St John Ambulance - South Region

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

We rated safe as good. We assessed seven quality statements. There was a positive learning safety culture most of the time where events were investigated, and learning was shared to promote good practice. Most staff were open and honest when things went wrong or if they identified a risk that required action. Staff protected people from abuse. Staff provided safe care and treatment. The environment was safe, well maintained, free from infection and met people’s needs. Staff were trained and competent and had the right skills to meet people’s needs. They had the opportunity to learn and gain experience. Medicines were stored safely. The service made sure shifts were covered. However, not all staff had permanent contracts, clinical volunteers and bank staff had’ Terms of Engagement’ to care and convey patients. The service utilised clinical volunteers to care for and convey patients on various activities.

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.

Staff could explain how information about incident and complaint investigations was used to prevent similar situations occurring in the future, with findings and resulting actions being discussed and cascaded to the team though meetings and bulletins. The CQC received 8 anonymous information of concern cases about leaders not being open about incidents and leaders discouraging staff from reporting incidents. Staff we spoke to advised us that there was an issue with the current IT system in collating themes and trends, but the leadership team were aware of this and implemented manual workarounds as a temporary solution. Incident data reviewed by us showed investigations had taken place. After the inspection minutes shared from the CQC Concern and response team showed that not all equipment failures were reported via the incident reporting system. Anonymous staff had raised concerns with the CQC regarding repeated breakdowns on the Stryker load trolley which we followed up during the inspection process. Fault reporting data showed that from Jan 2024 to date showed 11 faults associated with Stryker load trolleys. However, a review of St John Ambulance (SJA) incidents showed only one to have been reported as an incident. The others were reported via the fault reporting system. Staff we spoke with understood the need to be open and transparent with patients. Staff knew about duty of Candor and apologised when things went wrong.

The service had processes and policies to report and investigate incidents and risks. The service completed a review of how they managed, reported and reviewed incidents designed to drive improvement. Staff followed the ‘Incident Management’ policy which had been reviewed in April 2024 the policy included incident reporting flowcharts, serious incident escalation process and the external reporting requirements. Also, driver investigations policy reviewed in March 2024 included a hazard risk matrix to ensure leaders had oversight of any identified risks. Driving incidents were investigated by an approved Investigator with support from the Driving Education manager. We looked at 3 driving incident investigations and found that leaders completed a thorough investigation, where dashboard CCTV footage was used. All incidents were RAG rated to highlight the current risk. We saw that the that the driver education team maintained a driving incident dashboard which showed the number of total collisions in every region over the year. Leaders completed monthly reports that included incident data which showed the outcome of investigations and those investigations that were ongoing. However, we found that incident data was captured in various ways which made it hard to assess. For example, a spreadsheet named themes and trends was not dated and showed 4 incidents, but the June 2024 monthly operations report for the paediatric repatriation service showed 8 incidents. Also, the quality and safety team held monthly incident review meetings. These meetings looked at how many incidents were overdue, the data showed that urgent and emergency care had 28 overdue incidents. Evidence from the May 2024 meeting showed that there was a potential risk with the new electronic patient records systems because of the way data was captured and input. Leaders were aware and added this to their internal risk register to monitor.

During the inspection there were no patients conveyed at the location we visited. Therefore we were unable to capture the experiences of people being cared for. However, feedback provided on the providers website showed people were thankful to staff for taking care of them. Also, we spoke with one third party NHS provider who had not received any negative feedback from patients about St John Ambulance staff.

