ABC Event Cover

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. We did not re-rate this key question during this inspection.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

An incident reporting policy was in place which was last reviewed in July 2025. This policy covered personal injury, damage or incident and near misses. For each of the different type of incident identified, there was a form for staff to complete. Managers were confident all staff knew how to report incidents and would report incidents if they occurred.

The senior management team were aware of the requirements for reporting incidents to the CQC using the statutory notification route if this met the criteria, under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

There was 1 serious incident reported for the service in the last 12 months. Serious incidents are events in health care where there is potential for learning, or the consequences are so significant that they warrant using additional resources to mount a comprehensive response.

The service had a ‘being open and duty of candour policy’, and next review date was due in June 2026; The policy covered the principles of the duty of candour. A senior staff member was able to explain the process they would undertake if they needed to implement the duty of candour following an incident which met the requirements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

All staff received basic life support training. The level of life support training depended on the role and responsibility of the staff member, for example first aid staff were required to complete basic life support. Paramedics completed advanced life support training, usually with their primary employer but informed the managers and provided evidence once completed. All staff were required to complete paediatric first aid and basic paediatric life support training.

At each event, staff completed an environment audit to ensure staff were working in a safe environment. We reviewed six audits of event risk assessments where the service was contracted to convey patients if required. The audits showed no additional concerns were identified.

The service used the National Early Warning Score system (NEWS) and the sepsis screening pathway for detecting early signs of deteriorating patients. Early warning scores are systems for early identification of a deteriorating patient. Sepsis is a life-threatening reaction to an infection. Staff told us they regularly performed physiological observations (blood pressure, pulse, oxygen saturation, respirations and temperature) and neurological observations on patients. Any concerns about a patient’s condition were escalated to the highest level of staff member on the team, and decisions would be made for whether the patient required transportation.

The service health and safety officer had oversight of all risk assessments and updated them as and when required. At each event the risk assessment was reviewed by the on-site team to ensure this was accurate and covered all risks relevant to the event. We reviewed some examples of event risk assessments, where the service was contracted to convey patients if required and found them to be thorough.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

The lead for safeguarding at the service had completed level four safeguarding. This had enabled them to develop a training programme for all the staff at the service to develop their safeguarding knowledge.

Staff knew how to make a safeguarding referral and who to inform if they had concerns.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

At the time of our inspection, all staff were compliant with the required levels of safeguarding training. We saw evidence of safeguarding level two training in personal files. In addition to the safeguarding level two training for children and safeguarding vulnerable adult training, additional safeguarding modules were completed including PREVENT, female genital mutilation and domestic violence.

The provider 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 used a nationally recognised tool to identify deteriorating patients and escalated them appropriately.

Systems were in place to ensure all patient records were stored securely in line with local policy and information governance requirements. Patients who were transferred to hospital by staff from the service had a patient report form (PRF) completed for them.

All patient report forms (PRF) were subjected to regular audit. This was conducted by one of the paramedics and a report was produced for the managers. The most recent audit was conducted between January 2025 and November 2025, and we saw majority of the PRF’s were completed correctly. The audits included all PRFs completed by the staff for all patients and included patients who were not conveyed to hospital.

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

The service had enough suitable equipment to help them to safely care for patients. Staff disposed of clinical waste safely. We found all equipment and vehicles were visibly clean on the day of our inspection.

The design, maintenance and use of facilities, premises, vehicles and equipment kept people safe. Staff were trained to use them. The service had 6 vehicles in total (3 ambulances and 3 cars). Only 2 ambulances vehicles were used for regulated activity, so we only reviewed the records for these vehicles. Both ambulances appeared well maintained and had in date vehicle tax, services and MOT tests. Vehicle fault forms were in the vehicles for staff to complete if required. A local company was contracted to maintain and service vehicles, Vehicle keys were (securely)stored in the administration office.

The ambulance vehicles were securely stored inside a garage area. The garage area was visibly clean, tidy and relatively spacious. The manager told us they had expanded the equipment room since last inspection.

We reviewed a sample of consumable items including syringes, dressings, cannulas and bandages, we found them all to be in date and stored appropriately.

Managers were responsible for providing and preparing advanced life support (ALS) bags to support the safe care and treatment of patients during events. These bags had equipment laid out for staff to use and each bag contained a numbered ID tag, this was used to identify which staff member were allocated to each bag. These numbers on bags were checked by staff and signed for prior to leaving site for an event.

In the office, we saw a white board with colour coordination for each upcoming events, containing details of the vehicles, and designated equipment with bag tag number. This was for staff to know instantly what items they had been allocated for the event they were staffing. This also ensured staff took responsibility for the booking in process after the event which included replenishing any items used. One of the senior managers ensured they kept photographic evidence of the board at each event, for auditable purposes.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well.

The service used an electronic staffing tool app for all future events. All staff had access to the electronic tool, so they could roster themselves on to cover an event.

The system had rules built into it so only staff who were qualified for the role could roster themselves on to this to prevent not having the correct skill mix for an event. An example of this was for the role of a driver, only the paramedics, registered manager and health and safety director had the right competencies and skills for this so were the only ones who could roster themselves into this position.

The service also had a working chat app group, for those staff that required sickness cover etc, they could swap shifts or pick up extra shifts if they wanted to and a means of team communication.

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

Staff had training in infection prevention and control processes. Evidence showed 100% compliance with this training requirement. There was an infection prevention and control policy in place which was due for review in June 2026.

There were adequate amounts of personal protective equipment (PPE) for staff to use when caring for patients. Staff told us linen used during the conveyance of a patient to hospital was disposed of by staff at the receiving hospital. New linen was then collected to replace that disposed of. This was in accordance with the providers policy. We also saw a well equipped and organised linen cupboard at the main site.

The service used systems and processes to safely prescribe, administer and record medicines. The service held a Home Office Drugs Licence at the time of the inspection, and we found significant improvements around the storing of medicines and medical gases and were securely stored.

There was an in-date medicines management policy in place. This outlined the protocols to follow and responsibilities of staff with regards to the safe prescribing, administration, recording and storage of medicines.

We found significant improvements around the storing of medicines and medical gases, which were all securely stored. The service had access to a clinical pharmacist who worked at the local NHS hospital, managers told us this was additional support and a source of up-to-date medicine information and advice. They reviewed the processes and policies in place at the service and conducted regular medicine audits.

The service stored controlled drugs (CDs) in a safe and only allocated person(s) had access to the safe. The service used a safe process for staff signing any medicines out of the safe at the start of their shift and signing any unused medicines back in afterwards. We saw examples of this during our inspection.

The service now had a Home Office Drugs Licence which they required for the service they provided. This was not in place during the last inspection; we saw evidence of significant changes around medicine management, and regular stock checks of all medicines were carried out by the service.