UCS 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 Independent Ambulance service provided the following activities: personal care, transport services triage and medical advice provided remotely and treatment of disease, disorder and injury.

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 we have used this evidence to inform our assessment and report findings.

We looked for evidence that safety was a priority for everyone and that managers had embedded a culture of openness and collaboration; however, this was not demonstrated. Managers did not have effective systems for identifying and responding to safety risks, and the service lacked robust safety processes for the preparation of vehicles, equipment, and the patient journey between locations.

We identified serious shortfalls in staffing, recruitment, and safeguarding arrangements. The service could not be assured that staff were safely recruited, appropriately trained, or competent for their roles, as pre-employment checks, induction, mandatory training, supervision, and appraisal processes were inconsistent or absent. There were not enough staff with the right skills, qualifications, and experience to ensure high-quality care, and managers did not ensure staff received up-to-date training or regular appraisals.

The service did not demonstrate a strong learning culture; staff reported feeling unable to raise concerns, patient feedback was not always acted upon, and incidents were not consistently or thoroughly investigated. While staff understood local safeguarding arrangements, these were not supported by clear or effective systems and processes at service level.

There were significant concerns regarding the safety of patient care and transport, particularly for bariatric and high-risk patients, due to unsuitable vehicles, lack of appropriate equipment, and insufficient staff training. Vehicles and equipment did not consistently meet patients’ needs, as they were not always clean or well-maintained, and risks were not adequately mitigated. The care environment presented additional risks, including damaged and poorly maintained equipment, expired consumables, and inconsistent cleaning practices. Furthermore, medicines management and infection prevention and control systems were ineffective, increasing the risk of harm to both patients and staff.

This is the first assessment of the service and safe is rated as inadequate. Patients were not 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 some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not manage patient safety incidents effectively. Although an incident reporting policy and risk assessment process existed, staff largely failed to follow it—only four had read the policy, and incidents were often reported verbally instead of through the formal system. There had been 18 reported adverse events in the preceding year. While some incidents were recorded and investigated by managers, lessons learned were not widely shared, and trend analysis was lacking.

Staff understood how to respond when things went wrong, including being open with patients, but there were no records of duty of candour discussions. Feedback, debriefing, and support after incidents were minimal. Although some actions were taken to reduce risks, record-keeping was poor, particularly after a system change, and staff competence and training were not properly tracked.

Despite being able to identify risks, staff lacked confidence that concerns would be addressed.

The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was not a priority throughout people’s care pathway. Patients were not routinely assessed prior to arranging their transport needs. The service had a criterion for accepting patients as suitable for the available vehicles and resources. However, not all staff and managers where aware of the policy and it was not routinely used. Work was allocated to the staff and vehicles that were available in the absence of risk assessments based on patient need.

EUC vehicles were not fit for the conveyance of bariatric patients when considering the space and weight distribution requirements. Managers told us that ‘conversion kits’ to adapt the vehicles for specialist bariatric use were held at the head office. Staff told us that these were not readily available, and training had not been provided to use them. Staff told us they had repeatedly raised concerns about the care of bariatric patients regarding equipment and appropriate staff training.

Systems and processes to ensure the correct patients were collected and transferred between locations were not effective. We did not see evidence that the provider monitored that staff had appropriate driving skills and experience.

The service did have a deteriorating patient policy; however, not all staff were aware of this and the process to follow should the patient’s condition change during transport.

The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Not all staff we spoke with felt confident identifying or responding to safeguarding concerns and how to protect patients from abuse and report concerns. Leaders told us safeguarding concerns had been raised by staff appropriately and these were passed to the local authority, however we did not receive any evidence to support this. No safeguarding concerns had been raised or reported to the local authority in the last 12 months prior to assessment.

The service had safeguarding policies for adults, children and young people which reflected the national guidance for adults and children. Staff could access to these policies and procedures via their electronic devices but only 4 staff members had done so.

The service did not have effective systems in place to ensure staff were appropriately trained to protect service users from abuse. Compliance for both adult and children safeguarding level 3 training was only 36% which was below the 90% target set by the provider. The service did not have a staff induction package therefore they could not provide assurance that staff would recognise signs of abuse and potentially put staff and service users at risk of harm or abuse.

