G4S Patient Transport Services Lordswood

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration.

We found that leaders had safe systems for identifying and responding to safety risks. Patients were safe from neglect, abuse, and discrimination. The service had enough suitably qualified staff to provide safe care. Staff received appropriate training and support, and managed risks relating to the environment, infection control, equipment and vehicles. Staff responded appropriately to patient deterioration and patients were safe and protected from avoidable harm.

This was the first assessment of G4S Patient Transport Services Lordswood. This is the first assessment for this service. This key question has been rated good and we acknowledge elements of outstanding for learning culture and environments.

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 an exceptional standard. The service fostered a strong, proactive and positive culture of safety, based on openness and complete honesty. Staff and leaders actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were learnt to continually identify quality improvement initiatives and embed good practice. Leaders shared themes, trends and outcomes from incidents widely across the service and with stakeholders.

The service demonstrated a strong and embedded learning culture. Leaders promoted openness and supported staff to report incidents, concerns and near misses. Staff understood how to use reporting systems and felt confident to raise issues, which were reviewed promptly and consistently.

Experienced patient safety leaders had strengthened incident management processes. Incidents were reviewed weekly to assess risk, with investigations allocated to independent managers to reduce bias. A multidisciplinary patient safety group met regularly to oversee learning, trends and actions, in line with the Patient Safety Incident Response Framework (PSIRF), a national approach that focuses on learning from patient safety incidents and improving systems rather than attributing blame, which had been introduced to the service in 2025.

Leaders used incident data effectively to identify themes and drive improvement. Learning was shared widely across the service and with external partners, including NHS organisations. Staff received clear and regular feedback through safety briefings, team communication and visible quality boards at each base.

There was clear evidence that learning led to sustained improvements. For example, targeted safety campaigns and the use of human factors approach reduced equipment-related incidents. Additional initiatives to improve patient and road safety demonstrated a proactive and preventative approach.

The patient safety incident review group met monthly to review and investigate incidents, with quarterly reporting used to analyse themes, trends and learning. This data indicated that implementation of PSIRF had improved the quality and consistency of incident reviews.

Leaders shared themes and learning from incidents with the service’s contracted NHS patient transport services and acute NHS trust every month. The registered manager supported staff welfare, by offering downtime and psychological support.

We saw clear evidence that learning from incidents led to meaningful and sustained improvements in practice. Incident investigations identified actions to reduce the risk of recurrence, and leaders used structured approaches to ensure changes were embedded.

Leaders analysed themes in incident data, including those involving wheelchairs, stretchers and seatbelts. They used the 'Systems Engineering Initiative for Patient Safety' (SEIPS) approach to understand risks holistically, including equipment design, environment and staff interaction. This informed a targeted patient safety campaign, supported by live safety messages on quality boards across bases. Staff were encouraged to pause and check equipment before use. These actions led to a 25% reduction in equipment-related incidents in the first quarter of 2026.

The service introduced additional safety campaigns to respond to identified risks. For example, the ‘STOP’ campaign promoted safer driving by reminding staff to stop, think, pause, observe and proceed. There were clear processes for managing road traffic incidents, including immediate escalation, welfare checks and coordinated response from the control centre. Vehicles were equipped with CCTV, which supported effective investigation and learning.

Learning also led to targeted improvements in patient safety. Following repeated falls linked to vehicle steps, the service introduced the ‘Mind the Step’ initiative. This included clear messaging to staff and patient engagement to raise awareness and reduce risk.

Staff demonstrated good awareness of risk and used electronic systems to report incidents promptly, including through handheld devices. They felt confident to act quickly where there was an immediate risk of harm. Incidents were managed in line with the service’s post-incident policy, which reflected national guidance.

The service monitored incident activity and trends. Between October 2025 and April 2026, 92 incidents were reported, including delays, falls, road traffic incidents and conduct concerns. Leaders used this information to inform ongoing learning and improvement.

