DHL PTS Ponders End

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 requires improvement. We assessed seven quality statements. We were not assured that when staff had raised concerns that action would be taken. We were not assured that effective equipment or vehicle checks had been conducted as we found examples of damaged or missing equipment. We were not assured that infection, prevention and control was managed appropriately, we found an unclean storeroom and some vehicles were not clean. We were not assured the service had safe and effective recruitment systems in place. The storeroom organisation was inadequate and staff adherence to procedures was not consistent. However, we were assured that incidents were investigated and learning communicated to staff. That the service effectively managed complaints. The service had effective systems to book transport. Assessing people's needs and driver safety was managed well. Improvements were seen from the previous inspection and people knew what safeguarding was and how to report it. We were assured that mandatory training was compliant and current.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were happy with the service, .

Managers and leaders told us updates and information were shared with staff and if urgent information would be shared via PDAs (handheld computer device) or through staff briefings which should be signed and acknowledged by staff. We were told that briefing notes would be displayed on a noticeboard in the staff lounge at the base. Staff told us they were not always confident to raise concerns, that action would be taken or that they would be supported when things went wrong.

The service had systems for staff to raise concerns or issues formally and informally. A Freedom to Speak Up Process was being set up but not yet embedded. There were systems for people to complain which the service shared with the relevant trust. The service had a one hour notification process which was used to report, assess and action road traffic accidents or incident involving a patient or staff member and any safeguarding incident of concern. Any learning that had been identified was passed on to staff through different channels dependent on urgency and risk.

We saw systems were in place to effectively investigate incidents and people or those they represented were given an apology and explanation of the event in a timely way. We were assured people could raise concerns with the service and that complaint and incident oversight was shared between the commissioning trusts and the service. We saw a verbal staff briefing on vehicle equipment, stock checks and how to dispose and replace expired stock by a manager, however we did not see any staff briefings displayed on notice boards. As staff worked staggered shifts, we were not assured that briefings had been given to and acknowledged by all staff. We were provided with a briefing document which showed some staff but not all staff had signed to show acknowledgement of the briefing.

Leaders told us they had regular meetings with Trusts and shared journey performance data with them. They said regular meetings had been held with people that had used the service and reviewed feedback to improve the service provided. Staff told us sometimes where commissioning trusts had booked journeys directly using an electronic system, the information was not always complete or accurate which had sometimes led to delays or cancellations.

Trust representatives felt the service was satisfactory, but ward staff said return journeys were not always well organised and people sometimes experienced delays.

There were effective systems for people and Trusts to book patient transport. Journeys were planned and used forecasted staffing levels against service volume in advance. When the service was busy callers could request a call back. Daily compliance updates formed part of a daily management meeting that reviewed current and future performance and any issues that could impact on performance.

We saw staff taking calls and book transport effectively and professionally and planners co-ordinated journeys based on staffing levels, people’s needs and vehicle availability. We saw service policies and processes that supported people throughout their care journey. The service had identified accident trends and changed ways of working and increased relevant training which led to a 67% road traffic accident reduction previous year to date

Staff and leaders knew who the safeguarding leads were, could describe how to recognise and report abuse and gave examples of concerns and the action they would take.

The service had effective systems to report and monitor safeguarding incidents and we saw evidence of when the process had been actioned. The service conducted an annual audit which was last conducted in June 2024. The service provided different levels of training based on role and a rotational two and three yearly refresher which was role dependant. Road staff carried paper copies of the safeguarding standard operating procedure and reporting form as part of the equipment carried on vehicles.

Between October 2023 to October 2024 93 referrals had been made to the local authority. At the time of inspection 98% of Road staff were trained at level 2 safeguarding for adults and children and 100% of safeguarding leads were trained to level 4 safeguarding. 89% of all other staff were safeguarding trained and 75% of customer services were level 2 safeguarding trained. 98% of road staff had received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty (DoLS) and Dementia. The service had completed a safeguarding audit in June 2024 which showed zero non-road staff had been trained on the safeguarding standard operating procedure and zero off-site and transport leads were safeguarding trained. The audit stated that the Safeguarding policy had required updating to reflect inaccuracies and some staff were unsure who the safeguarding leads were. The safeguarding policy provided to CQC by the service had not been updated.

Staff told us they had a system of assessment based on peoples’ needs using an electronic system which dictated the level of care and vehicle type allocated to the journey. Staff told us on collection of patients they made dynamic risk assessments and if necessary, contacted control to request further support, which could sometimes cause delays.

The service had an effective electronic system which was used by call takers to assess eligibility to use the service, assess people’s needs and dictated the level of vehicle and trained staff required for transport. Staff dynamically assessed people at collection points and any concerns should be referred to control for support.

Although people told us they felt the environment was safe and clean we found this was not always the case.

Leaders told us staff should report faults and missing equipment to managers. Staff told us they report faults with vehicles and equipment and they were not always repaired or replaced. Inspectors found some staff were using their own equipment. Staff told us a defibrillator was missing an oxygen monitoring attachment so had purchased their own. The provider following our inspection told us they have briefed staff staff to inform and request replacement of missing equipment from supervisors of as part of their daily vehicle checks. Some staff said they could not access medical gas as they had no access key or had obtained their own key. Following the inspection the service notified us medical keys were stored in grab bags on High Dependency Unit (HDU) vehicles and briefed all staff on where these keys were stored in vehicles. We found all defibrillator pads in stock and on vehicles had expired on the 24.09.2024. We told the service on the day of the inspection and all defibrillator pads were replaced the following day.

We inspected eight vehicles, four had tears to chairs or mattresses. Three vehicles had rust and/or visible dirt on the floor. Not all life support equipment was well-maintained or complete (oxygen monitoring lead, suction tubing and defibrillator pads out of date). Three vehicles had uncalibrated fire extinguishers. Two vehicles had a wheel missing from access ramps. We saw two vehicles had been audited on the day we inspected them, the audits identified no issues but we found one of those vehicles had rips to the stretcher mattress, a broken interior door catch and a damaged stair climber retention belt and the other had dirty, rusty floor mounts and a wheel missing from an access ramp. We found unauthorised medication on a vehicle in contravention of the service’s medication policy which stated medicines may be carried by Patient Transport Service staff in relation to their role: Medical gases, Oxygen by Ambulance Care Assistant’s (ACA) and Oxygen, Medical Air and Entonox by Emergency Medical Technician’s (EMT). The service conducted an audit in July 2024 which showed staff were not compliant with medical gas checks and medical gas keys had not been stored securely. We saw staff incorrectly documenting medical gas checks and said they did not know where the medical gas key was, so staff did not know if there was enough gas on the vehicle to support people being transported. Inspectors noted there was no standardised storage locations of equipment and consumables in vehicles. The site was appropriately layed out with security and safety managed by staff. A notice board in reception named fire marshalls and first aiders. Fire alarms had been regularly tested and environmental and health and safety inspections had been conducted. The service had systems to monitor safety and servicing of vehicles. We reviewed 10 random vehicles’ documentation which were legally compliant and had been inspected for safety and road worthiness.

Staff should complete a vehicle daily inspection list on vehicle condition, equipment and stock on board. Any faults with vehicles, missing or broken equipment should be documented and reported to a manager. The manager should then request repairs and replacements. Vehicles were audited regularly: vehicles that were about to leave the site were checked for vehicle and equipment defects and end of shift audits for vehicle cleanliness. The service had scheduled regular vehicle maintenance and deep cleaning to subcontracted companies. Following every deep clean, staff should swab touch points and electronically test for hygiene. The service held regular fire alarm tests, environmental audits, IPC and health and safety audits.

People said they felt staff were caring and professional.

Leaders told us they aimed to recruit staff with relevant backgrounds. As a result of staff feedback they had implemented new ways of working which they felt had improved staff morale. Staffing levels were felt to be their biggest risk and sub-contractors had been used to support the service. They said road staff could not access electronic systems and policies but had made a business plan to obtain one.

New road staff completed a comprehensive two-week training programme followed by one week shadowing an experienced member of staff. Drivers were assessed to a specific system and assessed annually on driving standards and movement of patients. The service had an effective accident, incident reporting and investigation process and shared lessons learned where appropriate. Following the inspection the service told us they did not request references for staff unless previously employed in a health or social care setting or with children or vulnerable adults as stated in the Health and Social Care Act 2008. The service told us they had started to use a new document to record Curriculum Vitaes (CV) in 2024 for staff.