Staff had established links with the providers who contracted their services. They worked together to ensure the transport needs of the patient were met safely by identifying and managing risks proactively and effectively. Most staff felt supported to provide the right care and treatment for patients. Most shifts were planned and those staff working on emergency calls worked with people they knew. Staff had the knowledge and skills and professional registration and knew how to assess risk. Staff knew how to escalate concerns and would liaise with the NHS emergency call centre's. Staff told us that patients were not left alone in vehicles. Staff completed mental capacity training and considered mental health as part of the overall assessment. Staff told us that there had been teething problems with the introduction of the electronic patient record and the leaders told us they were working hard to rectify this. We looked at 5 patient records and found that the information was recorded although sometimes it was documented in the wrong aspect of the app. However, from Jan 2024 to August 2024 the CQC received 8 anonymous allegations of provider failings, relating to the 'under' reporting of incidents, invalidated driving assessments and driving offences that were not followed up. Anonymous staff were concerned that recent leaders did not have full oversight of operations to ensure safety. However, during the inspection we found it difficult to substantiate this information most records we reviewed showed the service had process to keep people safe. But, anonymous staff made claims that leaders did not make sure practice was embedded.

We spoke to one NHS provider during the inspection process who advised that they had a memorandum of understanding produced with standard operating procedures to provide support to 999 but no obligation from St John Ambulance (SJA). St John staff do not respond to urgent 999 calls. However, the NHS provider used the service for non-paramedic, urgent transportation vehicles where patients have been pre-assessed only. The feedback was positive, SJA ensure that staff have valid registration and disclosure and barring checks and acknowledged that some SJA volunteer staff are substantive staff for the NHS. The partner spoke highly of the clinical team working out of a local hub and recognised they worked hard to avoid patients having to be admitted to hospital emergency departments. The partner said that the SJA crews worked well as a team alongside the partner services staff. The NHS provider advised us that they would like to increase the provision of work from SJA, but recognised this would be reliant upon volunteer staff to save cost. However, they hoped that the relationship between the 2 services would increase and that SJA will gradually be able to build a volunteer team who will be able to support the external stakeholder more in the future. The NHS provider had no knowledge of any patient safety incidents related to any SJA staff or equipment.

Staff used the emergency ambulance crew patient assessment tool which included a primary survey patient assessment process, danger, response, catastrophic bleeding, airway management, breathing, circulation, disability and exposure and evaluation. Staff conveying patients were paramedics, ambulance technicians and emergency ambulance crew who had the right training and followed national urgent and emergency care guidance. Staff working on ambulances completed a primary survey and risk assessments and made sure that patients had the adequate safety belts for transfer to hospitals. Staff followed national guidance to complete physical observations on patients during transfer and recorded this on the patient records on the electronic PRF tablet. Staff followed a business continuity plan in the event of major incidents that may affect services. For example, there was guidance on any localised incidents that created a disruption and meant the organisation temporarily lost its ability to deliver critical care services or where patients were at the risk of harm, leading to a critical incident would trigger an internal escalation response. Managers were rostered to be on call available round the clock 7 days per week to support staff to deliver care.

The service had a designated experienced safeguarding lead who was trained to level 4 safeguarding. Staff received safeguarding training specific for their role on how to recognise the signs of abuse. Patient facing staff received Level 3 safeguarding training for children and adults. The service supported its volunteer ambulance crew and volunteer healthcare professionals to transfer like-for-like training from their employed roles, often in the NHS, to save duplicating training which was the same. Staff used a personal digital assistant (PDA) to report safeguarding referrals. They could demonstrate what constituted abuse and could give examples when they had raised safeguarding concerns. The service had a safeguarding policy which was under review. Leaders told us that the people committee were reviewing safeguarding process and systems within St John Ambulance to strengthen process. The service created safeguarding pocket cards to help staff make informed decisions and follow the correct process to identify and report abuse. The provider had commissioned the Social Care Institute of Excellence to complete an audit of safeguarding processes. This was because leaders asked the people committee to strengthen safeguarding processes and develop a bespoke safeguarding model for St John Ambulance countrywide. For example, including sexual safety awareness in safeguarding training and policies. Staff and leaders made the appropriate safeguarding referrals and notifications when required.