When things went wrong, staff generally followed Duty of Candor and were open with patients. Where this was not fully applied, leaders took prompt action. This included additional training, targeted “Toolbox Talks” and audits to improve compliance and strengthen practice.

Overall, the service demonstrated a proactive approach to learning, with evidence that incident analysis led to improvements in safety and staff practice Leaders responded by completing a full investigation, risk assessing the impact, and identifying how to re‑establish accurate training data. They implemented an action plan, restarted training records to ensure reliable oversight, and offered staff overtime to complete required modules. Staff engaged positively, demonstrating commitment to completing training within the agreed time frame. Data for November 2025 had shown a compliance rate of 91.5% prior to the loss of the records, and the service was working towards returning to this level, with a completion target of June 2026.

Managers used changes in national guidance, incidents, safeguarding, and appraisals to identify gaps in learning to ensure improvements were made. They shared current data with the local Integrated Care Board and maintained transparency about the risk.

The evidence showed a good standard. The service worked with stakeholders, healthcare partners and patients to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The service was contracted by Kent and Medway Integrated Care Board to convey non-emergency patients to and from NHS services across Kent and Medway and beyond. The contract included key performance targets, which included safe response times, continuity for patients and prioritisation of patients with higher clinical need, including those requiring kidney dialysis or cancer treatment.

The service accepted patient transport requests based on assessments completed by hospital and community clinical staff There were clear criteria for accepting patients as suitable for the available vehicles and resources. These criteria set out the service’s limitations and minimised risks by excluding patients requiring urgent clinical care.

The service had an operations centre managed by a senior booking manager. Operations staff fielded bookings, used digital systems, vehicle tracking and large-scale locational maps to coordinate resources and arranged staff to respond to ‘same day’ discharges requested by hospital staff. Operations staff liaised with patients and hospital staff to keep them updated on delays or fleet issues.

The service monitored drivers through a road safety app, tracking devices and CCTV in all vehicles. These systems provided dashboard metrics such as harsh braking and a 10% speeding threshold, and recorded idling time over a set number of minutes. This supported safer driving and improved fuel efficiency, as fuel was the service’s second highest expense.

Staff followed processes to ensure they collected the correct patients and transferred them safely between locations. We accompanied staff on 2 patient journeys, 1 was conveyed from home to a hospital appointment and the other from 1 hospital to another. We observed staff checking patient identification, managing discharge notification, documenting the patient’s medication, and handing over information to the receiving location, as well as obtaining relevant information from staff before taking patients’ home.

The service’s vehicle tracking device used a telematics system within a road safety manager app. This was a camera-based tool which scored staff driving. The app displayed vehicle-specific metrics including whether consumables were in date. Drivers could photograph and record any vehicle defects. Managers were able to replay video footage to determine the cause of any accident or incident. Leaders told us the app supported improvements in road safety and helped reduce incidents.

Crews received their dashboard driving summary upon logging into the system. Managers received monthly driving performance reports, with top 10 scoreboards based on yesterday, last week and last month. This helped managers address driving non-compliance promptly.

NHS stakeholders shared patient information on a need-to-know basis. Staff received patient name, journey details, additional needs such as wheelchair requirements or hoisting for bariatric patients, the number of staff required, and whether oxygen would be needed during the journey.

When overall responsibility for care and treatment of a patient moved to another provider, such as the NHS, there was effective communication, which allowed for seamless transfer.

Staff followed their ‘Bad Weather Escalation’ policy which outlined the procedures for the service during adverse weather. The main objective was to maintain life-preserving treatment services, for example, dialysis and oncology, while making sure staff and patients were safe. During bad weather, control room staff followed an ‘adverse weather’ checklist to determine the safest route for patients and crews. The service also made at least one 4x4 vehicle available at each base.

Staff considered patients’ care needs and understood the importance of people attending outpatient appointments arriving on time. Staff escalated delays to the central control room so that outpatient departments were aware and could facilitate the appointment once the patient arrived. Outpatient staff understood the challenges and adapted care most of the time. Although, there were times when staff had to rearrange appointments for patients when delays could not be avoided.

The evidence showed a good standard. The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on 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 understood how to protect patients from abuse, and the service worked well with other agencies to do so. They understood their responsibilities for notifying the contractor of services of safeguarding incidents. The service had well-established partner working and safeguarding contacts with contractors and local authorities.

The registered manager and other directors completed level 5 safeguarding training. Managers received level 4 safeguarding training as they oversaw safeguarding referrals, reports and training. Ambulance care assistants (ACAs) received level 2 safeguarding training, aligned with national intercollegiate safeguarding guidance and therefore includes adults and children. The service also planned to introduce level 3 safeguarding for some staff to ensure each area has a complement of safeguarding champions.

Staff knew how to identify adults and children at risk of significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

Staff considered patients’ safeguarding needs when an incident occurred and made referrals or sought further advice when necessary.The onboard information folder contained important safeguarding referral guidance and links to external agencies. in the event they were needed. Leaders had reviewed the safeguarding referral form and co-designed a more informative version so that it captured as much information as possible to ensure timely review by social care. There were visual aids, such as a clutter scale supported staff to assess patients’ accommodation objectively to make sure people were not suffering from neglect or harm. This is because the service took responsibility for escalating concerns about the living environment to consider raising a safeguard for people in need.

Expert safeguarding advice was available to support staff from Monday to Friday, with additional advice from senior colleagues trained to level 4 or 5 safeguarding out of hours.

The service received feedback from the contract provider about safeguarding concerns they had raised, to enable learning. For example, staff escalated concerns about a patient who often use the service with frequent attender with complex care needs. The service worked with safeguarding teams and the local NHS trust to develop a support strategy and improve the patient’s experience and well-being.

The registered manager made sure they submitted safeguarding notifications to CQC as legally mandated and kept clear records of actions and outcomes. They used a dashboard to monitor the progress of safeguarding referrals and inform incident reviews. Data we reviewed showed that from January to May 2026, staff made 60 safeguarding referrals. These were categorised by type of abuse or need.

Leaders produced annual safeguarding reports which showed data categorised by theme. For example, in 2025 the service reported 30 concerns relating to patients’ living conditions and 53 relating to suicidal intent or self-harm.

The service also planned to implement an additional level of assurance by adding safeguarding referrals to the incident review process using the PSIRF model.

Where relevant, staff checked that people claiming Lasting Power of Attorney had the appropriate documents to support this.

In addition, leaders followed the ‘Safeguarding the Mental Health and Wellbeing of Our Employees’ policy. The aim of this policy was to create a framework for a safe and healthy working environment for all employees, to signpost employees to relevant tools to support their mental health, and to foster a supportive culture by nurturing staff with mental health needs.

The evidence showed a good standard. The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patients’ needs which was safe, supportive and enabled patients to do the things that mattered to them.

Operations staff used transfer reports, to understand the requirements of patients. They gained as much information as possible to risk assess patients. Staff included the date and time of booking and considered medicines and mobility under ‘other information’.

The service worked with patients to understand and manage risks. Staff met patients' needs and supported them to do the things that mattered to them. This included for example, getting to appointments on time.

We spoke to 2 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, to reduce the risk of injury, staff used a hoist for patients with mobility needs and explained this process. Although it was raining and staff could not prevent the patient getting slightly wet, the patient did not appear to mind as they understood the safety reasons for using the hoist. Discharge and return journeys were organised safely. Patients knew what to expect and when they would be collected by staff.

Patients we spoke with told us they felt safe with staff and during transportation.

Staff could accommodate bariatric patients under the maximum limits of their heavily weighted stretchers, with extra crew members assigned to support bariatric patient journeys to ensure safe moving and handling.

Staff accessed timely advice and support from senior leaders when they identified unexpected risks. The service did not transport high‑risk patients. Staff completed dynamic risk assessments for patients with additional needs and ensured, where required, that a parent, carer or chaperone accompanied them, including those with mental health needs, dementia, autism or learning disabilities.

Staff completed basic life support and resuscitation for adults, and some staff completed paediatric life support as part of their statutory and mandatory training.

Drivers used a safety app during shifts to support vehicle compliance, as well as a time tracking app to monitor driving performance and record working hours.

Staff followed the service’s health and safety policy which outlined the risk assessment process, including for manual handling.

Operations staff completed welfare checks for patients involved in road traffic collisions or other incidents to make sure they were debriefed and supported.

The evidence showed an exceptional standard. The service was fully aware of all potential risks in the care environment and controlled them exceptionally well. Leaders were innovative and worked with staff and external stakeholders to make sure equipment, facilities and technology supported the delivery of safe care.

The design, maintenance and use of facilities, premises and equipment, consistently prioritised patient safety and experience. Leaders maintained oversight of all equipment and vehicles, ensuring they were safe, well-maintained and ready for use. They completed regular maintenance audits, shared outcomes with staff, and acted promptly on any issues identified. Staff were well trained and confident in using equipment safely, including the management of different types of waste. They reported having sufficient, high-quality equipment to meet patient needs and deliver safe care.

The fleet management team maintained comprehensive and well-organised records, including vehicle registration, MOT documentation and detailed fault logs, enabling full visibility of each vehicle’s history and performance. Staff carried out thorough daily vehicle and equipment checks, including under‑bonnet inspections, and promptly reported and escalated faults through an effective system. The service clearly labelled and segregated faulty equipment to prevent use until repairs were completed.

Leaders demonstrated innovation through the co-design and development of a new fleet vehicle prototype. They worked collaboratively with manufacturers, internal design teams, frontline staff and patients to redesign vehicle interiors in response to identified risks, such as trips, falls and minor injuries. This proactive and inclusive approach aimed to significantly improve safety, comfort and the overall patient experience. There were clear plans to implement the redesigned fleet following evaluation, showing a strong commitment to continuous improvement.

We inspected 6 vehicles at 2 bases, and all were consistently clean, well-stocked and purposefully equipped, including safety restraints, child seating, stretchers, hoists and wheelchairs. Maintenance records were detailed and readily accessible. Vehicles were stored securely, with restricted access and controlled key management. The service also used driver login and monitoring systems to promote safe driving behaviours and provide feedback to staff.

Fire and safety arrangements were well managed. Fire exits were clearly signposted and clear of clutter.

Leaders recognised system-wide challenges, such as the transition to an electric fleet, and demonstrated forward planning by aligning future developments with infrastructure improvements. Overall, the service demonstrated a strong culture of safety, innovation and continuous improvement in its environment and equipment management.

The evidence showed a good standard. The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough staff with the right skills, experience and training to keep patients safe and meet their needs. Staffing levels were planned and reviewed each day based on patient activity. Managers adjusted staffing to respond to changes, which meant patient journeys and discharges were not delayed due to staffing.

The service employed 625 staff and had recently over‑recruited to maintain safe staffing levels for future demand. Bank staff use was limited and, where needed, managers used staff familiar with the service to ensure continuity and safety. Staff told us they felt there were enough colleagues on shift and that they were able to take breaks.

The service supported staff development through regular supervision and annual appraisal. Data showed 100% appraisal compliance. Additional support roles, such as ‘change champions’, were visible across bases to promote good practice and improvement.

The service supported flexible working to meet staff wellbeing and personal needs. Managers also ensured staff had access to team meetings, safety briefings and learning, including ‘7 minutes/7 points’ updates and quality board displays at each base.

Robust recruitment processes were in place, including Disclosure and Barring Service (DBS) checks. Records showed over 95% compliance, with checks completed before staff started and reviewed every 3 years.

The service supported ongoing learning and made sure staff had access to training relevant to their role. Following a system error in March 2026, some training records were incorrectly reset. Leaders acted quickly with a recovery plan. At the time of inspection, 54% of staff were compliant, and remaining staff were being supported to complete training by the end of June 2026. This showed leaders had clear oversight and took action to address risk.

