DHL PTS Ponders End

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• 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

We rated well led as requires improvement. We assessed four quality statements. We were not assured that all audits accurately reflected findings. We were not assured recruitment practices were sufficient and found missing employment checks. We found some leaders were not clear on their responsibilities and found non-compliance in storage of confidential patient documents. We found senior leaders did not attend engagement meetings with staff and were not always visible. We found all senior leaders had no previous experience of Patient Transport. We were not assured there was effective management of stock, patient safety equipment and IPC. However, we found leaders had a shared vision which was echoed by staff. That they recognised staff had concerns and had sought ways to improve performance, give staff a voice and improve the patient experience. Leaders reviewed performance regularly on various matrices.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A leader told us they had developed three options for the shared vision and all staff had voted for “To move every patient safely with dignity and care by providing a safe, healthy and fulfilling work environment for our staff”. We saw this vision displayed throughout the base and on road staff equipment boxes, but we were not provided with a strategy of how the service would achieve his vision displayed throughout the base and on road staff equipment boxes. Leaders held regular meetings internally and with partners which looked at risk to performance and relevant local factors that could impact on service delivery. They had developed KPIs to measure performance and these were shared with partners. Road staff told us they did not feel they could raise issues or that they would be actioned, however office staff felt supported and could raise concerns.

We were not assured that the service prioritised a culture of safe care due to the IPC issues observed, lack of available stock for peoples’ care, broken and missing equipment on vehicles, auditing issues and road staff not being able to easily access policies. We were not assured that leaders had developed a strategy to reduce delays to people transported home from appointments particularly for non-dialysis patients. We were not assured that all staff could raise concerns or those already raised had been acknowledged and actioned. We were not provided with minutes of any engagement meetings showing if leaders had attended or any issues that had been raised. We saw a document that showed issues raised at engagement meetings between April 2024 and July 2024 which had been allocated to managers, but half had no outcomes updates. We saw notice boards in staff areas that displayed the shared vision and the 2024 staff survey showed 69% of staff supported this value.

However, we were assured that the service listened to people using the service and had ways for them to provide feedback. That leaders regularly engaged with partners to review and monitor their performance against the service and Trust KPIs. We saw notice boards in staff areas that displayed the shared vision and the 2024 staff survey showed 69% of staff supported this value.

Some road staff said they never see senior leaders, whilst office-based staff told us that they felt supported and listened to by their leadership team. Leaders told us they valued staff and made themselves available and visible. Leaders told us they recognised issues that impacted on staff and patient care and had taken action to improve cohesion and improve understanding between staff in different roles. Staff told us control staff and road staff had worked in each other’s environment and said this had been useful to understand their needs. Leaders were aware of issues and priorities that impacted on the quality of the service and said the patient experience and safety were their priorities.

All senior leaders we spoke with were experienced in logistics and managing staff but had no experience of working in Patient Transport services. Senior Leaders relied on managers to ensure staff compliance through audits, however inspectors did not always find effective checks had been made. Leaders did not attend staff engagement meetings and staff did not feel any action would be taken when issues were raised. Leaders were not always knowledgeable about their responsibilities (GDPR). Although areas of risk were audited and checked regularly by staff, the detail was not always reliable and we did not see any effective supervisory or assurance checks made of those audits. We saw documents that showed staff engagement days and staff recognition. Leaders had identified and created a new system to give staff a meaningful voice and access to electronic systems for road staff that had not yet been implemented.

Staff told us although they had regular meetings with line managers, they did not feel confident that issues raised would be dealt with. Leaders told us although DHL have a concerns hotline the annual staff survey had raised that staff did not feel confident to raise concerns and they had developed a Freedom to Speak Up process to allow staff to raise concerns in a confidential way. They said they had recruited staff and anticipated the service would be in place by the new year.

There was no requirement for an independent health service to provide a freedom to speak up process, however leaders had recognised that staff wanted a voice and had started to setup the process up at the time of inspection.

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.

Leaders told us the service held a monthly meeting which covers Health and Safety, IPC, Governance and Quality. They also hold meetings that cover other key themes covering daily performance and risk management. They acknowledged that road staff do not have any computer access which prevented them accessing policies and other key information, though office-based staff have access to policies and sharepoint. They told us they had planned to provide access to electronic systems to road staff in the future.

Inspectors saw ineffective auditing and risk monitoring (i.e. vehicle equipment checks, hand hygiene, IPC, SLT engagement meeting attendance, stock management, no risk register, lack of formal meeting minutes) were all risks to the service. We were not assured the service had a safe and effective recruitment process and system as they could not show that staff had provided employment history prior to being employed or where references were required actions had been taken to assure the service of any potential risks. We found staff and leaders knowledge of these processes was not always comprehensive. We were not assured that staff knew or felt confident to escalate risk or governance issues or that they would be dealt with effectively. We were provided minutes for governance, HSE and IPC meetings, however they appeared to be a presentation updated with actions and attendees but did not document discussion or decision making. Health and Safety (HSE) PowerPoints provided were inaccessible. Inspectors requested the risk register, but it was not provided. However, there were regular meetings for service leads which reviewed performance, compliance, safety and governance. We saw effective workforce planning and contingency planning to maintain the service in case of a major incident or emergency. There were effective systems and governance on vehicle safety, maintenance and driver safety.

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.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.