The service was required to have an identified safeguarding lead who staff could refer to if they required further advice and support. The training undertaken by the services safeguarding lead did not meet the required standards outlined in the intercollegiate guidance ‘Adult Safeguarding: Roles and Competencies for Health Care Staff’. We subsequently received information showing that the service’s safeguarding lead had been stood down from the role in July 2025 and had not been replaced.

Safeguarding concerns were not considered when an incident occurred. Staff could not provide examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Score 1

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service did not use Transfer Report Forms (TRFs), to understand the requirements of the patient. Managers took direct phone calls from other agencies requesting transport. Routine assessments were not undertaken at the booking stage to gain as much information as possible to risk assess patients. Risks relating to medicines, mobility or infection were not always considered. The freehand information gathered at the booking call was then passed to the staff undertaking the transport.

The service did not liaise with patients to understand and manage risks which resulted in patients' needs being met in ways which were safe and supportive and enabled them to do the things that mattered to them.

We reviewed 13 service risk assessments. The controls identified in risk assessments did not exist or were not always in place. The services ‘Movement of Bariatric Patients’ risk assessment control measures relied on staff training, vehicle and equipment checks, and access to bariatric kits to mitigate risks. Mitigations were not in place in line with risk assessments putting staff and service users at risk of injury and harm. Stretchers used to transport bariatric patients were not fit for purpose or designed to support the weight of a bariatric patient.

Staff we spoke with said they could access advice and support from managers by telephone where unexpected risks were identified, however decisions made were not recorded.

Managers could not evidence that staff had completed basic life support and resuscitation for adults, paediatric and newborn patients modules as part of their statutory and mandatory training.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Staff were not trained to use equipment and to manage different types of waste safely.

We inspected 2 ambulances that were in use at the time of the assessment used for both PTS and EUC work. In 1 vehicle we found damage to an electrical plug socket. The socket was held in place by tape and had not been reported as damaged. The defibrillators in both vehicles, were not securely mounted as the locking mechanism to hold them place was either missing or damaged. This was a risk to staff and patients should the vehicle be involved in an accident as they would dislodge. These vehicles were in use for transporting patients during the assessment. We brought these concerns to the provider’s attention, and the damaged socket and defective mounting mechanisms were repaired during the course of the inspection.

Vehicles were not equipped for the type of services and records of equipment maintenance and schedules were not kept, if indeed they were undertaken. We reviewed annual equipment maintenance reports completed by an external contractor, for vehicle stretchers that were currently in use. These reported clear damage to straps used to secure patients to stretchers and included photographic evidence. Corrective remedial action had not been taken to repair the damage to the straps. There was a system for staff to report faulty equipment and vehicles, but this was not always used. None of the faults we observed had been reported on the system.

Checks of specialist equipment was not undertaken. Expired defibrillator pads were found in the vehicles. This was a potential risk as staff could use expired consumables when delivering care in an emergency. One ambulance had two types of defibrillators. One machine had a flat battery and the other had no batteries installed. Hazardous substances were not stored safely in vehicles and information about the products was not readily available to staff. We found an unlabelled spray bottle in an unsecured locker in one ambulance, which staff told us was floor cleaner. We observed on another ambulance bottles of anti-freeze and de-icer in an unsecured locker. This could potentially be accessed by non-crew members and be a risk to the health of service users. Hazardous substances were not stored safely to protect people from harm.

Managers did not maintain oversight of equipment to ensure it was safe and ready to use. Equipment audits were not completed. Staff told us they had repeatedly raised concerns over vehicle safety including an incident where a patient was delayed in transit due to a known engine problem that was ignored.

Fire safety equipment was available on vehicles and had been serviced. Fire exits were clear and free from obstruction in office areas. Oxygen cylinders were stored correctly, upright and in cages with no flammable or electrical equipment nearby. All fire extinguishers onboard vehicles were securely fastened, checked and well within expiry date.

Staff disposed of clinical waste safely, both inside vehicles and outside the storage areas. Waste was segregated and labelled in accordance with the local policy.

