Yormed Ambulance Station

On this page

• 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

On CQC’s last PTS inspection in November 2023, it rated Well led as Inadequate. On this inspection Well led was rated Good. Managers were clear about the service’s vision. Staff at all levels were competent, skilled and trained for their roles and responsibilities. The service and staff were well-led by leaders who embodied the cultures and values of their workforce. Managers promoted and encouraged a speak up and blame-free culture indicative to learning where staff could raise concerns. Managers and staff treated everyone fairly and equitably. Staff had good awareness of their environmental initiatives and impact. The service’s governance and risk management culture had significantly improved since CQC’s last inspection. However, managers did not respond promptly to CQC’s offsite requests for governance and risk documentation. Some governance areas needed strengthening and further embedding before the service’s regulated activity increased. CQC were not clear how the service would enact their mission or strategy. Eight of the 14 whistleblowing cases CQC received about the service since their last inspection shared concerns. However, managers took all appropriate actions to address these concerns.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

During the service’s induction process, managers and training leads encouraged new staff to ensure everyone involved at every stage of a PTS transfer had a positive experience of the service. Trainers included roleplays on induction to help ensure this. Governance leads had drafted a quality strategy which managers were still reviewing during CQC’s assessment. This was done in consultation with staff.

At CQC’s last inspection in November 2023 the service could not evidence a strategy for turning its vision into action. At this inspection CQC found the service had made some improvement. Governance leads had drafted a quality strategy which managers were still reviewing during CQC’s assessment. This was done in consultation with staff. The service’s mission was to provide exceptional and excellent care for patient safety and transportation. CQC reviewed the vision and values mission statement. The service had ten values; patient-centred care, excellence, safety, integrity, collaboration, continuous improvement, community engagement, reliability, professionalism and empathy. Managers and staff embodied and were aware of these values. However, it was still unclear how PTS managers and staff would enact their mission or values. It contained no measurable objectives and did not mention a strategy.

Staff told us managers were dedicated; they lived and breathed the service. One member of staff felt the service’s downsizing after CQC’s last inspection rating had helped give managers time to make the required improvements. Managers were assured staff with disclosure and barring service (DBS) disclosures were suitable for employment. They requested enhanced DBS background checks for all new staff. The RM discussed and investigated any positive disclosures with relevant staff members, including the situation and circumstances. They adhered to the Rehabilitation Act and referred back to the service’s contractors or commissioners if necessary. Managers checked the health and care professions council (HCPC) register. This was the statutory regulator of all non-medical and nursing professions in the UK. This ensured staff met the standards for training, professional skills, behaviour and health. The service only recognised ambulance technicians who had attained first response emergency care level five (FREC5), associate ambulance practitioners (AAPs) and institute of health and care development (IHCD) registered paramedics. CQC reviewed three staff files, including enhanced DBS certificates as per the service’s recruitment policy requirements. Recruitment processes were in accordance with Schedule 3 requirements of the Health and Social Care Act 2009 (Regulations) 2014. Managers ensured background checks were undertaken when recruiting staff to adhere to fit and proper persons and safeguard patients and other staff. The RM was aware of all PTS staff backgrounds. They spent time with all their staff and were approachable. CQC also reviewed monthly management meeting minutes for 2024. The notes showed managers relied on an external governance lead for prompts about progressing CQC work. Managers had recruited lead and senior administrative staff to help manage their governance and risk processes. The registered manager needed more daily oversight of the service.

