Air Alliance Medflight UK NewApproachComprehensive Report ...

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, other information known to CQC and information given to us from patients, the public andother organisations.

Air Alliance Medflight UK Limited

AirAir AlliancAlliancee MedflightMedflight UKUKQuality Report

Business Aviation Centre, Terminal RoadBirmingham AirportBirmingham B26 3QNTel: 01227 647054Website: www.air-alliance.de

Date of inspection visit: 3 July 2018Date of publication: 19/11/2018

1 Air Alliance Medflight UK Quality Report 19/11/2018

Letter from the Chief Inspector of Hospitals

Air Alliance is operated by Air Alliance Medflight UK Limited. The service provides a planned and emergency patienttransport service for adults and children abroad.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of theinspection on 3 July 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led?

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

Services we do not rate

We regulate independent ambulance services but we do not currently have a legal duty to rate them. We highlight goodpractice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• There was a good incident reporting culture which resulted in improvements in practice.

• Staff were up to date with mandatory training, all of which had evidence of reviews and updates. Staff hadcompleted safeguarding children and adults training to the required level. The registered manager was trained to alevel 4 qualification in safeguarding adults and children.

• There was a strong focus on infection prevention and control measures to ensure ongoing compliance, includingregular audit.

• The equipment and environment used by the provider were appropriate and well maintained. There were effectivesystems to ensure ongoing safety.

• Staffing levels were appropriate to meet the needs of the patients. There were sufficient numbers of qualified staffon the sub-contractors register.

• Patients records were complete and up to date and accessible to those that needed them.

• There were safe medicines management policies/processes/practices which included a service level agreementwith a local NHS trust for supply and audit.

• Patients had their nutrition and hydration needs met and staff used evidence based risk screening tools to assessand manage risks.

• The service operated a 24-hour, seven-day week service with operational staff who were multi-lingual carrying outassessments.

• Staff were employed based on their competency to ensure they were skilled to meet the needs of the individualpatients. Staff were multi-disciplinary and worked well together to provide good quality care.

• People provided feedback about the care they received. The feedback about staff was overwhelming positive, forexample staff were described as caring and experiences were good.

Summary of findings


• The service met people’s individual needs. For example, they sourced aeroplanes that were the right size toaccommodate patients with families. They had accessible translation services to communicate with patients usingtheir own language. Staff were from diverse backgrounds and when assessing a job, staff could be employed basedon their cultural or religious background, for example, employing a Muslim team member if that was a patient’spreference.

• The leadership and staff team were highly qualified. There were effective governance systems to ensure oversightand standards were being met.

• Staff worked alongside accredited bodies, were involved with other regulatory bodies and were involved inresearch.

However, we found the following issues that the service provider needs to improve:

• Sub-contracted patient transport services on the ground did not always have all the relevant checks in place toassure the provider that vehicles had up to date insurance certificates.

• Patient outcomes were not routinely monitored.

• The provider was in the process of writing a business strategy, however it was not available at the time ofinspection.

• Documentation to confirm staff competency was not checked and verified by an experienced member of staff.

• Managers did not have a system in place to document and review annual appraisals and supervision.

Heidi Smoult

Deputy Chief Inspector of Hospitals), on behalf of the Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Emergencyand urgentcare services

We regulate independent ambulance services but we donot currently have a legal duty to rate them. Wehighlight good practice and issues that service providersneed to improve and take regulatory action asnecessary:

• There was a good incident reporting culture whichresulted in improvements in practice.

• Staff were up to date with mandatory training, all ofwhich had evidence of reviews and updates. Staffhad completed safeguarding children and adultstraining to the required level. The registeredmanager was trained to a level four qualification insafeguarding adults and children.

• There was a strong focus on infection preventionand control measures to ensure ongoingcompliance, including regular audit.

• The equipment and environment used by theprovider were appropriate and well maintained.There were effective systems to ensure ongoingsafety.

• Staffing levels were appropriate to meet the needsof the patients. There were sufficient numbers ofqualified staff on the sub-contractors register.

• Patients records were complete and up to date andaccessible to those that needed them.

• There were safe medicines management policies/processes/practices which included a service levelagreement with a local NHS trust for supply andaudit.

• Patients had their nutrition and hydration needsmet and staff used evidence based risk screeningtools to assess and manage risks.

• The service operated a 24-hour, seven day weekservice with operational staff who weremulti-lingual carrying out assessments.

Summaryoffindings

Summary of findings


• Staff were employed based on their competency toensure they were skilled to meet the needs of theindividual patients. Staff were multi-disciplinaryand worked well together to provide good qualitycare.

• People provided feedback about the care theyreceived. The feedback about staff wasoverwhelming positive, for example staff weredescribed as caring and experiences were good.

• The service met people’s individual needs. Forexample, they sourced aeroplanes that were theright size to accommodate patients with families.They had accessible translation services tocommunicate with patients using their ownlanguage. Staff were from diverse backgrounds andwhen assessing a job, staff could be employedbased their cultural or religious background, forexample, employing a Muslim team member if thatwas a patient’s preference.

• The leadership and staff team were highly qualified.There were effective governance systems to ensureoversight and standards were being met.

• Staff worked alongside accredited bodies, wereinvolved with other regulatory bodies and wereinvolved in research.

However,

• Sub-contracted patient transport services on theground did not always have all the relevant checksin place to assure the provider that vehicles had upto date insurance certificates.

• Patient outcomes were not routinely monitored andthere was no system to record outcomes.

• The provider was in the process of writing abusiness strategy, however it was not available atthe time of inspection.

• Documentation to confirm staff competency wasnot checked and verified by an experiencedmember of staff.

• Managers did not have a system in place todocument and review annual appraisals andsupervision.

Summaryoffindings

Summary of findings


AirAir AlliancAlliancee MedflightMedflight UKUKDetailed findings

Services we looked at

Emergency and urgent care


Contents

PageDetailed findings from this inspectionBackground to Air Alliance Medflight UK 7

Our inspection team 8

Findings by main service 9

Action we have told the provider to take 24

Background to Air Alliance Medflight UK

Air Alliance is operated by Air Alliance Medflight UKLimited. The service opened in 2016. It is an independentair ambulance service based at Birmingham Airport.

They are a 24/7 multilingual operation and leader inaircraft technology. They employ 150 staff pool of seniordoctors and nurses on an adhoc basis. They areaccredited by the European Aeromedical Institute andCommission on Accreditation and carry out over 950 airambulance missions per year. For their paediatric andneonatal services they have 14 of their own aircraft basedacross Germany, Austria and UK. The service has had aregistered manager in post since 2016.

The aircraft are a combination of short, mid and longrange. The configurations are two to three stretchers. Thelong-range aircraft can accommodate up to 10 people. AirAlliance Medflight has a team of health workers onstandby to help in case of emergency: using aircraft withmedical equipment to transfer patients quickly andreliably to the desired hospital. The repartition serviceincludes collecting patient anywhere in the world andcared for them until the handover at the destinationhospital. Whether dealing with accident victims whorequire monitoring or critically ill intensive care patients,complex transport requirements can also be met.

This service is registered with CQC under the Health andSocial Care Act 2008 in respect of some, but not all, of theservices it provides. There are some exemptions fromregulation by CQC which relate to particular types ofservice and these are set out in Schedule 2 of The Healthand Social Care Act 2008 (Regulated Activities)Regulations 2014.

Air Alliance Medflight UK Limited provides repatriationservices to patients who have privately funded (or partprivately funded) and this is regulated by CQC. However,they also provide treatment under arrangements of aninsurance policy not primarily or solely intended fordiagnosis and treatment (e.g. travel insurance), which isexempt by law from CQC regulation. CQC’s remit is alsolimited to services provided within England. Air Alliancewere unable to record for each patient how theirtreatment was funded, but were able to confirm that thesame process, policies and procedures are in place for allpatients.

The service is registered to provide the followingregulated activities:

• Diagnostic and screening procedures

• Transport services, triage and medical advice providedremotely

• Treatment of disease, disorder and injury

While on inspection we spoke with the chief flight nursewho has a background in critical care and is the infectionprevention control lead. We spoke with the registeredmanager, who is a registered nurse with a background incritical care, the director for the UK with a background inflight crew, the medical director, a consultantanaesthetist/intensivist, who had clinical oversight, aparamedic and senior flight nurse.

During the inspection, we visited the UK base atBirmingham Airport. We spoke with six members of staff

Detailed findings


including; a registered paramedic, a medical director, theregistered manager, the general manager and two seniornurses, all staff we spoke with also worked within theNHS.

During our inspection, we reviewed nine sets of patientrecords.

There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection. This was the service’s firstinspection since registration with CQC, which found thatthe service was meeting all standards of quality andsafety it was inspected against.

Activity from 2 January 2018 to 21 May 2018 was 131flights from various destinations.

The staff were registered paramedics and nurses,consultants, general managers, and a bank ofsubcontracted staff that could be utilised by the provider.The accountable officer for controlled drugs (CDs) wasthe registered manager.

Track record on safety

• There were no never events

• There were no clinical incidents that met the thresholdfor CQC notification.

• There were no reportable serious injuries.

Our inspection team

The team that inspected the service comprised a CQClead inspector, an additional CQC inspector and a

specialist advisor with expertise in urgent and emergencypatient transport services. The inspection team wasoverseen by Victoria Watkins, Head of HospitalInspection.

Detailed findings


Safe

EffectiveCaringResponsiveWell-ledOverall

Information about the service Summary of findingsWe found the following areas of good practice:

• There was a good incident reporting culture withimprovements made to practice as a result.

• Staff were up to date with mandatory training, allhad evidence of reviews and updates. Staff weretrained to safeguard children and adults. Theregistered manager was trained to a level fourqualification in safeguarding for adult and children.

• There was a strong focus on infection prevention andcontrol with measures to ensure ongoingcompliance, including regular audit andimprovements as a result.

• The equipment and environment used by theprovider was appropriate and well maintained. Therewere effective systems to ensure ongoing safety.

• Staffing levels were appropriate to meet the needs ofthe patients. There were sufficient numbers ofqualified staff on the sub-contractors register.

• Patients records were complete and up to date andaccessible to those that needed them. There weregood medicines management policies/procedures/practices, including a service level agreement with alocal NHS trust for supply and audit.

• Patients received evidence based care and therewere policies and procedures aligned with evidencebased guidance to support good quality care.Patient’s had their nutrition and hydration needs metand staff used evidence based risk screening tools toassess and manage risks.

Emergencyandurgentcare

Emergency and urgent care services


• The central referral service were based in Germany,they operated a 24-hour, seven day a week servicewith operational staff who were multilingual carryingout assessments.

• Staff were employed based on their competency, toensure they were skilled to meet the needs of theindividual patients. Staff were multi-disciplinary andworked well together to provide good quality care.

• People provided feedback about the care theyreceived. The feedback about staff wasoverwhelming positive, for example staff weredescribed as caring and experiences were good.

• The service was set up to meet people’s individualneeds. For example, they could source aeroplanes ofthe right size to accommodate patients with families.They had accessible translation services in the formof a mobile phone application to communicate withpatients using their own language. Staff were fromdiverse backgrounds and when assessing a job, staffcould book staff based on cultural or religiouspreferences, for example, employing a Muslim teammember if that was a patient’s preference.

• The leadership and staff team were highly qualified.There were effective governance systems to ensureoversight and standards were being met.

• Staff worked alongside accredited bodies, wereinvolved with other regulatory bodies and wereinvolved in research.

However, we found the following issues that the serviceprovider needs to improve:

• Sub-contracted patient transport services on theground did not always have all the relevant checks inplace to assure themselves that vehicles had up todate insurance certificates.

• Patient outcomes were not routinely monitored andthere was no system to do so.

• The provider was in the process of writing a strategy,however it was not available at the time ofinspection.

• Staff competencies were observed, however, therewas no related documentation to confirm staffcompetency was not checked and verified by anexperienced member of staff.

• There was not a system in place to document andreview annual appraisals and supervision forsubcontracted staff.




Are emergency and urgent care servicessafe?

Incidents

• Staff were trained to identify and report incidents andwe saw documented evidence of incident reporting.Staff used a paper based system to record incidents.Each flight crew carried a pack of documentation whichincluded an incident report form. This meant that staffhad access to the documentation which they couldcomplete at each flight if required.

• In the event of an incident, staff completed thedocumentation, this was followed up by a review from amanager. Where appropriate, this would be followed bya root cause analysis carried out by the registeredmanager who was suitably trained. We saw evidence ofrecording of incidents over the previous 12 months. Theincidents were assessed using a severity and likelihoodmatrix. Learning points were discussed at clinicalgovernance meetings and then disseminated to staffusing a communication book that had to be signed toevidence staff had read and understood the content.

• We looked at six months of governance meetingminutes and saw incidents were discussed as standardat each meeting. We saw evidence of improvements inpractice as a result of incident reporting. For example, apre-flight briefing form was introduced for crews toensure they carried all the necessary equipment todeliver treatment.

• We asked the leadership team about how safetyperformance compared with other similar services. Theytold us that this was very difficult to do because theywere a specialist service. They had looked at nationalaccreditation data, however it was not always relevantand they could not benchmark or measure against thedata. This was made difficult because data wascommercial and sharing between companies did nothappen.

• We saw that there were specific considerations to theservice within England. For example, staff knew andunderstood duty of candour. Every healthcareprofessional must be ‘open’ and ‘honest’ with patientswhen something that goes wrong with their treatmentor care causes, or has the potential to cause, harm or

distress, apologise to the patient (or, where appropriate,the patient's advocate, carer or family). Medical teamsreferred all duty of candour issues to a medical directorto ensure each case was addressed. Senior staff metmonthly and a medical director attended a quarterlymeeting where duty of candour could be discussed.There had been no deaths or incidents that requiredduty of candour processes to be followed.

Mandatory training

• Any training completed by staff employed by the NHSwas accepted and staff were expected to share theirtraining certificates with the provider. The servicemandatory training requirements were outlined inpolicy. All staff were a minimum level two safeguardingadults and children, Mental Capacity Act 2005 training,infection prevention and control and immediate oradvanced life support this included paediatric lifesupport.

• There was a system to ensure all staff had the minimummandatory required training which was evidenced withcertificates. We looked at the provider’s training matrixwhich highlighted all staff had up-to-date mandatorytraining. We looked at four staff files and each containedup-to-date certificates that met the minimummandatory service requirements. This meant there wasan effective assurance system to ensure staff had therequired minimum training to fulfil the requirements ofthe role.

• Managers had access to a database to check expirydates. The system prompted renewed and updatedevidence of certificates. If people could not provideevidence of up-to-date training they were taken off theflight rota. They then had to reapply for their positionsand go through the recruitment process again. We sawthis evidenced in staff files and in the database kept bymanagers.

• All flight staff were appropriately trained and qualifiedwith mandatory training completed and on file. Some ofthe medical staff, for example, the medical director wasalso a qualified pilot. This meant that there weresubstantive staff who were qualified to fly the aircraft aswell as those subcontracted.

Safeguarding




• All staff had completed safeguarding adults andchildren training. We saw evidence on the trainingmatrix and in staff files of training completed at leveltwo and level three safeguarding adults and children.The registered manager was trained to a level four forboth children and adult. This is in line with theintercollegiate guidance.

• There were safeguarding systems, processes andpractices developed, implemented and communicatedto staff. We looked at safeguarding posters shared withstaff which clearly highlighted the process for sharingsafeguarding information, who to contact and how tocontact them. Staff we spoke with could provide us withexamples of when they had identified a concern and thesteps they took to do ensure the patients ongoingwellbeing. This meant staff were appropriately trained insafeguarding, knew who and how to contact when therewere identified safeguarding concerns.

• The safeguarding lead had completed the level foursafeguarding training for both children and adults in2018. They gave us an example of what they had learnedfrom the higher-level training and what they would nowdo differently. For example, prior to training they hadidentified a safeguarding concern and raised this withthe receiving hospital. Since completing the level fourtraining, they advised they would manage the incidentdifferently. They would make a direct safeguardingreferral to the local safeguarding team. This meant theyhad a better understanding of safeguarding processessince completing a higher-level qualification. Staff wespoke with knew about this incident and had shared thelearning from it to improve their understanding.

Cleanliness, infection control and hygiene

• There was an infection prevention and control lead andan externally validated policy with an aligned auditprotocol to monitor that the policy was followed. Therecognised external validator provided suggestions forimprovements and assurances about the effectivenessof procedures. This meant that their policy andprocedures were effective and in line with nationalguidance.

• There were monthly reviews of documentation toensure the policy was followed. Staff carried out spotchecks of documentation to ensure compliance. Inaddition, there was cleaning and fogging of the aircraft

at least weekly which included disinsection. This waswhere staff shut the aircraft door, sprayed insecticide toreduce the incidence of bugs that might carry risks, forexample, malaria. Staff were kept aware of localdiseases that could be brought on to the aircraft.

• An external provider was employed to deep clean eachaircraft before and after each flight. This was required toprevent and control infections. For example, theycarried out a deep clean fog for MRSA. Each clean wasdocumented and infection notes completed to relayspecific response that had to be dealt with. Staff usedspecialist equipment to measure cleaning efficiency.The instruments used were evidence based tools tomeasure effectiveness of surface cleaning anddisinfection in healthcare settings. Care was takenparticularly in the main patient contact areas includingcockpit. Staff cleaning the aircraft were not permitted totouch anything in the cockpit and therefore relied onsteam clean only. All products used were aviation safeassured.

• The aircraft we inspected was visibly clean, equipmentwere cleaned after each usage, we saw document tosupport this.

• The leadership team kept up to date with worldwideinfections using approved websites when they travelledto, and within, high risk areas. Staff who were suitablyknowledgeable and skilled were employed to ensurethey were competent to assess and managecommunicable diseases that might be anticipated froma country. For example, countries were there had beenEbola risks. This meant they were assured competentstaff were on board to deal with potential concernsspecific to that country.

• Staff emptied clinical and general waste into anappropriately sized locked container each day. AirAlliance had an agreement with a local trust for disposalof any clinical waste such as sharps bins. This meantwaste was disposed of using an approved provider.

• All staff were registered professionals who workedsubstantively in healthcare settings. This meant thatthey had a level of training with annual infectionprevention updates from their NHS role. We saw thisevidenced in a training matrix and in staff files. Staff hadlocal induction updates which were audited.




• Infection prevention and control was discussed andrecorded at clinical governance meetings. For example,at each meeting we saw references to policies, training,and addressing concerns related to preventing thespread of infections. Staff kept up to date by looking at acommunication folder which had to be signed toconfirm staff had read the most up to date information.Staff used a closed group social media to transmitupdates and there was a clinical folder to be read on theaircraft.

