Head Office

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. We found evidence of a positive culture of learning and improvement. Individual patient risks were assessed and mitigated. Vehicles were well maintained and staff had appropriate skills and training. However, we had concerns the monitoring of physical health during and after manual restraint and sedation and the recording of observations about this

This meant people were safe and protected from avoidable harm.

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 evidence showed a good standard. 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.

There had been 19 incidents between April 2025 and June 2026. These included incidents where physical restraint or handcuffs had been used, safeguarding and incidents of violence and aggression.

All staff knew what incidents to report and how to report them. Transport staff understood what they needed to report and were supported by office staff in this process. Staff understood the duty of candour. They were open and transparent and gave patients, families and care staff a full explanation when things went wrong.

A post incident review was held as part of incident investigations. The transport coordinator and clinical lead led reviews and investigations and organised debriefs for staff involved. Staff received feedback from investigation of incidents, both internal and external to the service. They met to discuss feedback, and managers and staff described training and scenario reviews that were conducted to ensure incidents were reflected on and learning was applied to ensure improvements where needed.

There was evidence that changes had been made because of feedback. For example, following an incident where transport crews were speaking in their native language, feedback and training was provided to staff. Service leads also reviewed the staffing mix of crews following this incident.

The evidence showed some shortfalls. Communication systems used by crews during patient transport were not secure and had the potential to impact on continuity of care. Records did not always demonstrate that patient safety was monitored.

We reviewed 3 patient transport records and saw this included information on individual risks, capturing complex case histories and a patient risk profile completed by the referrer. This information was used to support appropriate crew dispatch in terms of skill mix and size. Patient transport records were then used by crews to detail care during transportation. The service used an instant messaging app for each individual job, where communication was shared between crew and office staff about transportation details. However, we saw this included confidential patient information that was shared between staff. This presented a risk to the confidentiality and secure storage of patient information. It also meant there was no clear audit trail, reducing assurance that sensitive information was managed appropriately.

The service had systems in place for monitoring patient safety during transportation. However, records about this were not consistently maintained. For example, we observed a patient record where clinical observations had been carried out following the use of sedation prior to transportation. However, records of observations were not maintained, and the restraint policy did not include clear details of what observations should be carried out. Following our assessment the provider shared an updated restraint policy that included an outline of the observations required. However, this did not reference National Institute for Health and Care Excellence (NICE) guidance, including Violence and aggression: short-term management in mental health, health and community settings.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The transport booking form included the assessment of risk in a range of areas such as the risk of absconding, violence and aggression, self-harm, suicide and physical health risks. A risk assessment was carried out by the referring service and reviewed by the transport coordinator, with further information or discussions with the referrer to ensure the patient’s needs could be met safely.

At our previous assessment we found that the service did not have a clear inclusion or exclusion criteria for the service stating the providers capability to provide care and support. At this assessment we found there was exclusion criterion included on the transport booking form. This stated that stretchers could only hold a maximum of 120 kg and patients requiring oxygen and those requiring medical support or nursing care could not be transported unless a registered nurse was provided by the referring hospital. They also had a requirement that patients who had received sedation within 6 hours of transportation had to be conscious and they provided their own registered mental health nurse as part of the transport team to monitor the patient in this event.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and following transportation. Patient’s care was handed over to the receiving service, with relevant information and patient records shared.

The service ensured that up to date do not attempt cardiopulmonary resuscitation (DNACPR) order records accompanied the patient and were communicated to the receiving service when patients were being transported.

The evidence showed a good standard. 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 were trained in safeguarding and knew how and when to make a safeguarding alert. All patient facing staff were trained to adult and child safeguarding level 3. The operations manager was trained to safeguarding level 5. Safeguarding policies were available to staff and up to date, these included information on local safeguarding contacts and reporting processes.

Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act (2010). They knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff we spoke with demonstrated a clear understanding of their safeguarding responsibilities and how they would raise concerns in line with the provider safeguarding policies. We saw that details of the local authority safeguarding team were available for staff to raise safeguarding concerns should they need to, however, staff we spoke with had not needed to do this.

Staff had a good understanding of restraint and restrictive practice in relation to safeguarding. They had received training and regular training updates in relation to prevention and management of violence and aggression, safe physical intervention skills and the use of handcuffs. Incidents of physical intervention and restraint were recorded as incidents and reviews in line with the service incident policy with post incident reviews carried out. This included scenario training for staff so that learning from incidents was identified and shared.

The service worked with healthcare partners, including referring services to ensure patients were appropriately protected. This included the local authority designated officer (LADO), referring and receiving services and local authority safeguarding teams. We viewed records about safeguarding and found these were appropriately maintained, including records of investigations, internal and external communications.

The evidence showed a good standard. 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.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff enabled patients to give feedback on the service they received for example, through satisfaction surveys.

Staff ensured that patients could access advocacy. This included working with referring and receiving services to ensure that patient’s needs were met appropriately. Staff had a good understanding of restrictive practices and how these impacted patients. They had received training in assessing risks and proportionate restrictive practices and the use of restraint.

