place of care. For example, they noted patient’s ward number and two contact numbers for the clinical site or bed managers post transfer.

Staff covered the correct use of all specialist equipment as part of their induction with a senior staff trainer. On induction PTS staff’s carry chair training involved demonstrations and staff being carried on the chair to experience from the patient’s perspective. Managers had completed numerous moving and handling training courses. They only used certified and accredited external trainers to ensure their competence. During CQC’s assessment, the registered manager was the only staff member carrying out moving and manual handling training. Staff also carried out daily, weekly and monthly environmental checks in accordance with their amount of regulated activity. This ensured the service adhered to regulation 15 requirements. CQC reviewed the latest check from 14 October 2024 and found all areas were compliant.

At CQC’s last inspection in November 2023 the service failed to ensure all areas of the operational environment were safe and free from hazards. We served a requirement notice under regulation 15 premises and equipment. At this inspection CQC found no environmental breaches or concerns. All medical gases on the premises such as oxygen cylinders were stored correctly, upright and chained in locked cages with hazard signs. There was no flammable or electrical equipment nearby. The control of substances hazardous to health (COSHH) cabinet was clearly labelled and locked. All oxygen and fire extinguishers onboard vehicles were securely fastened, tagged, annually checked and within expiry date. CQC inspected two patient transport service (PTS) ambulance vehicles which managers had purchased after the last inspection. Both vehicles were up to specifications with all suitable equipment onboard. No faults or issues were found. The service maintained asset registers for each PTS vehicle’s specialist equipment and when it was next due for service. Ambulance and specialist bariatric stretchers were serviced, suitable and available for use. All confidential waste was shredded in line with data protection requirements. The service had a contractor for confidential waste collection. Staff could request disposal if bins were full before the due collection date.

All consumables were stored on the two PTS vehicles. Staff disposed of any expired stock towards charity appeals in Pakistan and more recently Ukraine. Staff used digital tools to ensure they safely transported patients in accordance with the Highway Code. Drivers used the road safety app during shifts to ensure full vehicle compliance. They used an employee time tracking app for clocking in and out of shifts. Clinical engineering services completed annual vehicle checks. The main dealers of ambulance vehicle manufacturers completed vehicle health checks. The service monitored these checks on an asset register. Contractors for any spare vehicle work like handbrake checks and oxygen lines were completed bi-monthly onsite. Wherever possible the service reverted to the original vehicle manufacturer’s main dealer or equipment manufacturer for routine annual servicing. For example, defibrillators and stretchers were returned to their manufacturer for periodic checks. This was more costly but ensured the service covered everything.

The service was only undertaking a small number of patient transport journeys during CQC’s assessment. The PTS employed six staff; the registered manager, senior administrator, a paramedic and three emergency care assistances, trained to level 4 certificate in first response emergency care (FREC4). Due to very limited NHS work, the PTS staff were mostly on bank shifts and two were employed on the payroll. The service’s biggest contract with their regional NHS ambulance service meant staff staggered shifts across six ambulances a day until February 2024. This left the registered manager scope to move staff onto later shifts if necessary. The service encouraged staff to pursue continuing professional development opportunities. For example, two paramedics had qualified from the service’s apprenticeship scheme under an external clinical training provider (FREC3 and above).

At CQC’s last inspection in November 2023 the service failed to ensure there were systems in place for the proper and safe recruitment of staff. At this inspection CQC found systems in place to ensure the service properly and safely recruited staff. For example, managers had implemented a recruitment policy which staff followed. Managers gave all new staff a full induction tailored to their role. This consisted of completing the relevant NHS E-learning training modules of all statutory and mandatory training within four weeks. PTS staff had to complete the care certificate within 12 months. This was a mandatory requirement when recruiting staff. Managers recognised completion was time-consuming, so they encouraged staff to progress at the right pace for them, and complete training in smaller sections. New recruits shadowed over the year including on ride-along journeys, audits, spot checks and record keeping. Office staff kept a personnel file of all training the new staff had completed. Managers reviewed this annually. The service only recruited PTS staff or emergency care assistants (ECA). The service’s training and development policy covered their induction process. Managers could deliver this as a group intake or on a one-to-one individual basis. Their five week classroom-based apprenticeship scheme was very tailored. ECA inductions were paramedic-led. However, the service had not recruited since CQC’s last inspection, as they had downsized due to less regular contractual PTS work.

The service had utilised a deep cleaning company service since February 2022. The company carried out pre and post swabbing at the registered location. They shared their deep cleaning reports with service managers after all scheduled deep cleans. The CQC saw their report from March 2024. The registered manager monitored their deep clean swabbing start and finish times. Managers found PTS drivers were not wiping down the gearstick after their shift. CQC saw on deep clean reports this vehicle area had the highest swabbing score. As a result, managers ensured staff cleaned all areas properly. Deep cleans were quarterly as PTS vehicles were rarely used. The service’s next deep clean was due in early November 2024. PTS staff completed stock checks and cleaned down after every shift at a contractor location. Staff used cleaning wipes when arriving back at their ambulance station.

CQC assessed the two PTS vehicles in service and found both were very clean, well maintained and free from clutter. Hand sanitiser and personal protective equipment (PPE) such as gloves in all sizes were stocked for staff to use. Managers ensured suitable PPE was provided to all staff needed for protection, as per their health and safety policy. They notified staff of any potential risks which required PPE for special duties or specific tasks. Clinical waste bins were secure and used appropriately. Staff placed clinical waste in yellow bags as per the service’s health and safety policy. Waste was collected at least every eight weeks.

On CQC’s last inspection in November 2023 the service failed to ensure there were systems in place to monitor infection prevention and control. On this inspection we found the service had implemented monthly hand hygiene audits and infection prevention control (IPC) spot checks by the manager to ensure compliance. Managers also now had oversight of their vehicle deep cleaning from monthly reports. All the service’s IPC audits were kept in a large file in their office. PTS staff completed infection prevention and control training.

The service only used oxygen onboard PTS vehicles. On CQC’s last inspection in November 2023, staff were appropriately trained in medical gas administration as part of their Level 3 Certificate in First Response Emergency Care (FREC 3). However, the report was not amended accordingly. At this inspection CQC found all staff were still appropriately trained and had maintained medical gas training. This formed part of their first response emergency care level three (FREC3) course qualification. Leads had sent a copy of the FREC3 syllabus to CQC the day after CQC’s last inspection. The service had an oxygen policy which staff followed when administering emergency oxygen.

The service carried out monthly medicines management audits on medical gas stock levels. These were correct as of February 2024. The service’s latest medicines management policy incorporated oxygen for PTS use, as per the British Oxygen Company (BOC) guidance. CQC reviewed this policy which included the hazards of using oxygen, causes of oxygen fires and explosions, correct or optimal storage, and non-compatible materials. The policy described the RM’s responsibility to report any adverse reactions to the patient’s own medications to the medicines and healthcare products regulatory agency (MHRA).