Leaders told us that there were 2 types of urgent and emergency work carried out by the St John Ambulance. A critical care transport service – where a driver technician supported an NHS clinician to move critical care patients between hospitals and a NHS Ambulance support and event ambulance where a crew of 2 were provided for frontline NHS services to manage patient emergency and urgent care episodes. The service maximised the effectiveness of peoples care and treatment by completing monthly operations reports to ensure that they deployed the right staff with the knowledge and skills to safely assess and review patients during transportation. Staff told us that there 2 crew were required for each patient journey. However, information of concern received by the CQC from anonymous staff stated that there had been the odd occasion when 1 staff member had been asked to convey a patient. The operations report for June 2024 adult critical care showed that there was only one incident reported when a vehicle could not be deployed due to staff sickness. Staff told us that key information to keep people safe was documented on the electronic patient record. The information was recorded by the crew and hospital staff could access the information, completed documentation and handovers via the electronic patient record portal.

Staff followed national guidance to care for patients during attending and conveyance to hospital. The service completed monthly operations reports for repatriating paediatric and adult patients for one NHS trust. Data showed that up to June 2024 the service conveyed 430 adults and 621 paediatric patients. Patient had their individual risks assessed when a journey was booked. This included information on mental health issues, safeguarding, do not attempt cardiopulmonary resuscitation orders (DNACPR) and patients who were at risk of a fall. Third party NHS contractors booked the ambulance based on the patients need. Key information to keep patients safe was shared with crew members via their personal digital assistants (PDAs) at the start of their shifts. Crews would also make a dynamic risk assessment prior to each journey to reduce risks. If they had concerns, this would be communicated to the controller back at base for support or clarification. Staff attending urgent and emergency situations had all the necessary knowledge and skills to care for patients. For example, the service employed or recruited volunteer paramedics, medical staff and ambulance technicians. Staff used the emergency ambulance crew patient assessment tool which included a primary patient assessment process, and considered the physical, environmental and emotional risks. Staff completed clinical observations of physical indicators such as pulse, heart rate and oxygen saturation level. The services commissioned NHS work was risk assessed at the point of contact by the NHS provider. St John staff and clinical volunteers pick patients up, take handover and use their electronic handheld devices to record information – or in the event of system failure they use paper ambulance records which are given back to the NHS provider as per GDPR guidance. Therefore, there processes are governed by the NHS provider they work with and they have one patient feedback letter.

Staff told us there was not always enough vehicles and equipment to deliver the service provision and to prove safe care to patients. The CQC received 8 concerns regarding vehicle safety and equipment failure from January to July 2024. One anonymous concern was raised about the power load trolleys with wheels that repeatedly failed. A review by St John staff found that from January 2024 the were 11 recorded faults associated with the trolleys, 5 incidents related to error, 4 instances related to component failure and 3 to physical damage. Only 1 was recorded via the incident reporting system. Leaders assured the CQC that there was a system to replace and repair equipment and further training had been implemented to reduce the amount of failures. Vehicle failure was one of the top causes of concern for staff. The Paediatric operations report for June 2024 showed there were 3 incidents of vehicle failure one during patient transfer. During the inspection at the Brighton location there were 3 vehicles all in working order. After the inspection leaders told us that the number of vehicles had been reduced because certain vehicles were outdated or required high levels of maintenance, but vehicle sustainability was regularly reviewed Dedicated staff were responsible for checking and replenishing any consumables. Storerooms were tidy and well organised. This meant consumables were easily located for staff. We checked a sample of consumable items for expiration dates both in the storeroom and on the vehicles and found most were in-date.

The service had enough suitable equipment to ensure safe care for patients. This included the specialised equipment required for transporting complex patients such as bariatric patients and secure mental health transfers. Equipment reviewed was maintained and fit for purpose and staff had been trained how to use it properly. The ambulance station was based in Brighton and fit for purpose, it contained a garage where emergency vehicles were stored, a clinical room where medication and single use equipment was stored including grab bags. There were training rooms, staff rest room and hot desks, equipment storage and a meeting room with IT access. All areas at the Brighton location were clutter-free and equipment stored safely. However, the CQC did not visit the unmanned garages in various locations across the South region. During our inspection we reviewed 3 urgent and emergency care vehicles. We found that vehicles were clean, stocked with all the appropriate lifesaving equipment and single use items. The couches were clean, and staff checked the vehicles at the beginning of each shift. The service complete regular environmental risk assessments to ensure safety.

