UCS Medical

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that patients and communities achieved the best possible outcomes because their needs were effectively assessed. However, the service did not consistently assess, plan, or deliver care in a way that ensured it was effective or met people’s individual needs.

In the previous 12 months the service had not undertaken any EUC services for patients. Where evidence gathered from the Patient Transport Service (PTS) was directly applicable to EUC, including patient record keeping, governance arrangements, monitoring of outcomes, and consent processes, we have used this evidence to inform our assessment and report findings.

Patient assessments were not always thorough, timely, or clearly documented, and gaps in records meant leaders could not be assured that people’s health, wellbeing, communication, and support needs were fully understood or reviewed throughout their care. As a result, there was limited assurance that care, support, and treatment were consistently tailored to individual needs, including protected equality characteristics.

Staff did not always have access to up-to-date policies or evidence-based clinical guidance, and there were no effective audit processes in place to monitor the quality of assessments, care delivery, or clinical outcomes. Patient outcomes were not routinely monitored, and patient feedback was not collected, further limiting the service’s ability to assess effectiveness.

We also looked for evidence that managers had embedded a culture of continuous improvement, where understanding outcomes and applying best practice formed part of everyday work. Although staff generally worked well together and with external services to support continuity of care, governance systems were not effective. Many policies were out of date, training compliance in key areas such as consent and capacity was low, and documentation systems did not adequately support the recording of capacity assessments where required.

The service did not routinely monitor outcomes, patient experience, or health inequalities, which limited its ability to identify risks, drive improvement, and provide assurance of effective care.

This was the first assessment of the service, and the effective domain is rated as inadequate.

We have not awarded this service a score for Effective.

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

The evidence showed significant shortfalls. The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

The service used information provided by referring organisations to identify patient needs. However, this information was not consistently used for patient risk assessments and care planning purposes.

Staff relied on their personal skills and experience to support patients. Staff described how they would support patient’s communication needs, particularly those with disabilities and with a sensory loss and how they would consider cultural and social needs when they met the patient rather than in advance.

Staff did not have access to up‑to‑date clinical policies, which increased the risk that assessments were not aligned with current guidance or agreed standards. The service did not audit patient care records, limiting oversight and preventing the identification of poor‑quality assessments, learning opportunities, or areas for improvement.

The evidence showed significant shortfalls. The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff did not have up-to-date policies to plan and deliver high quality care. Of the 30 policies available to staff, 18 were out of date for review. Policies we looked at did not contain references to current national guidelines. There were no systems in place to communicate changes in guidance through meetings and management newsletters to staff. Staff said they received information via their other employer or through personal enquiry.

There were no systems in place to ensure that staff were up to date with National Institute of Care and Excellence (NICE) guidelines and evidence-based practice. The service did not fund access to the Joint Royal Collages Ambulance Liaison Committee (JRCALC) guidelines. The service did not have processes in place to ensure staff had access to up-to-date clinical practice guidelines.

Staff we spoke with said they could access advice and support from senior managers in a prompt manner via telephone, in cases where unexpected risks were identified. Staff were expected to seek advice for “red flag” concerns but not if it delayed urgent care or calling 999.

The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff told us they worked together as a team to benefit patients. They supported each other to provide good care and deliver a quality service.

Managers had not fully considered staff welfare. For example, they did not take into account staffs’ other jobs and ensure adequate rest in between shifts. The service had a Health and safety policy to describe responsibilities at all levels but did not include safe driving hours.

Staff reported that information was shared between teams and services to ensure continuity of care verbally.

The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

The service did not support staff to maximise patient’s independence through identifying risks to people’s health and wellbeing early to prevent deterioration. Staff relied on their initiative and experience to manage this in the absence of embedded systems and processes.

Where appropriate, and within their role, clinicians supported patients through safe medication management although this was not always documented. Staff told us they built health advice into treatment, wherever they could.

The evidence showed significant shortfalls. The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service did not have effective systems to assess, monitor and improve the quality and safety of the service. We requested the services audit schedule and audit results as part of the data request following our assessment of the service. The registered manager told us that no audits were currently being undertaken in the service due to capacity. There was a risk that the service may not identify issues with the quality or safety of care which places services users at risk of harm.

The provider did not consider health inequalities and had not taken steps to ensure outcomes across people with protected characteristics were in line with the wider community.

Managers reviewed the service key performance indicators (KPIs) and targets the quarterly business review meeting. However, the KPIs discussed where predominately for the development of other aspects of the services business model and reviewing clinical outcomes.

Services commissioned by NHS services were ad hoc and patient outcomes were not assured or monitored.

The evidence showed significant shortfalls. The service did not tell people about their rights around consent or respect these when delivering care and treatment.

The service provided transport for people based on implied consent by the referral being made by a health professional working with the patient. Guidance regarding the responsibility of the ambulance staff in obtaining consent was documented in the services Consent and Capacity policy.

The service Mental Health policy directed staff to record mental capacity assessments on the patient report form however the forms that we reviewed did not have a section where this could be documented if required. The service had not delivered any secure mental health transfers service since December 2024 and leaders informed us this was due to a lack of suitably trained staff.

The provider could evidence that 59% of staff had completed consent, mental capacity act (MCA) and deprivation of liberty safeguards (DoLS) training modules.

There were inconsistencies in the understanding of the use of restraint and the training required. The provider was not a member of the Restraint Reduction Network. Training was not compliant with the BILD Restraint Reduction Network training standards 2019. The Care Quality Commission expect all care services to only use training in restrictive practices that is certified as complying with the Restraint Reduction Network training standards. These are standards set out to protect human rights and support the elimination of unnecessary restrictive practices. We were not assured that the service was compliant with these standards.

Interpreters were available to support patients to give informed consent, including for BSL and face to face interpreting. Records were not kept of how often the service was used. Staff sought permission before sharing patient information with family or friends.