• Staff ensured standards of cleanliness were maintainedby carrying out monthly infection control audits relatingto the environment, hand hygiene and personalprotective equipment. We looked at recorded auditsand saw that from March 2018, each month the auditswere at 90% compliance which met their target.

Environment and equipment

• Equipment and aeroplanes were maintained accordingto manufacturer’s instructions. The aeroplanes werekept in a locked warehouse at the main provider site.Staff were required to attend the main office to collecttheir identity badge and sign out for the day. Beforetaking out the aeroplane out on transfer, each crewmember and pilot carried out flight worthiness checksto ensure safety measures were in place.Air Alliance had medical equipment on board, someequipment for monitoring, diagnosis and therapy aswell as back-up devices. This included non-invasive andinvasive pressure monitoring (blood pressure, centralvenous pressure, cerebral pressure, tissue compartmentpressure). They had assisted spontaneous andcontrolled ventilation of intubated and non-intubatedpatients. Ventilatory adjustments were governed byportable blood gas analysis. Large oxygen tankson-board the aircrafts enabled ventilation, even withhigh inspiratory oxygen concentrations. Thepermanently installed double-stretcher allowedtransport of two patients if medically acceptable. On theChallenger 604, up to three stretchers could be installed.

• Staff could access oxygen and nitrous oxide cylinders insuitable secure locked rooms at the warehouse. On theaeroplane these were kept in a secured designated areain the back of the plane. Empty and full cylinders were

kept separate and were easily identified. Air Alliance hada contract with an approved third party for delivery andpick up of cylinders. This meant they were accessible,securely stored and disposed of appropriately.

• We were unable to review the equipment kit as both kitswere out on flight transfer, however we saw staff carriedout a weekly checklist for stock, and daily check out andcheck in equipment log. Staff told us that medical staffwere responsible for the checking in and out of theequipment and to ensure all stock was replaced in eachequipment bag.

• Staff told us that each equipment bag was sealed with atag and a serial number. When they checked out anequipment bag they always checked the tag was sealedand recorded the serial number and expiry date. We sawthis recorded to ensure the kits were safe to use.

• The chief nurse told us that they were waiting for threenew equipment kits. These kits were lighter to carry andmore electronically efficient. The deadline for fullimplementation was August 2018. There were processesto ensure replacement of equipment and consumables.There were also processes to reseal, check andreplenish equipment and consumables and there werechecklists in every bag.

• Arrangements were in place for the clinical engineeringcompany to contact Air Alliance when equipmentservicing was due. There was an equipmentspecification record in place. The record containeddetails of what equipment staff kept in each equipmentbag.

• We checked the restraints on the stretchers on oneaeroplane and found them to be in good condition. Thestretchers on the aeroplane could transport patients upto 130kg depending on the specification on theaeroplane.

• Staff demonstrated they had three different extendableseat belts for children all depending on weight andheight of the child. We were also told by staff that theyhave an incubator pod that could replace a stretcher ona flight transfer if needed. This meant the needs ofchildren were considered and equipment was availableto meet their needs.




• Staff told us and we saw that they provided patientswith an additional air mattress such as ‘vac’ mattressspecific for spinal patients and those patients onlong-haul flights. This was to ensure patients’ pressureareas were relieved as much as possible.

• Patients were transferred from the airport to theiragreed destination using a sub-contracted patienttransport services. We looked at the patient transportservice records to ensure all the checks were in place,for example, insurance was up to date and saw thatthese checks were incomplete for one regularsubcontractor ground patient transport service. Onemanager told us that this was a piece of work that theyneeded to do to improve their checks with patienttransport services on the ground.

Assessing and responding to patient risk

• Patient information could be limited at referral stage,however, staff carried out a bedside assessment inaddition to the information received. Staff workedclosely with the leadership team to ensure that eachflight was well planned. The process of transportingpatients from a range of other countries brought with itvarying complex issues that could have an impact onthe safety and wellbeing of patients.

• Staff used an integrated web-based quality and riskmanagement system for aviation this was implementedin 2018. The flight crew were fully trained; however, themedical crew training had been planned for roll out theweek following this inspection. Trained staff were in aposition to support medical staff during flights inaccessing information if needed.

• The electronic system meant staff could log in andreview patient online reports and risk assessments.When fully implemented, staff would have a phone appto access patient information and to submit reportswhile mobile. This meant all information relating topatient transfers could be managed while trained staffwere on the go and at any time.

• Staff could access patient transport pre-flight andpost-flight briefing documentation. This included achecklist to confirm staff were well rested, fit to go,maintenance issues, equipment safety and diversions

possibilities. The leadership team told us diversionswere a rarity, however, the pilot always planned for it.This meant there were robust systems in place to checkfor safety.

• Staff told us assessing and managing risk was anongoing consideration. Staff provided us with numerousexamples of some of the complex issues they had toconsider. For example, cases where flights had to bediverted. Staff considered in advance, countries theywere flying over and if expert care was accessible if adiversion was necessary. For example, they wouldconsider if they needed blood or neurosurgeryexpertise. These considerations would be assessed inadvance of each journey and were based on thepatient’s individual needs as well as which country theywould be travelling to and from.

• Staff used National Early Warning Scores (NEWS) whichmonitors patients’ physiological presentations such aspulse, temperatures and respiration to ascertain if theyare at risk of their health deteriorating. We reviewed fourpatient records and found NEWS was completedcorrectly. All patients’ vital signs were taken before anytransfer as a baseline observation. Staff told us anyconcerns would be considered to determine whether apatient was fit for transfer. Staff told us they monitoredany patients they were transporting closely for anychanges in condition and ensured they tookobservations regularly so they could share informationwith the admitting hospital.

• Staff gave us an example of when a patient who waswell on take-off, had deteriorated mid- flight and howthey managed it. There was an anaesthetist and seniornurse on board the flight. They discussed thedeteriorating patient to review options and used aninflight phone to call directly to the on-call clinicalco-ordinator for an independent view. Changes in thepatient’s clinical presentation meant changes might beneeded to ongoing care arrangements. If the patientrequired a greater level of care this meant the hospitalmight have to find specialist beds or care facilities.

• Staff used a client risk assessment matrix to assesspatients’ needs. Each patient received a red, amber orgreen rating, which related to what medicalcoordinators had to consider to keep patients safe.Some clients had a reputation for not providing all theinformation needed to safely assess the patient’s needs.




The leadership team told us they sometimes refused ordeferred jobs as a result and we were given examples.Referrals are accepted on the basis that there is verylittle risk of deterioration.

Staffing

• There were 8.5 substantively employed staff at the UKAir Alliance location. This included 1 whole timeequivalent general manager, 1.8 whole time equivalentmedical team, five whole time equivalent pilots, 0.5whole time equivalent administrative support. Theremaining staff were subcontracted with up to 50 staff,made up of a range of nurses, doctors, consultants andparamedics. The staffing ratio minimum was 1:1, often2:1 (doctor and nurse: one patient) and all were suitablyqualified.

• The leadership team deployed sufficient numbers ofclinical staff with the right qualifications and skills tokeep people safe from avoidable harm and abuse. Theregistered manager planned staffing levels, skill mix andgender balance to ensure that patients received safecare and treatment at all times. Staff followed variousshift patterns, Air Alliance ensured pilots and clinicalcrew staff always had 12 hour breaks. This was includedin their staffing policy.

• Staffing was managed using an online calendar, whichwas colour coded with each staff member’s availability.The staffing mix was a combination of doctors,consultants and nurses. All staff were employed to flyregularly to build their skills base. The senior flight nursechecked if there were any gaps in skills, if so, staff wouldthose staff would not be used. The management teamwere also qualified nursing and medical staff and ifneeded could step in. This meant it was rare that flightswere not accepted due to competency or staffingdeficits.

• Consultants on the staff team could be employed on theflying or medical roster. Staff in Germany and Viennacould also be used on the rota. Staffing numbers variedmarkedly. The staffing list could be anywhere from 20 to50 staff. This meant that there were sufficient staffinglevels to cover each flight.

• Category of care required determined staffing levels. Forexample, for those patients who required normal andspecial care, a specialist registered nurse and seniorregistered practitioner were deployed. For those

patients who were assessed as high dependency,intensive care and high risk intensive care, acardiothoracic or consultant would form part of theteam who transported the patient to their destination.This meant the staffing mix was adjusted to meet themedical needs of each patient.

Records

• We looked at nine paper patient records. They werecomplete, legible and included all the informationneeded to assess the level of care and treatmentrequired.

• Staff recorded when they received inadequate medicalnotes from referring clients. For example, the patient’snotes may have not have identified all medical issueswhich could complicate or preclude safe transfer. Themedical coordinator reviewed the notes and looked atexisting mitigation. Staff used a client risk matrix toidentify organisations who regularly providedinadequate patient information. The leadership teamhad made the decision to refuse to work withorganisations who failed to provide sufficientinformation.

• Staff completed documentation audits, for example 10sets of transfer notes were audited for November/December 2017. Staff carried out documentation auditsto ensure records were completed in line with policy. Inresponse to audits, staff had access to a trainingprogrammes on how to complete good qualityassessments and documentation. The notice board inclinical room displayed an example of gooddocumentation for staff to see.

• All patient information was locked in the clinical roomand then scanned into the system to make itelectronically accessible. The notes clearly indicatedhow long they should be retained for and there was asystem in place for confidential disposal. The areawhere records were kept was secure and only medicalteams had access to it. Sometimes patient data wassent to the company who paid for the job. This was withpatient consent and was password protected before itwas securely sent. This meant that there was a securesystem with consent required to share and storeinformation.

• Patient information needed to deliver safe care andtreatment was often determined by an international




system of computerised exchange. Many hospitalsexchanging information were cautious about what theyshared. This sometimes meant that not all patientinformation was received until the point of patientcollection.

• Staff were trained in information governance andunderstood the principles of data protection. Staff toldus they treated patient information confidentially whichcomplied with the Data Protection Act. Staff used secureprocesses to share information and there was a policyand protocols in place to ensure ongoing confidentiality.

Medicines

• Medicines were stored safely and managedappropriately. There was a related policy for prescribedand stored medicines in line with local and nationalguidelines. Air Alliance had a service level agreementwith local hospital NHS trust who provided stock andpharmacy advice when needed. This meant the servicewas supplied and supported by a local hospitalpharmacy department.

• Staff completed documentation to ensure medicationswere checked and securely stored. The documentationwas consistently and accurately completed. Thecontrolled medicine book was signed daily by twoclinicians and dated to verify checks were completed.Temperatures for the storage of medicines wererecorded appropriately and any medicines relatingconcerns could be discussed with the NHS trust deputychief pharmacist for guidance and direction.

• Controlled drug orders were carried out by fax. Orderingsheets were retained for 2 years and supplied by theHome Office. There was a security arrangement forcontrolled drugs and a policy written and checked byawarding/licensing body. This meant there wereprocesses to ensure standards were met relating tocontrolled drugs.

• Intravenous fluids were safely and securely stored in aroom locked by a key that was kept in a key coded pad.Only clinical staff had access.

Are emergency and urgent care serviceseffective?

Evidence-based care and treatment

• Managers worked with referring agents to ensure theyhad the right information to assess people's physical,mental health and social needs holistically. We weregiven examples of when clinical staff providedadditional support to referring agents to ensure theyprovided the right information. This helped to make aholistic assessment to ensure care, treatment andsupport was planned and delivered in line withlegislation, standards and evidence-based guidance. Forexample, National Institute of Health and CareExcellence (NICE) and other expert professional bodies,to achieve effective outcomes such as asthma,monitoring airway inflammation, Atrial fibrillationmanagement, diabetes.

• Staff used many NICE guidance documents to ensurethey were being evidence based in their approach. Forexample, we looked at the local protocols thatreferenced National Institute for Health and CareExcellence guidance links. Staff used care of strokepatients and pressure ulcer prevention documentation.We saw protocols and the use of safety guidelines. All ofwhich supported evidence based practice.

• Staff used an adaptation of intensive care societyguidance, which was relevant to their operations. Theyalso used the Royal College of Nursing standards forprescribing and the Royal College of Physicians forNational Early Warning Score. This meant they used upto date evidence based guidance to help them makedecisions using established standards.

• Air Alliance were an approved provider for EuropeanAiromedical Institute (EURAMI) and Commission onAccreditation of Medical Transport Systems. This meantthey had met the standards set out by these bodies toensure their practice was acceptable. Staff were trained,knew and understood the Mental Capacity Act (MCA).

• All staff were expected to keep up to date withdevelopments. For example, the registered manager, aregistered nurse, was the chair at the critical care andflight nursing forum. This was a forum for the RoyalCollege of Nursing members working in critical care andflight nursing. The registered manager was also part ofthe Royal College of Physicians press conference at thelaunch of NEWS. This meant staff were involved inopportunities to learn and share practice related to theirfield.




• Staff normalised the journey by wearing every dayclothes. There was a protocol for those who presentedin a challenging manner. In those circumstances,patients could be chemically restrained. For example,staff were experienced in managing patients withdelirium.

• Mortality and Morbidity reviews were discussed atgovernance meetings. We looked at governance recordshowever there were no recorded mortality cases fromUK base. We saw a morbidity review recorded outliningan urgent flight. Leaders discussed the case at lengthbut transfer was declined due to their unstablecondition. Alternatives were discussed and conclusionswere based on the safety and wellbeing of the patient.We saw other referrals that had been reviewed anddeclined based on the safety and wellbeing of thereferred patient. This meant that all referrals wereassessed for suitability and patient safety and prioritisedbased on whether it was in their best interest toproceed.

Nutrition and hydration

• Staff used Malnutrition Universal Screening Tool andGULP (a dehydration risk screening tool) scores toassess and manage patient’s nutrition and hydrationneeds. Dietary and nutritional needs were assessed inadvance and preferences provided where possible. Thisinformation was handed over to the receiving hospitalstaff.

• All aircraft carried a good supply of water and infusions.Staff had limited resources on flights and patients werein their care for a short period of time. The provider hada contract with a local catering company who suppliedfood for each flight. This could also be tailored topatient’s dietary requirements, for example, gluten freeor halal. This meant that they met patient patient’snutrition and hydration needs where possible.

Response times/patient outcomes

• The central operations team operated 24 hours a day, 7days a week and responded to referrals immediately.Suitability and acceptability were considered, as well asthe timing and urgency of the transfer. Those who werenot medically suitable for transfer were referred back tothe referring agent. Patient outcomes were the overalldeciding factor for suitability.

• The registered manager told us information aboutpatient care and treatment outcomes were not routinelycollected and monitored. However, they told us theiraudits were benchmarked against EURAMI (EuropeanAeromedical Institute) and Commission onAccreditation of Medical Transport Systems for neonataland paediatric referrals. They could not fully monitoroutcomes. This information would have needed aresponse from accepting hospitals who could notrelease the data.

• The service did not submit data to the Intensive CareNational Audit and Research Centre (ICNARC) audit, asthey are not an admitting unit. However, the leadershipteam use ICNARC data to help improve outcomes andwere regularly invited to conferences. Using this data,they studied the process of level three (highdependency) admission via air ambulance. Theycollected data on a number of jobs, timing, time takenand any delays getting critically ill patients back to UK.In addition, they looked at waiting times for beds. Thismeant that they were using data to try to understandand improve outcomes.

Competent staff

• All staff received an induction, which was documented.They were trained in flight specific manual handling,aircraft safety and hanger safety where risks werespecific and could be dangerous. The leadership teamwere in the process of introducing a double module ininternational aeromedical repatriation and the providerhad registered appropriate staff as associate lecturerswith Birmingham City University. The induction processmeant that everyone had a base level of knowledge thatcould be built upon.

• Specialist learning was included in the induction, forexample, infection prevention and control on an aircraft.There was an anticipated level of cleaning on the aircraft which was detailed within induction. All staff weregiven a copy of a medical operations manual and signedfor receipt of it. All staff’s first few flights was with aregular flyer. Staff had to be confident that they knewand understood policies and procedures. All staff’scompetencies, for example, infection prevention andcontrol specific to flights was checked by an




experienced member of staff, however there was limiteddocumentation in staff files to confirm these checks hadtaken place. The leadership team identified this was anarea for improvement.

• Staff could access continuing professionaldevelopment. This ranged from airway management tohuman factors awareness. We looked at trainingcertificates in staff files and on a training matrix. We sawup to date certificates relating to, PREVENT, mentalhealth, dementia, as well as others. One member of staffwas completing an academic qualification in Bachelorof Science paramedic sciences. This showed that staffwere engaged in their professional development.

• All staff were supported to deliver effective care andtreatment. Managers told us substantive staff receivedannual appraisals. However, we did not find a system inplace to record supervision sessions, or to monitorappraisals. This meant we were unable to see whetherstaff were set objectives and were supported inachieving them.

• All registered nurses were required to demonstrate thatthey were suitably qualified. They did this throughrevalidation process with the Nursing and MidwiferyCouncil. This was evidenced in all staff files we lookedat. The leadership team discussed education andtraining at monthly governance meetings. We saw that astudy day covering essential aviation physiology andsafety had carried out on 23 February 2017. This meantthat registered clinicians evidenced their continuingprofessional development.

• The leadership team provided us with an example ofhow poor, or variable staff performance was identifiedand managed. They told us staff were supported toimprove, however they provided one example of wherea staff member had to be dismissed, this meant staffperformance was assessed, supported and whennecessary staff were dismissed if it meant people wereput at risk.

Multidisciplinary working

• All necessary staff, including those in different teams,services and organisations, were involved in assessing,planning and delivering care and treatment. Care wasdelivered and reviewed in a coordinated way whendifferent teams, services or organisations were involved.There were clinical co-ordinators who were registered

senior clinical staff available seven days a week andthere was an on-call duty rota. This meant there was acompetent person available to co-ordinate care andtreatment for patients at all times.

• Leaders could access specialists to join crews whenneeded. For example, when they needed anaesthetistand intensivist or a senior paediatric clinician.

Health promotion

• The registered manager had a teaching qualificationand a post graduate qualification in health promotion.They told us that they promoted wellbeing at all times.They were limited in how much work they do in terms ofhealth promotion, however patient information leafletsformed part of this process.

Consent, Mental Capacity Act

• Staff were trained and understood consent anddecision-making principles outlined in the MentalCapacity Act 2005. All patients signed a consent formand a copy was kept in their records. Staff gave usexamples of when they identified capacity issues, madebest interest decisions involving family and otherprofessionals and made a decision based on thepatient’s best interests.