We were not assured the service had systems and processes in place for safe and effective recruitment. We were not assured that all staff had been assessed as suitably qualified, competent, skilled and experienced. We viewed six randomly selected staff files: All staff had been DBS checked. Three records could not be viewed as staff had been transferred from another company prior to 2019. We were later supplied with curriculum vitaes (CV) for those employees which had been signed and dated in 2024. One staff member employed since 2022 had an undated CV and one staff member employed since 2020 had a CV dated in 2024, but contained no reference which was required. The service said several unsuccessful attempts had been made to obtain this reference, but we were not provided with any other background checks to show suitability. The final staff file was fully compliant. Documentation provided from governance meetings (June, August and September 2024) showed actions to obtain CVs and references for all staff already employed. The service said they did not request staff references unless previously employed in a health or social care setting or with children or vulnerable adults in line with the Health and Social Care Act 2008. CQC were provided with a DHL resourcing guide which did not include the requirement for an applicant’s previous employment record or for references where applicable.

However, the service had enough suitably trained staff to provide safe care and treatment. Mandatory training for road staff was above the service target of 95%. HDU staff specific training on Sepsis, National Early Warning Scores (NEWS,) advanced paediatric life support and trauma life support was 100%. The lowest compliance rates were Equality Diversity and Inclusion (EDI) at 60%, Health Safety and Welfare 60%, Conflict resolution 60%, ACA/EMT Fire safety 21%, Resuscitation for ACA at 9% and EMT at 16%.

Staff told us they replenished vehicle stock and Personal Protection Equipment (PPE) when needed but it was not always available – two crews said there were no extra-large gloves available at the time of the inspection. Staff said they preferred anti-bacterial wipes which had not always been available and the service provided alternatives which they did not consider as effective. Staff told us anti-bacterial wipes were not ordered rotationally and the first stock list supplied to inspectors did not include anti-bacterial wipes. Leaders told us a manager performed daily spot checks of vehicles for damage, stock levels and equipment. Leaders told us all vehicles were deep cleaned rotationally or when needed and IPC compliance monitored through swabbing touch points. Leaders told us IPC checks of vehicles and staff (hand hygiene) had been conducted at Trust venues, which were supplied to the IPC lead, however we inspected an audit sheet at a Trust venue and saw no audit had been completed for 4 working days . The IPC Annual Programme 2024 stated that hand hygiene audits should be conducted at each of the five Trust venues at the rate of one per day. We were provided documentation that showed monthly hand hygiene audit volumes of around 250 audits had been conducted in 2024. Staff were responsible for cleaning vehicles between patient transfer and at the end of their shift. Staff told us control sometimes had tried to redeploy them to new calls which would either reduce their cleaning time or forced them to work overtime. Some staff said vehicles were not always cleaned well by colleagues.

We were not assured there was an effective approach to assess and manage the risk of infection. We did not see any supervisor checks of vehicles or documentation to show any had been completed. We saw staff “end of shift” audit sheets from July to October 2024 that showed vehicle cleanliness checks. However, we noted some blank entries already initialled by an auditor. We inspected eight vehicles, four had tears or repairs to patient chairs or stretchers and two vehicles had rust and dirt on the floor. Inspectors observed a systematic deep clean of a vehicle that followed the cleaning guidance. It was swabbed for hygiene and the results uploaded electronically; however, staff did not know what the scores meant. We saw the cleaning bay had a cleaning guide and equipment was colour coded. Clean mops were hanging in the bay and there was a large container with disinfectant fluid. We saw some cleaning equipment stored in a shed that did not appear IPC compliant. We requested basic stock from stores, which staff were unable to supply, however fleet office staff were able to provide some consumables. We found the storeroom was not well organised: some items were mislabelled, inaccessible by being placed on high shelves and access blocked by equipment. We saw out of date and dirty consumables, broken or unserviced equipment, opened and incomplete first aid kits. The room was dirty and evidence of vermin seen. Staff could not explain the stock control system. We saw an audit from July 2024 that stated the storeroom was used to store vehicle equipment, a lack of daily inspections or suitable stock control.

There were systems to audit and monitor IPC. All vehicles were deep cleaned on a six-week rotational basis regularly, or as necessary. Touch points were swabbed for cleanliness electronically, the scores reviewed by a manager and forwarded to the IPC lead. However, the person responsible for cleaning and the manager responsible for reviewing and notifying the IPC lead of the results did not know what the swab results meant so did not know if vehicles were IPC compliant. The outcome of the swab (not the score) was provided to the IPC lead so they had no oversight of the level of cleanliness. Staff should be allocated time to clean vehicles after patient journeys and at the end of their shift.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.