The service provided mandatory training in key skills to all staff. Staff received a 13-day ‘in-house’ induction programme prior to conveying patients, which included driver awareness training. ROSPA (Royal Society for the Prevention of Accidents) assessors were based in the community to observe driver training, with 7 assessors covering the service.

In addition, staff completed 17 online ‘e-learning’ modules. ROSPA assessors also carried out ‘ride along’ observations and conducted 2 driving assessments, reviewing the patient journey to ensure compliance, support staff wellbeing and maintain patient safety.

Managers monitored mandatory training and alerted staff when they needed to complete updates.

Leaders updated the digital e‑learning system to include additional training. However, on the day of implementation, the system went offline and, when restored, all staff training records had been deleted. Because staff stored their training certificates within the system, staff lost evidence of training compliance for April 2025 to January 2026.

The evidence showed a good standard. The service managed infection risks well most of the time. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and premises visibly clean. Where required, actions were taken to improve any shortcomings.

Staff had access to a local infection, prevention and control (IPC) policy and supporting guidance was accessible. Staff received IPC training, which supported them to respond to risks such as transmittable infections.

Staff had access to personal protective equipment (PPE) which was well stocked at bases and available to stock up vehicles during pre-shift checks. We saw staff following infection control principles, including compliant handwashing and appropriate use of PPE as outlined in the service’s standard operating procedure.

The service had a programme of IPC audits, including for hand hygiene and touch point checks. The IPC lead conducted monthly audits and created reports that fed into governance and oversight arrangements. Data from the March 2026 audit showed a high standard of waste management and general cleanliness. During our assessment, we found that staff showed a good understanding of infection control.

Team leaders completed a weekly clean ‘dip test’ on vehicle touch points, which meant that the cockpit, foot-wells, walls and ceilings, seatbelts, seating, stretchers and trolleys were checked and photographed and were scored. Records showed that performance outcomes were fed back to staff, and any gaps were escalated and rectified.

Staff had access to hand hygiene and mouth-nose protection guidance on all vehicles and within each base as well as through the staff intranet.

Staff understood the process for managing spillage of body fluids. The staff folder within each base and vehicle showed the process for cleaning vehicles and equipment, including mopping up body fluids, with supporting images and information on antimicrobial products.

Staff disposed of clinical waste safely, both inside vehicles and in designated external storage areas. Staff segregated and labelled waste in accordance with local policy. COSHH (Control of Substances Hazardous to Health) products were well maintained and clearly labelled on and off the vehicles in colour-coded containers.

Staff adhered to the uniform policy which supported infection prevention.

Staff routinely cleaned the interior of vehicles and equipment. A record of cleaning was retained within each vehicle.

However, data from the monthly ‘Integrated Governance Committee’ report showed that some bases performed better than others. The service shared this data monthly with the Integrated Care Board (ICB). In the April 2026 data set we saw that leaders had reported issues with the cleaning of vehicles. Leaders also, reported that some bases did not have on-site washing facilities and as a result of this an action plan was implemented, which included staff bulletins and additional IPC training.

The evidence showed a good standard. The service did not manage medicines generally, as it did not form part of their remit. This was a patient transport service designed to convey patients with their own medicines. However, there were times when patients were conveyed on oxygen or when they may need oxygen support.

People using oxygen were transported with their cylinder which were stored securely during journeys. Also, the service maintained a stock of oxygen cylinders in the event of people requiring oxygen support. All staff were appropriately trained and had completed medical gas administration training as part of their First Response Emergency Care Level 3 (FREC3) qualification.

The service had an oxygen policy, which staff told us they followed when administering emergency oxygen. The service’s medicines management policy included the use of oxygen, in line with the Health and Safety Executive (HSE) guidance on oxygen use in the workplace. This included information about the hazards of using oxygen, causes of oxygen fires and explosion risk, correct or optimal storage, and incompatible materials. The policy also outlined the registered manager’s responsibility to report any adverse reactions to patient’s own medicines to the Medicines and Healthcare products Regulatory Agency (MHRA)