Monitoring questions for ambulance services (NHS and independent)

• Are infection risks to people using the service being thoroughly assessed and managed?
• Have changes been made to the layout/environment of clinical and non-clinical areas to continue to provide services safely in this period? For example, clean sites, vehicle layout, separate entrances and waiting areas for known/suspected COVID patients, additional signage, spaces between stations, isolation facilities, ensuring compliance with best practice guidance when visiting people in their own homes etc.
• Does the service have the resources to obtain, and have reliable access to, all the supplies, personal protective equipment and COVID-19 testing it needs, for both staff and, where appropriate, people who use the service?
• Are working arrangements and procedures clear and accessible to staff, people who use the service, their supporters and, where appropriate, visitors to the service?
• Are people using the service being protected from abuse, neglect, discrimination, and loss of their human rights?
• Where applicable, has the provider identified when they may be depriving a person of their liberty, and followed the correct and lawful procedures? (for example, DoLS application, Court of Protection)
• Are the service’s safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights?

S1. Additional prompts

Emergency and urgent care

• Has there been any impact from the pandemic on the routine checking and maintenance of equipment and vehicle checks and breakdown support? How have these risks been managed? 
• Has there been a need to arrange additional breakdown support (for example, access to extra vehicles, spare parts) to keep more vehicles on the road?

Patient transport services

• Has there been any impact from the pandemic on the routine checking and maintenance of equipment and vehicle checks and breakdown support? How have these risks been managed? 
• Has there been a need to arrange additional breakdown support (for example, access to extra vehicles, spare parts) to keep more vehicles on the road? To meet demand, is patient transport being undertaken in vehicles that fall outside of CQC’s scope of registration (by the trust or sub-contractors?) If so, how is the service ensuring patients are transported in vehicles appropriate to their needs?

• Are risks to the health and wellbeing of people using the service being properly assessed, monitored and managed?
• Are there enough suitable staff to provide safe care and treatment in a dignified and respectful way? Are escalation plans in place in response to surges in demand for example, second wave, seasonal pressures?
• How is the service identifying and managing risks for patients, including any restrictive practices or issues affecting their legal or human rights?
• How is the provider maintaining an oversight of any new staff, volunteers, and sub-contractors to ensure there are robust and safe recruitment practices and staff induction?

S2: Additional prompts

Patient transport services

• What training and support are staff given to recognise and respond appropriately to deterioration in the health of a patient? What is the escalation process for deteriorating or seriously ill patients?

Emergency operations centre

• How does the triage and clinical risk system keep people safe, (this includes dispatch of appropriate skill mix to the patient, use of any ‘special notes and appropriate response to deterioration of the health of a patient whilst waiting for an ambulance response)?

• Does the service have access to guidelines around Treatment Escalation Plans (TEPs), anticipatory care planning, Do Not Attempt CPR(DNACPR) orders and individualised care plans? Is it following them? Are there plans for rapid transfer to preferred places of care?
• Is the service able to effectively manage referrals and, where relevant, discharges, and ensure safe transfers of care? Where relevant, what are the arrangements for testing, and how does the service handle transfers of patients with known/suspected COVID safely? How is the service working with other partners?

• Are medicines being managed safely and effectively? Has COVID-19 affected the service’s ability to manage medicines?

S4: Additional prompts

Emergency and urgent care

• How does medicines management practice account for lone working and safe storage of medicines on vehicles including medication in kit bags, medical gas cylinders, and controlled drugs?

• Are there any significant trends in non-COVID-19 activity? for example, never events, significant incidents, themes in incidents, mortality, unexpected deaths? What is the provider doing to assess and learn, including mortality reviews of non-COVID patients?
• Are there any significant trends where groups of patients are doing worse in terms of safety concerns?

• How is the service identifying, cascading and keeping up to date with changes in clinical guidance?
• Where people are subject to the Mental Health Act, how is the service ensuring compliance with the Act?

E1: Additional prompts

Emergency and urgent care

• Can staff explain the current policy and procedure for not conveying patients to hospital?

• How is the service collecting information about people's care treatment and outcomes? Where relevant, is the service continuing to submit to relevant national clinical audits?
• How are outcomes being monitored for groups of people that may be at higher risk, such as ethnic groups and older people?

E2: Additional prompts

Emergency and urgent care

• If policy on see and treat has changed, how has the safety of patients been monitored?
• What changes have you made to facilitate/improve access and maintain response times to your services in response to COVID-19?  

Emergency operations centre

• If policy on hear and treat has changed, how has the safety of patients been monitored?

• How is the service ensuring that all staff, including those being flexibly re-deployed, have the skills and training to carry out their roles effectively?

• How is the service ensuring that the necessary staff, teams and services are involved in assessing, planning and delivering people’s care and treatment?

E4: Additional prompts

Emergency and urgent care

• Where the NHS Trust is sub-contracting to independent ambulance services, how have you built relationships and worked together to meet demand?

Patient transport services: additional prompts

• Where the NHS Trust is sub-contracting to independent ambulance services, how have you built relationships and worked together to meet demand?

• How does the service ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
  • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
  • promoting supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
  • ensuring staff apply relevant legislation where people may lack capacity to consent to particular care and treatment, including the Mental Capacity Act 2005 (including DoLS) and the Children’s Acts 1989 and 2004?

• How has the service adapted how it supports and engages with patients and their families/loved ones?
• How does the service ensure the care delivered is compassionate and upholds people's human rights?

C1: Additional prompts

Emergency and urgent care

• Where patients are treated in public or other settings, how do you ensure their dignity is maintained during treatment and care and that patients, relatives and carers are supported through distressing events.

• How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
• How does the service communicate to patients where it has made changes to how it operates to manage COVID and non-COVID patients?

C2: Additional prompts

Emergency operations centre

• For hear and treat patients, how does the service engage callers to ensure that they understand the advice they have been given?

• How does the service ensure that it meets the needs of the population served and does it enable flexibility, choice and continuity of care?

R1: Additional prompts

Emergency and urgent care

• If the proportion of non-conveyance activity has increased, how have you ensured that patient safety and care wasn’t compromised if patients have not received paramedic or hospital care?

• How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
  • ensuring that each patient’s information and communication needs are identified, recorded, flagged, shared and met?
  • identifying and making other reasonable adjustments for disabled people?
  • Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?
  • Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?

• How is the service managing access to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including re-instating services and handling backlogs of activity?
• Is there a structured approach to patient flow that ensures all components of the system are appreciated and managed appropriately, and flow issues are escalated appropriately? How does the approach take account of the pandemic?
• Has the policy on non-conveyance changed?

R3: Additional prompts

Emergency and urgent care

• If there have been longer patient transfer times at ED, how has this been managed?

Patient transport services

• Where you have made changes to how you operate to manage COVID-19 and non-COVID-19 patients, how are staff made aware of these changes?

Emergency operations centre

• Where you have made changes to how you operate to manage COVID-19 and non-COVID-19 patients, how are staff made aware of these changes?

• Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place if it is affected?
• Do leaders understand the challenges to quality and sustainability during this period, and can they identify the actions needed to address them?

• Is the service monitoring and protecting the health, safety and wellbeing of staff?
• How is the service taking action to protect the health, safety and wellbeing of staff, for example, access to emotional support, supporting staff to raise concerns, adequately risk-assessing and placing staff in appropriate environments to protect their health and safety, including staff in different ethnic groups and other staff at high risk of COVID 19?

• Is the service able to work effectively with system partners when care and treatment is being commissioned, shared or transferred?
• How is the service maintaining oversight of quality and governance for sub-contracted services?

• Does the service have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed?