CIPHER Medical

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment of the service we did not rate the service. At this assessment the rating is good.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had an incident and investigation policy which set out clear expectations for reporting, reviewing and learning from safety events. Managers adopted and promoted a just culture response for staff to report incidents and near misses. Managers supported staff to raise concerns without fear of blame.

Staff understood the policy and were able to describe how to report incidents through the electronic internal system.

Managers reviewed incidents promptly and ensured appropriate actions were taken to reduce the risk of recurrence. Lessons were shared with the whole team and the wider service, including external and contracted partner organisations. Wider learning was shared with the service’s contracted NHS ambulance services and acute trust.

The provider was committed to meeting the requirements of the NHS England Patient Safety Incident Response Framework (PSIRF). Mangers had embedded PSIRF principles across NHS funded and non NHS activity.

Incident data from March to September 2025 showed investigations were completed appropriately and we saw evidence of learning, staff reflection and changes made to improve safety and prevent recurrence.

Incident themes and trends were monitored and discussed through governance structures. Learning from incidents was cascaded to all staff through internal communications, staff boards and safety briefings. Staff were able to give examples of changes made following incidents and we saw evidence of learning being used to improve practice.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service operated within the 999-response framework contract and delivered urgent and emergency care (UEC) and patient transport services (PTS) on behalf of the NHS ambulance trust under a service level agreement (SLA). We found that the service had clear and effective systems in place to support assessment, treatment and transfer of patients across both its urgent and emergency care (UEC) contract and its patient transport service (PTS). As an external provider, services are reliant on the NHS ambulance trust command and control systems, clinical pathways and operational policies with resources deployed via the NHS ambulance trust emergency operations centre (EOC).

For PTS, booking and transport arrangements were consistently managed in line with contractual requirements. Staff demonstrated safe handover practices and maintained continuity of care for patients throughout their journey.

The provider operated within an established Quality Management System (QMS) and had their own policies in place which staff could access. This provided assurance that operational processes and governance structures were regularly reviewed.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. They understood their responsibilities for notification of safeguarding incidents to the contractor of services. The service had well established partner working and contacts around safeguarding with their contractors and local authorities.

Staff received adult and children's safeguarding training. Data showed that staff had achieved the organisational 95% compliance target. There were current safeguarding policies, and these reflected the national guidance for adults and children.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff had daily access to expert safeguarding advice, available both within the service and externally via the NHS ambulance trust. Staff knew how to raise concerns out of hours. The service had three designated safeguarding leads, and they had been trained to level 4.

We saw evidence of safeguarding referrals and action taken which were all appropriate.

The service had a duty of candour policy which set out clear expectations for being open and honest with patients and families when things went wrong. It required staff to notify promptly, offer appropriate support and explain actions taken to prevent similar incidents happening again. We saw evidence that the provider complied with the duty of candour.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

For PTS activity, staff assessed mobility, oxygen requirements and any safeguarding concerns to ensure people could be conveyed safely. Crews involved patients in decisions, what support they needed and how best to maintain comfort and dignity during transport. We saw examples of staff safety netting effectively when concerns about a person safety or home environment were identified. For example, crews conveyed a patient home who was expected to have a package of care to support their needs. On arrival, crews identified that this had not been set up and the patient would be unsafe to be left without immediate support. Crews reassessed the situation, discussed the risks with the patient and made the appropriate decision to return them to hospital to ensure their safety. Staff were vigilant, responsive and proactive in manging emerging risks.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had a comprehensive vehicle maintenance policy which set out clear expectations for the servicing, upkeep and safety of the vehicle fleet and equipment maintenance. There was a dedicated fleet team who had oversight of fleet and equipment maintenance. Records showed that all vehicles were serviced in line with manufacturer guidance, all had current MOT certificates and were roadworthy and safe for operational use. Health checks of emergency vehicles were carried out every 8 weeks, while patient transport vehicles underwent checks every 12 weeks to ensure they remained safe, roadworthy and fit for purpose.

