Archived: Swadlincote Station

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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

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

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

We identified breaches of legal requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically relating to safe care and treatment, equipment and staffing.

The provider failed to ensure that care and treatment were delivered in a safe manner. Medicines were not consistently stored in accordance with recommended guidelines, posing a risk to patient safety. Infection prevention and control measures were inadequate; during inspection, the ambulance and associated equipment were found to be visibly unclean both on the vehicle and at the ambulance station. The provider did not ensure that vehicles were safe and roadworthy. Staff were not provided with appropriate training or a structured induction programme.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice

Operational clinical staff were not directly employed by the service; instead, event staffing was provided through a subcontractor. The service did not deliver training to these staff or maintain training records. As a result, we could not be assured that subcontracted staff were familiar with the service’s policies on incident reporting or duty of candour. Leaders told us they understood the principles of duty of candour and the importance of being open and honest when things go wrong. A standard operating procedure for duty of candour was in place.

The service had a policy and process for reporting significant incidents, and leaders reported that one significant incident had been recorded since March 2025. However, we identified an unreported incident involving an ambulance at an event where the driver’s door could not be opened from the outside. Leaders stated the vehicle had been checked prior to deployment and were unaware of the issue. This meant we could not be assured of the reliability of incident reporting and investigation processes.

We reviewed the previously reported incident, which involved an ambulance attending an event without valid insurance. Once identified, the issue was rectified and discussed at a governance meeting. Learning was identified and actions were taken to reduce the risk of recurrence.

The evidence showed significant shortfalls. The provider did not maintain safe systems of care. They did not manage or monitor people’s safety.

The provider did not maintain effective oversight of patients who received treatment at events. Detailed patient records were not held by the provider. We were informed by leaders that patient record forms were completed for all individuals treated. The service did not routinely receive copies as these were retained by the subcontractor responsible for supplying clinical staff. The service was provided with limited demographic and clinical information—such as age, gender, and presenting complaint—and would only request full records in the event of a significant incident, such as a death.

Leaders demonstrated that patient report forms could be obtained from the subcontractor promptly when requested however, as the registered provider, 25Eight Medical Group Ltd is responsible for maintaining continuous oversight of care delivered under its registration. This issue was raised with leaders during our visit and following the inspection, the service implemented a data transfer policy and process to ensure that all patient records are received within 48 hours of any event, improving accountability and oversight.

The evidence showed significant shortfalls. The provider did not ensure that staff supplied by subcontractors received appropriate safeguarding training. At the time of inspection, the service did not have a formal safeguarding policy in place. However, a reporting form was available for documenting safeguarding concerns, and information on how to escalate concerns to the relevant local authority was clearly displayed throughout the ambulance station.

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.

Due to the nature of the service, we were unable to observe direct patient care. As the service did not directly employ or maintain oversight of the operational clinical staff delivering care, we could not be assured that patients were consistently involved in decisions regarding their care and treatment.

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

The service did not ensure that vehicles were consistently maintained to a safe and roadworthy standard. We examined one of the service’s ambulances following its use at an event and found it to be in poor condition. The driver-side front door could not be opened from the outside, and a section of the vehicle’s bodywork was missing, leaving the battery exposed and posing a significant risk of harm.

The interior of the ambulance showed visible signs of rust and dirt, and some equipment stored within such as a Samarit Transglide was unclean. Additionally, we found a Samarit Transglide and a curved glideboard at the ambulance station, both of which were visibly dirty. Although both items at the ambulance station displayed stickers indicating a next test date of March 2025, there was no evidence to confirm that this testing had been carried out.

Vehicle maintenance checks were scheduled every six weeks; however, documentation reviewed during the inspection indicated that these checks were not consistently completed in full. The service utilised a vehicle audit sheet prior to deployment and had recently introduced a pre-deployment checklist following an incident in which an ambulance attended an event without valid insurance.

All cleaning chemicals were stored appropriately in a locked room, with COSHH data sheets readily available.

The evidence showed significant shortfalls. The provider 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.

The service did not directly employ operational clinical staff and staff working at events were supplied by a subcontractor. At the time of inspection, the service had not requested evidence of professional qualifications or Disclosure and Barring Service (DBS) certification from the subcontractor nor was it standard procedure to do so. Additionally, no induction or internal training was provided to these staff members. We could not be assured the provider was taking appropriate steps to ensure staff were suitably qualified and competent to deliver safe and effective care.

This concern was raised with the provider during our inspection. In response, the service developed a data transfer policy requiring subcontractors to submit, prior to deployment, documentation including enhanced DBS certification, proof of right to work in the UK, verified professional qualifications and registrations, employment references, and records of mandatory and clinical training.

We also reviewed the leadership team who were employed directly by 25Eight Medical Ltd. At the time of inspection, one individual, employed since the service’s registration in 2024 had not provided a valid DBS certificate. However, all other directly employed staff had submitted appropriate DBS documentation.

The evidence showed some shortfalls. The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We identified equipment that was visibly unclean, both within the ambulance and at the ambulance station, which posed an increased risk of harm to patients. We were only able to inspect one of the service’s ambulances, as the second vehicle was undergoing repairs at the time. Whilst the inspected vehicle had been deployed at a three-day event immediately prior to our inspection, the level of uncleanliness observed evidenced that some issues had existed prior to its use at the event.

However, the ambulance station was clean and well maintained. Appropriate cleaning practices were in place, including the use of disposable mop heads and colour-coded mop buckets to reduce the risk of cross-contamination.

The evidence showed significant shortfalls. The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We reviewed the service’s patient group directions (PGDs) and identified several concerns regarding their compliance with legal and professional standards. A number of PGDs had been signed by a doctor and a paramedic, which does not align with the requirements set out in the Human Medicines Regulations (HMR) 2012. These regulations stipulate that PGDs must be signed by a doctor (or dentist) and a pharmacist. According to guidance from the National Institute for Health and Care Excellence (NICE), both signatories share joint responsibility and accountability for the clinical and pharmaceutical accuracy of the PGD. There was no evidence that a pharmacist had been involved in the oversight or approval of these documents.

All PGDs had been signed by a paramedic who was the clinical lead at the time of signing. However, this individual was no longer employed by the service at the time of our inspection. As the responsibility for PGDs lies with the current clinical lead, these documents should have been reviewed and re-signed to reflect the change in leadership. Additionally, we noted that some PGDs contained incorrect dates, with both the issue and review dates listed as September 2025.

We inspected the storage of medications on the ambulance which had recently attended an event. Medications were poorly organised, with blister packs and vials found loose within drug bags. We observed a sleeve of ibuprofen stored inside a paracetamol box, which posed a risk of medication errors and potential harm to patients. All medications and consumables reviewed on the ambulance and at the ambulance station were found to be within their expiry dates.