At our previous assessment we identified that the provider did not have a comprehensive system for recording individual risk assessments and they did not ensure that individual risks were reviewed and suitably mitigated. At this assessment we saw that individual risks were identified by the referrer as part of the transport booking process. We saw examples of risks identified that included the risk of absconding, violence and aggression, self-harm and physical health risks. Risk assessments were reviewed by the transport coordinator and mitigations included additional crew members allocated where necessary. Transport crews then undertook a further risk review when collecting the patient.

Risk assessment records we viewed were comprehensive. They included the use of a risk matrix, a risk score and key mitigations. This process was seen in all 3 patient records we reviewed as part of our assessment. Staff demonstrated a clear understanding of risk within the patient transfer episode.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care.

There were 12 vehicles within the service’s fleet, 2 accommodated patients on stretchers and 10 were appropriate for secure transportation and included a secure place of safety within the vehicle. Vehicles were monitored by a staff member with lead responsibility for the fleet.

The service maintained a vehicle tracking and monitoring system. This included up to date MOTs, insurance, road tax, ownership, maintenance and vehicle service history. We reviewed vehicle records and saw that they had relevant safety and maintenance records completed and had up to date MOTs and insurance.

The fleet manager told us that crews were advised to inform the office when vehicles were 2000 miles from a due service. Any vehicle faults were reported to the fleet manager and repairs arranged. Critical faults leading to breakdown were assessed through a recovery contract with a breakdown service. The policy for this service was in date.

Incidents about vehicles were reported using the service’s incident reporting system. There were clear processes in place, including for in the event of a collision.

We inspected 2 vehicles including a stretcher ambulance and a secure transfer ambulance. Vehicles were well maintained and in good condition. Harnesses and seat belts were serviceable moving and handling equipment such as stretchers and wheelchairs were compliant with annual maintenance plans. The service had enough suitable equipment to help them care safely for patients.

Vehicles were large enough to carry additional crew and escorts. The secure place of safety on secure transfer ambulances was visible to the crew and allowed for two-way communication.

The evidence showed a good standard. 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 employed 15 people in various roles to deliver the service. As the service operated at flexible times, on an ad-hoc basis, seven days a week to cover patient transport using, staff had flexible working time arrangements. Service roles included a transport coordinator, fleet manager, human resources and sales manager, drivers, healthcare assistants, and a mental health nurses. The service did not use bank or agency workers.

Staff were allocated transport jobs based on availability and skill mix, with a minimum of a driver and one health care assistant per job. However, jobs regularly involved additional staff based on the needs and risk assessment for the individual patient. If the service was unable to allocate an appropriate number and skill mix to a job, they would not accept it.

The service followed an up-to-date recruitment policy that was based on relevant guidance including the employment rights act (2025), the equality act (2010) and professional registration legislation and legal frameworks.

We reviewed 3 staff files and found recruitment processes were followed. All staff had disclosure and barring service (DBS) checks, references, professional registration checks, vaccination records and driving checks on record as relevant to their role.

Mandatory training included modules such as moving and handling, fire safety, risk assessments, infection control and first aid. In addition, staff involved in front line transportation had completed prevention and management of violence and aggression training and safe use of handcuff training. Some crew members had level 3 or 4 training in first response emergency care, although this was not a requirement of the role. We viewed the service training log and staff files and found that mandatory training was up to date. Managers monitored training and ensured staff completed timely updates.

We reviewed the records of 3 drivers and saw driving licence checks were carried out every 6 months in line with the service policy. All drivers had a driver evaluation assessment when starting in post and there was a documented process evaluating key safe driving requirements. There was not a process for re-evaluating driving beyond when staff were initially recruited, however, service leads told us they would review this and we saw that all drivers had been assessed within the last year.

There was a registered mental health nurse employed by the service as the clinical lead. The clinical lead was also a qualified registered general nurse and practice educator. They provided support to front line crews around training, policies and procedures, supervision and appraisal. They facilitated updates for crews where learning and evaluation of practice were a focus to ensure staff had up to date skills.

The evidence showed a good standard. 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.

Staff maintained equipment well and kept it clean. All vehicles were visibly clean and were well-maintained. We saw records of vehicle checks that included cleaning. Cleaning records were up to date and demonstrated that the vehicles were cleaned regularly.

Staff adhered to infection control principles, including hand hygiene. They received training and there were clear guidelines on the use of alcohol hand gel and personal protective equipment (PPE). Staff told us PPE and cleaning materials were readily available, and we saw these stored safely on vehicles. Cleaning materials were appropriate for the use of spillages of bodily fluids and there were processes in place for this. PPE was disposed of in clinical waste bags and there was an agreement to dispose of these in clinical waste bins at hospital sites crews were transporting patients to.

At the time of our assessment there was no clear contract with an external cleaning company. Leads told us crews would access local commercial cleaning companies. However, there was no assurance of the quality of the cleaning processes. Following our on-site assessment, the provider arranged a deep cleaning contract with a local cleaning company and introduced quality assurance checks for cleaning. These actions were taken in response to issues identified during the assessment.

The service was not involved in the administration of medicines.