All ambulances were kept within a secure and monitored compound. Vehicles were equipped with all essential emergency equipment required for the scope of practice. Staff completed daily vehicle and equipment checks; any defects were reported and actioned.

All consumables were in date and stored appropriately. Stock rotation processes were in place. Drug bags were checked at the start of every shift.

The service ensured all medical device equipment were safe, well maintained and fit for purpose. All equipment underwent annual maintenance in line with manufacturer guidance. This was monitored through scheduled checks and formal audit processes. Each piece of equipment was paired with a dedicated training video, accessible via QR code. This supported safe and consistent use of equipment across the service.

Staff had also established a quarterly equipment committee, formed on a volunteer basis, to review equipment, highlight any operational issues with equipment, identify improvements and feedback to leaders. This structure supported continuous improvement in equipment safety and usability.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and support.

Staffing levels were planned to ensure full compliance with contractual requirements for service delivery. Recruitment was determined by contractual requirements and was reviewed regularly as part of senior leadership meetings review. The service had a pool of bank staff to deploy to maintain safe staffing levels when required.

The provider had effective systems in place to ensure staff completed mandatory and statutory training. They had recently moved to an annual training week model during which contracted staff were released to complete all required training modules within set dates to support full compliance. Bank staff were able to complete training more flexibly around their other commitments. Staff who did not complete their training within the required timescale were issued a formal reminder, and continued non-compliance resulted in temporary removal from the roster until training was complete. Data received following the assessment showed high compliance levels, 97% of PTS staff and 98% of 999 staff were up to date with mandatory training.

The service had introduced four new training modules: dementia awareness, learning disability awareness, Action Counter Terrorism (ACT) and medical gases. Dementia awareness and medical gases were delivered as top up modules to renew and reinforce initial training already provided.

All new staff, including temporary workers, completed an induction that was relevant to their role when starting. Managers supported them through structured supervision, monthly appraisals, and weekly feedback. Clinical supervision formed part of this process to help staff develop confidence and skills.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had an Infection Prevention and Control (IPC) policy aligned to national guidance. Staff told us they understood the policy and knew how to access it.

The provider carried out monthly IPC audits across all environments and ambulance vehicles. Audit results were displayed within each audited area. We reviewed the last 6 months of audit data, which showed an overall 98% compliance rate. Where audits identified areas below 100%, leaders developed an action plan, and we saw evidence that actions were completed and improvements sustained.

Staff received IPC training at induction, annual refresher training and hand hygiene competency assessments.

During our observations crews consistently:

• Wore appropriate Personal Protective Equipment (PPE)
• Adhered to hand hygiene practices appropriately
• Cleaned equipment between patient contacts
• Maintained clean and organised vehicles

A programme of deep cleaning for all vehicles was in place. Records showed that this was carried out in addition to routine daily cleaning. The vehicles were cleaned and maintained to a high standard.

The service did not consistently manage medicines risks appropriately.

The provider had a comprehensive medicines management policy that reflected all relevant legislation and national guidance. The policy clearly set out the responsibilities and processes for safe handling of medicines across the service. Additional policies were available for:

• Medical gases

Oxygen and Entonox were used onboard vehicles. Cylinders were stored safely. All staff were appropriately trained and had completed medical gas administration training as part of their First Response Emergency Care Level 3 (FREC3) course qualification and emergency use of oxygen training

We reviewed medicines audit data for January, April, June and November 2025. Across all audits we found repeated and persistent issues relating to medicines management with no clear evidence of sustained improvement or effective action to address the issues. A statement dated 30 December 2025 confirmed that the provider had no reported medicines incidents in the previous three months, however this was not consistent with the audit findings. Each of the audits we reviewed identified medicines related issues. These included drug discrepancies, unaccounted for medicines, incorrect stock numbers of items that were found in cupboards that were not recorded and errors across multiple drug lines. Corrective actions were largely unchanged across all audits and focused on reminding staff to pay attention to detail. This demonstrates that medicines related incidents were occurring but were not consistently recognised or reported in line with policy.