The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service employed paramedics, ambulance care staff and those with no previous care experience in the sector. Staff told us they were employed to work for the PTS and EUC service provision. The provider could not demonstrate there were 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.

Staff told us they had been asked to work for UCS Medical and they had not formally applied or had an interview. Staff had not been recruited following the processes outlined in the provider’s Safe Recruitment Policy which stated interviews for qualified/clinical staff would be completed by a minimum of 2 people who would record a set of interview notes each.

New staff did not have a full induction tailored to their role before they started work at the service. Managers told us staff completed mandatory training at their primary employer and evidence of completion was not routinely kept or checked by UCS Medical. There were no systems in place to monitor staff training compliance with other employers. Some staff employed service only worked for UCS Medical. Managers did not have oversight of staff performance, therefore staff were not supported to improve. Staff appraisals were not undertaken.

The service did not support the learning and development needs of staff and specialist training was not provided. Staff told us the mandatory training was not sufficient to deliver the roles expected of them. An electronic link to training courses had been provided but this was not comprehensive for the skills required.  Some staff told us they had not completed any training in the time they had worked for the service. Staff told us they had not received a face-to-face induction as outlined in the provider policy.

Staff were not appropriately trained in manual handling and the use of bariatric equipment. Compliance for staff moving and handling training was 73% which was below the 90% target set by the provider. Mandatory face to face moving and handling training for bariatric patients had not been provided. The lack of appropriate training put staff and service users at risk of injury and harm.

Managers told us that they did not keep records of all staff training compliance as some staff had already completed safeguarding training for both children and adults through their primary employer or other accredited providers. Managers did not have an established process for Accreditation of Prior Learning (APL), which would enable existing qualifications and mandatory training undertaken to be recognised where appropriate. Evidence of training elsewhere was not kept ensuring current national safeguarding standards and best‑practice guidance were met.

Team meetings did not take place and staff only had access to information verbally shared by managers.

The evidence showed significant shortfalls. The service did not assess or manage the risk of infection.

The service did not manage infection risks well. Patients at high risk of infection were not identified. Patients who were exposed to infections were not identified and appropriate precautions were not employed to reduce the spread of infections to others.

Vehicles used to transport patients were not cleaned regularly. Vehicle deep clean records provided showed that one ambulance was last deep cleaned on 25 August 2025.  A second ambulance was last evidenced as deep cleaned on 21 May 2025 and 2 August 2025.  Neither vehicle had been cleaned every six weeks as directed in the services Infection Control policy. A further vehicle used for the transport of patients had no record of cleaning. We observed vehicles and equipment not to be clean.

Infection prevention and control audits were not undertaken. There was electronic guidance to support staff to respond to infection prevention and control risks such as transmittable infections, however staff had not read it.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Although the service was predominantly conducting PTS, they had medicines and equipment available to manage emergency care work if needed.

We found that records used to record stocks of medicines were not always accurate so medicines could not be fully accounted for. For 1 medicine that required a shortened expiry once removed from the fridge we found this had not been recorded. The service did not monitor the temperature of any areas that were used to store medicines which meant that we could not be assured that medicines would be safe to use.

The service told us that they did not have a means of disposing of waste medicines and we found medicines waiting to be destroyed were not stored in line with the medicines policy.

Staff did not always keep a contemporaneous record related to a patient’s journey. For example, we found on one occasion staff had not documented the name of a medicine administered.

Staff did not receive any training related to medicines from the service. There was no mandatory training related to medicines. There was no evidence that staff, managing medicines including medical gases had been trained or been assessed as competent to do so. There was no evidence of any medicines audits to ensure effective oversight.

Although the service had a medicines policy, the staff portal only contained an expired version which meant that staff did not have access to the current medicines policy.

A Patient Group Direction (PGD) is a previously written instruction for the sale, supply and/or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. The health care professional working within the PGD is responsible for assessing that the patient fits the criteria set out in the PGD. On the day of the assessment, we found that the service had no record of if staff had read and understood the PGD’s they were using. By the end of the second day, we were told that half of the staff had since done this.