• Staff did not use physical restraint; however, they wouldconsider chemical restraint if it was assessed asappropriate.

• Staff assumed capacity unless it was suspected thepatient lacked capacity, then made best interestdecisions at the time.

Are emergency and urgent care servicescaring?

Compassionate care

• We did not see any patient interactions or speak withpatients; however we did see that staff interacted witheach other in a respectful and considerate way. Wereceived compliments directly from people who hadused services and we saw feedback from clients who feltthe service provided by staff was inclusive, supportiveand sensitive to people. One patient said, that staff gothe extra mile to ensure patient safety, wellbeing andcomfort.




• Staff told us they were mindful of respecting people’sprivacy and dignity especially in the confined spaceavailable on a plane. This included physical or intimatecare.

Emotional support

• Staff told us that they worked closely with patients toensure they were supported in their emotionalwellbeing. They gave us examples of when patientsmight be anxious in a small plane; small aircraft oftenmeans more turbulence. Staff were supportive byproviding clear information about what to expect fromthe start, to the end of their journey. Staff sometimesprovided anxiolytics in addition to lots of reassurance inadvance and throughout.

Understanding and involvement of patients andthose close to them

• Staff communicated with people so that theyunderstood their care, treatment and condition and anyadvice given. Staff were considerate of ways tocommunicate with people that was sensitive to theirindividual cultural needs. For example, to provide amale crew member to speak with men who might notfind it culturally acceptable to communicate with femalecrew.

• Staff took patients through what to expect as part of theconsent process. This outlined risks inherent, forexample, experience of turbulence, dehydration andfatigue.

• Staff assessed the suitability of involving and carryingpatient’s carers or involving other representatives in thedelivery of care. Wherever possible patient’s familiesand other significant people were involved in patientcare. If assessed as appropriate relatives and loved onescould travel with the patient, however, each situationwas assessed using individual information.

Are emergency and urgent care servicesresponsive to people’s needs?

Service delivery to meet the needs of local people

• Service was delivered to patients across many countriesand staff had access to a number of resources to

support them in knowing and understanding the needsof the local population. For example, the Foreign andCommonwealth Office. The information was used toinform how services were planned and delivered.

• Staff were used to working with diverse communities indifferent countries where there were culturalconsiderations. For example, many of their patientswere transferred from North Africa. This is a countrywhere some women were expected to cover their hair.Staff had access to a headscarf which was kept on theaircraft.

• There were service level agreements in place and staffworked with other providers and relevant stakeholdersinvolved in planning services. For example, working withlocal NHS trust for medicines and local patient transportservices to collect patients from the aircraft to theiragreed destination.

• The registered manager told us they protected peoplefrom avoidable harm and understood the Equality Act2010. They did this by employing a diverse mix of stafffrom the NHS workforce who were used to working therequirements under the Act. Assurance was provided inthe form of training and learning from work in theirsubstantive roles and in their contribution to the workwith the diverse group of patients they worked with atAir Alliance.

Meeting people’s individual needs

• Staff could access aircraft to meet the specific needs ofpatients and their families. For example, there wereplanes that could be used for bariatric (heavier) patientsand planes suitable for transferring paediatric patientsand their families.

• Where safe travelling companions were accepted toaccompany a patient, each case was individuallyassessed and companion support was activelyencouraged for patients living with dementia, learningdisabilities or at end of life. There were no recentexperiences of transports involving patients withlearning disabilities or cognitive deficits. For patients atend of life, care would be taken to have family memberstravel with them. Thought, care and consideration wasgiven to each situation based on their own individualcircumstances.




• Air Alliance had a clinical partnership with Embrace, aCommission on Accreditation of Medical TransportSystems for neonatal and paediatric referrals hosted bya children’s NHS hospital. To meet the needs ofneonates there were two incubator stretcher systems.One was an intensive therapy unit and the second washigh dependency unit with a portable incubator to helpinfants receive the critical care they needed by air. Thesewere supported by the latest ventilators andhumidifiers, capable of providing comprehensiverespiratory support to the smallest of lungs.

• While co-ordinating and planning care, staff consideredgender mix and tried to have a mixed gender crew toensure there were male staff for those patients whoculturally find it difficult to communicate directly withfemale staff. Staff were supported to understand culturalcomplexities and this was included in security andself-awareness training that all staff received.

• Staff had access to an app on a mobile telephone thatwould instantly translate both visually and audibly. Staffwe spoke with knew how to access and use this facility.This meant they could communicate with patientswhere English was not their first language.

• Patients had the option of food to suit their individualrequirement if possible on each flight, for example,vegetarian options. Staff told us they tried to have arange of food available to patients and those travelingwith them.

Access and flow

• A central operations team received each transfer requestfrom referral organisations and a full medical report wasrequested which should include initial assessment, testresults, diagnosis, and treatment. Patient details werediscussed with the medical director and senior medicalteam to confirm suitability and acceptability of therequest. The team considered the timing and urgency ofthe transfer. To ensure safety, there was a care pathwayand cross communication between differentgeographical areas. They used triage levels one to fourto establish which staff were required for which level ofcare. Level four, for example, was high risk intensivecare, this meant they would need an intensive therapyunit consultant for the transfer.

• If the patient was assessed as not medically suitable fortransfer the concerns were discussed with the referring

agent. The medical director had the final say on whetherto accept a transfer or not. This meant that suitabilityand acceptability was assessed by a team of seniorclinicians based on whether a patient was safe totransfer.

• The registered manager told us that delays were rare.For example, weather conditions meant flights might bedelayed. There could be technical issues when taxiingwhich might cause delays. There had been incidentswhere the plane has had to refuel and deal withtechnical issues prior to take off.

Learning from complaints and concerns

• Staff, people who used services and those who paid forthe service could raise complaints and concerns. Therewas an embedded complaints procedure and relateddocumentation. We saw this evidenced in the servicedocumentation which included how complaints weredealt with and what the learning was. For example, welooked at one complaint where a referring agent hadnot organised a hospital booking for a patient. Thisresulted in the provider no longer using the agent.

• All patients were provided with feedback forms and itexplained how to make a complaint or raise concerns.There was also the option to complain via the servicewebsite. There had been no complaints received frompatients. Referring agents were also encouraged to raisecomplaints and we saw examples of this documented inmeetings from minutes. We looked at four complaintsfrom referring agents. Each complaint was reviewed,assessed and shared with staff to drive improvement.They were also dealt with within appropriate timescales.