At CQC’s last inspection in November 2023 the service failed to demonstrate there were systems in place to ensure they had sufficient oversight of risk and performance. At this inspection we found this had improved. The service maintained a risk register. Managers and leads discussed, updated and reviewed any new risks at their monthly management meetings. They sought performance compliance reports from contractors. PTS staff followed the service’s recruitment policy. This was reviewed annually by the RM. All staff had to provide two professional references, proof of identification, right to work in the UK and driver and vehicle licensing agency (DVLA) driver’s license and code checks. Any staff who accrued more than nine points on their licence could not drive PTS vehicles. All staff drivers had to complete emergency response driver training (ERDT) from an emergency services training provider. All personnel files were kept in folders in the office. Staff’s complete care and scenario certificates, along with SMT, Oliver McGowan and MCA training records were included. This information was stored on their online human resources (HR) portal. The service had their own employer record for office staff to undertake DBS in-house for any ‘child and adult workforce’. They asked would-be staff applicants if they were known by any other name or alias. Staff’s proof of address was needed, and checks and balances were in place. For example, managers checked enhanced DBS’ every three years and driver’s licence twice yearly. All PTS staff had appraisals. Managers explained how their appraisals process had become more comprehensive. This covered absence, training and learning assessment of skills, knowledge understanding, achievements, improvements, objectives setting, and a declaration of understanding. CQC reviewed all six PTS staff’s annual appraisals and competency assessments. All followed the same format, were in date and order.

Managers acknowledged staff rarely used the FTSU due to their service size, and owner operator model whereby the same person set up and manages the service. They told CQC staff they could usually resolve informal concerns in-house. Staff said managers usually listened to any concerns they raised.

The service was the first private ambulance service to implement a freedom to speak up guardian (FTSUG) from November 2021. The guardian used to be the guardian for a regional NHS ambulance service. They sat on the national ambulance network panel for FTSU. They attended regional FTSU meetings on the service’s behalf. Patient transport service staff had the guardian’s contact number and made themselves available.

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.

Managers and leads did not always review or prioritise risks to the service. The governance lead had not reviewed the register since April 2024, seven months before CQC’s assessment. Other staff had to explain and reemphasise the importance of risk management and mitigation to managers. CQC saw the service’s latest risk register from October 2024. Risks were red, amber or green (RAG) rated, and scored from when they were first identified. The register used the standard risk scoring matrix between 1-25. The service’s top three risks were all scored nine. Risk leads had put mitigations and control measures in place. These three risks had been downgraded from scores of 16. The risks were loss or suspension of key contracts (from February 2024), lack of structured clinical staff supervision, and infection control relating to cross contamination between staff affecting their availability. The service’s next highest risk scored six was risk management and governance systems which required strengthening. All risk were recorded and monitored under three areas; strategic, people, or operational. The risk area determined the appointed risk lead. Some risks had joint leads. Three lead staff reviewed the risk register bi-monthly. These appointed risk leads covered governance, managerial and administrative responsibilities. All staff could raise, review and help appointed leads manage risks.

At CQC’s last inspection in November 2023 the service failed to demonstrate there were effective governance systems in place. At this inspection we found the service had implemented more governance processes PTS staff held monthly management meetings which included any governance discussions. There was a minimum staff attendance to be quorate if decisions were made. All meetings were attended by at least the core four staff leads, including one for governance where relevant. The service had contracted a full-time external head of compliance and governance since July 2019. They were experienced and had worked in the same role for a regional NHS ambulance trust. This contractor had made improvements to PTS policies, procedures and overall governance processes. Managers authored (drafted) and approved most policies. Governance leads then reviewed them all. They highlighted learning examples to managers from across the wider ambulance sector. Managers ensured staff had acknowledged all policies on their online HR staff portal. An office staff member received all read receipts to confirm their understanding. Managers referred to policy compliance at appraisals. Staff periodically reviewed and updated all policies. The office staff member planned to condense or combine their 65 policies and procedures which were due for renewal from July 2024. They added a statement in the front of their office’s policy folder to explain this rationale. CQC reviewed some combined policies, such as the one for health and safety, lone working and manual handling. These were clear, concise, version controlled and in date. The service set up daily fleet alerts from a patient transport system from April 2024. This system helped service staff manage all aspects of their business. Managers set up a system account to better show how many journeys staff undertook for a regional NHS ambulance service contractor. The service’s designated data protection officer was an office staff member.

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.

The RM was recovering the service’s old oxygen cylinders as an environmental and cost saving measure. Some cylinders had been stored uncollected at contracted acute hospitals for up to three years. The RM could offer staff loans and a support contact to alleviate bereaved staff’s financial difficulties and impact from the suicide of a family relative or someone close to them. The service donated to various charitable organisations. They looked after a charity called ‘the ambulance staff charity’ (TASC) which had a crisis line ambulance staff could use for support.