Staff completed weekly fire alarm tests, and one occurred during the inspection. Staff completed daily vehicle checks prior to the start of their shifts to make sure vehicles were road worthy and any the specialised equipment such as emergency equipment was in working order. Seat and trolley belts were in good working order. Vehicle checks were completed on the personal digital device (PDD’s) which were allocated to each vehicle. If faults were identified, such as a dent in the body work or broken wing mirror, these would be flagged and senior staff would decide the course of action, immediate repair or taken off road. Leaders had a system for completing vehicle checks, MOTS and servicing. Records were stored on a data base, and we saw that managers could access the certifications and servicing agreements. When a vehicle was due to be serviced or have its annual MOT the system provided a reminder for staff. Although, leaders told us that they were outsourcing this from August to a third-party organisation. We checked 3 vehicles; their certification records were accurate and up to date. The service maintained an equipment asset register which showed when equipment was due to be serviced and calibrated. Each piece of equipment was labelled with the service dates. The station kept records regarding the status of their vehicles which showed the service had a good overview of their fleet. All keys to the vehicles were stored securely in locked cupboard and key safes when outside of the driver’s possession which meant vehicles could not be used without authorisation. The service employed 3 equipment technicians. However, the service the technicians had to cover the whole of the country, trying to review, repair and source additional equipment.

The service had gone through a process of change which meant they had introduced redundancies for ambulance staff in some areas of the South region. Leaders had been criticised by anonymous staff for not completing a thorough consultation with staff or for completing a planned risk assessment. The operational report showed that across the South of England 16 substantive staff were retained to support an NHS contract with no shortfalls in staffing. However, evidence from the monthly paediatric operation report for June which showed some vacancies in critical care services which led to some gaps in shift fill rates. Anonymous staff had raised concerns and told us that there were times when the paediatric repatriation service was understaffed and the monthly operations report for paediatric services confirmed that there were there were 4 times during May 2024 when the service had to escalate staffing concerns. Shift patterns were aligned to the demands of the service. Volunteer staff told us that they could book shifts online and worked in teams to ensure shifts were covered. We found that the service used volunteers and bank staff to cover unfilled NHS urgent and emergency care shifts in particular for the South Coast area. But volunteers were happy with how shifts were allocated. Urgent and Emergency teams were clear about what they needed to achieve and made sure they did this. We spoke with 5 staff face to face who spoke highly of the team work and did not raise any concerns about culture. Substantive staff were available to cover the repatriation of adult patients for one NHS trust.

Managers reviewed staffing and aligned it to the needs of the service. From January 2024 to June 2024 the operational report showed the service had deployed a total of 430 emergency vehicles using a blue light to expedite the journey. For the same period, the service deployed 861 paediatric repatriation vehicles. However, records showed that the paediatric retrieval service was under-staffed and there had been times when agency staff covered shifts. This was a potential risk to patient care if shifts were unfulfilled at the last minute. The service had a process for training and appraising staff. Most managers supported staff to progress through development meetings and yearly appraisals. However, due to organisational change some staff told us they had not received a recent appraisal, and we did not see records of appraisals from the provider. Board reports and operational reports confirmed that the provider relied upon volunteer staff to backfill shifts in the South region. During the factual accuracy process leaders told us that they had an NHS auxiliary contract which was volunteer led and supported NHS England NHS Volunteering task force report and recommendations (2022). All new recruits received additional mandatory and driver awareness training. We saw evidence of life support training delivered across the wider community. Staff completed additional training like First Response Emergency Care Level 3 (FREC) and the prevention and management of violence and aggression (PMVA) course. Managers identified poor performance via feedback, incidents process and complaints and reviewed capability through appraisal. Staff required to drive as part of their role completed a driving assessment and driving was assessed every year by a station team member. If necessary, staff were referred to the operations manager for additional training. The provider kept detailed records of driver compliance, like driving license and we saw evidence of this.