Are emergency and urgent care serviceswell-led?

Leadership of service

• Staff at senior leadership level were suitably qualified,with substantive clinical roles and specialist training.The general manager had an extensive background inoperational aviation and was a trained flight instructor.The medical directors worked substantively in NHStrusts and provided clinical oversight and critical careinput.




• The leadership team applied strict recruitment criteria.All nursing staff had at least five years post qualifyingexperience in specialised intensive care. Each staffmember whether substantive or sub-contracted hadmonthly checks with General Medical Council, Nursingand Midwifery Council and the Health and CareProfessionals Council. This meant that all staff werechecked against these regulatory bodies for issuesrelating to their registration.

• The leadership team were supported in achievingadditional competencies through training andprofessional development experiences. For example,the registered manager completed a level foursafeguarding qualification. The medical directorcompleted a Caldicott Guardian course. This was Staffwere involved at a senior level with the Royal College ofNurses critical care flight nursing forum.

• The leadership team had completed accreditedmanagement studies courses and other leadershipqualifications. Two members of staff had a teachingcertificate to assist in training staff. One member of staffhad a diploma in end of life care which included ethics,which helped them guide decision making.

Vision and strategy for this service

• The leadership team told us that they did not have astrategy; however, they had a meeting planned on theday of inspection to work on a strategy to reflect thenew service.

• As an organisation the strapline was ‘We fly for your life’.We saw this on the company literature. The leadershipteam and staff we spoke with told us their missionstatement and values were that they were patientfocussed, quality and safety driven.

Culture within the service

• Staff we spoke with told us that they felt supported,respected and valued. This was evidenced in thecommitment to ensuring they were supported todevelop professionally. Staff told us they were affordedflexibility in their work patterns and that they feltlistened to and invested in. Staff told us they worked in aculture where they were encouraged to be open andhonest at all levels within the organisation, includingwith people who used services.

• All staff we spoke with told us that Air Alliance promotedthe concept of a ‘Just Culture’ organisation. This meantthere was a culture which encouraged incidentreporting without blame. We saw a poster in the staffarea about ‘Just Culture’. The poster explained to staffhow to raise complaints and incidents.

• Staff were encouraged to raise concerns aboutdisrespectful, discriminatory or abusive behaviour orattitudes. However, staff could not provide us withexamples of when this might have happened.

Governance

• The leadership team did not always assure themselvesthat sub-contracted patient transport services on theground had all the relevant checks. For example, onesub-contracted service did not have up to dateinsurance certificates and all the relevant checks inplace to ensure they offered a safe service whentransporting patients.

• There were good systems to ensure staff received all thenecessary checks to keep people safe. For examples,certificates of competence and recruitment processes.

• There were governance arrangements in place for safemedicines management. There were systems policies,processes and practice with a service level agreementwith a local NHS trust for supply and audit.

Management of risk, Issues and performance

• There were comprehensive assurance systems andperformance issues were escalated appropriatelythrough clear structures and processes

• There was a programme of internal audit to monitorquality and operational processes, and systems toidentify where action should be taken. We saw thismanaged at varying levels and evidenced in auditfeedback documentation, governance meetings whichincluded managing risk.

• The leadership team compiled a risk register with theinput of all employees. The risk register was site specificand included incidents, findings and processes. Therewere three areas of focus; medical, flight and generalrisks. All risks had a summary of consequences andmitigation. Any new risks were added to this register andthe document was discussed at monthly governancemeetings.




Information management

• The medical director was the Caldicott Guardian whohad completed an associated masterclass in April 2018and registered with NHS Digital in June 2018. A CaldicottGuardian is a senior person responsible for protectingthe confidentiality of people's health and careinformation and making sure it is used properly”. theCaldicott Guardian was to act as the “Moral Compass” ofthe company. They ensured that choices made wereclinically correct, ethically appropriate and not primarilydriven by commercial concerns. We saw this evidencedin the decisions made when assessing and acceptingsuitability of patients.

• Trained staff used an integrated web-based quality andrisk management system for aviation. The electronicsystem supported staff in accessing and completing realtime entries on to patient reports and risk assessments.This meant that trained staff, of which there was one ona flight could access real time information to help themmake decisions and use the information to effectively tomonitor and improve the quality of care.

Public and staff engagement

• People’s views and experiences were gathered usingfeedback forms. The registered manager told us that

feedback from people who used the service waspredominately positive. Staff were engaged to ensuretheir views were reflected in the planning and delivery ofservices and in shaping the culture.

• There were positive and collaborative relationships withexternal partners to build a shared understanding ofchallenges within the system and the needs of therelevant population. Staff engaged with services acrosscountries and considered their views and to deliverservices to meet those needs.

Innovation, improvement and sustainability

• The leadership team told us they were regularcontributors to industry publications (InternationalTravel Assistance Journal) and that they were Invitedspeakers to national (Royal Aeronautical Society) andInternational Tourism and Investment Conference. Theyalso contributed to the audit of UK intensive care unitadmissions.

• Staff were involved in a piece of work to identifyfrequency of repatriations from overseas, raise nationalawareness and formalise guidelines. This meant theywere working to ensure they were an improvingorganisation.




Areas for improvement

Action the hospital SHOULD take to improve

• Sub-contracted patient transport services on theground should have all the relevant checks in placeto provide assurance that they had up to dateinsurance certificates and all the relevant checks inplace to ensure they offer a safe service whentransporting patients.

• Patient outcomes should be monitored and used tomake improvements.

• There should be a business strategy that outlines theobjectives and plans for the service.

• Staff competency observations should bedocumented to evidence staff were safe to carry outtheir duties.

• Managers should have a system in place to hold,document and review annual appraisals andsupervision.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

This section is primarily information for the provider

Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.


Enforcement actionsEnforcementactions


Action we have told the provider to takeThe table below shows why there is a need for significant improvements in the quality of healthcare. The provider mustsend CQC a report that says what action they are going to take to make the significant improvements.

Why there is a need for significantimprovementsStart here... Start here...

Where these improvements need tohappen


Enforcement actions (s.29A Warning notice)Enforcementactions(s.29AWarningnotice)


Air Alliance Medflight UK NewApproachComprehensive Report ...

Documents

Transcript of Air Alliance Medflight UK NewApproachComprehensive Report ...