Staff told us that it was their responsibility to check and clean the vehicles and make sure they were cleaned after use paying particular attention to touch points . Also, they told us they had the correct equipment to clean up bodily fluids when required. Staff told us they had enough personal protective (PPE) single use products including masks. Staff received feedback from infection prevention control touch point swab audits. Touch points were areas often used by staff and patients like, handles, seat belts and doors.

The environment was clean and free from dust. Vehicles were visibly clean and stock rooms were dust free. Staff wore uniforms and name badges. We saw hand sanitiser at entry points. The location had a garage where vehicles could be stored and cleaned. Staff could access cleaning solutions, there was a power wash, sink and Control of Substances Hazardous to Health (COSHH) products were stored safely in locked cabinets in line with COSHH regulations 2002. We found equipment on vehicles designed to prevent and control infections and manage any bodily fluid spillages. This included vomit bowls and bags, urine bags for men, and spill kits. Spill kits enabled staff to clean up spillages such as blood, urine and vomit safely and effectively. We saw decontamination wipes and hand sanitiser were available on vehicles.

Leaders provided infection prevention control training and staff followed the infection prevention control policy. The service made sure staff had access to personal protective equipment, clinical antimicrobial wipes and hand sanitiser. Senior staff carried out infection prevention and control audits to make sure staff were following current relevant national guidance. Staff used monthly swab touch point testing on commonly touched areas of vehicles like, trolleys, seat belts, door handles and emergency life saving equipment to ensure that the touch points were free from dirt and potential infections. Outcomes from audits were fed back to staff to ensure that practice was embedded and we saw evidence of this. Staff were provided with a uniform which they were expected to launder at home. Through the service leaders displayed hand hygiene and bare below the elbows posters.

Because of regulated activities were sub contracted by third party NHS organisations we did not speak to people using the service.

The CQC received 4 cases of information of concern about the medicine grab bags which alluded to unsafe storage and expired medication. However, this was not confirmed during inspection, because of concerns we inspected medicines at the Brighton location and found 2 minor issues with medication grab bags but did not find out of date medication or missing medication. After the inspection and because of concerns the provider confirmed there were no supply issues and the formal system for checking and replacing medication was clear for staff to follow. Managers told us that grab bags were stocked and sealed at a central pharmacy location and provided to the spokes of hubs. Staff at the hubs were responsible for restocking and resealing grab bags with dated tags once they had commenced use. We did not see any robust audits for ensuring that the dates on external bags reflected the dates of medication within the bags.

The service had a designated area to store medication which could only be accessed by a secure passcode. Medicine grab bags had external tags with expiry dates and the pouches inside were also tagged with expiry dates. We inspected 5 grab bags and found all the items to be in date. However, 2 grab bags had external dates of October 2024 and internal tag dates of July 2024 we raised this with managers who reported this back to the central pharmacy stores. The controlled drugs cupboard was key coded, and only accessible to staff who had medication prescribers' qualifications. Controlled drugs were check out by 2 members of staff. However, we did not see a written controlled drugs log we were told this was updated on line by central pharmacy stores. We found the medication room to be well laid out and clearly stocked.

Staff followed various policies including the medicines management procedure, which had just expired, although after the inspection the provider shared the updated version which expired in August 2027. The ‘Clinical Practice Policy’ had expired in December 2023 with the review extended until December 2024 due to organisational change. Finally, the service had a standard operating procedure for the use of patient group directives (PGD) which had been reviewed in December 2023. All procedures could be accessed online. Medication incidents were discussed at the incident review meetings. Medication incident data showed there were 26 reported medication errors across the South region during the inspection process. One incident reflected what we found on site that the external tags which are dated had later dates than some of the medication within the medication bags. Controlled drugs were locked in a swipe card and password protected cupboard and only staff with prescribing rights had access. All sites which held controlled drugs had CCTV in the medication cupboard which was monitored by an external contractor. However, minutes from the incident review meeting for June showed that not all CCTV was networked so it cost the provider to access the footage if required for investigation. Finally, the service was unable to offer meaningful data about medication audits at Brighton and it wasn't clear how often medication audits were scheduled for. After the inspection we asked the provider to confirm which they were not able to do.