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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.

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 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 had an incident reporting policy that was in date which clearly states that all incidents must be reported to a senior member of staff, however it lacked key information such as how investigations are documented or reviewed, defined timescales for completion of investigations, duty of candour and organisational learning.

Staff told us they understood how to report an incident. However, some expressed reluctance due to fears of disciplinary action or other consequences.

When asked to describe incidents where lessons had been shared, most staff could not recall examples. Some described incidents that had been reported but not where learning or outcomes had been actioned or communicated. Our review of incident records confirmed this lack of shared learning.

The service had not implemented the Patient Safety Incident Reporting Framework (PSIRF) which replaced the Serious Incident framework in 2022. This is a mandated requirement for all Independent Health services including patient transport services that deliver services under an NHS Standard Contract.

The service shared an action plan in response to a serious incident which detailed actions that were taken including notifying external bodies such as the Health and Safety Executive (HSE), the Care Quality Commission (CQC), and the relevant NHS trust. The service held meetings with the staff member involved and implemented staff support measures. Following an action meeting in January, updates were made to the employee handbook, health and safety policy, and changes were made to key roles including the removal of the previous data controller and safeguarding lead. While these actions demonstrate a reactive response, the service did not clearly document the nature of the incident, its impact on people who use services, or the staff member involved or safeguarding considerations. There was no evidence of a structured investigation with clear findings, nor of learning or preventative measures to reduce future risk.

During our onsite assessment we spoke to staff and were told of three incidents that had resulted in staff disciplinary measures. We requested the investigation reports, but these were not provided. We were not assured that all incidents were monitored and reviewed in detail by leaders.

The service had a Duty of Candour policy in place, however this did not accurately reflect statutory and professional duties of candour.

We did not see any evidence that the provider had undertaken duty of candour following investigations.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service provided non-emergency patient transport services that could be pre-planned or booked on the same day.

The service held a service level agreement with a local NHS acute trust to provide non-emergency patient transport services (PTS). It operated four dual-crewed ambulance (DCA) vehicles daily to support the safe and timely transfer of patients.

The service also supported same-day and pre-booked discharges for patients with mental health conditions. These were arranged depending on patient need and availability.

Bookings were received directly from the trust by telephone or email. A call handler was responsible for inputting booking details into the provider’s electronic job management system. Once a booking was confirmed, the information was communicated to the transport crew either verbally or by telephone.

Call operators identified the needs of patients during their initial call including the patient information, pick up location, drop off location and risk factors such as mobility.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

The service had a safeguarding policy that referenced children and vulnerable adults. However, there was no designated safeguarding adult’s policy in place. The existing policy did not provide a comprehensive framework aligned with the six key principles of adult safeguarding: empowerment, prevention, protection, proportionality, partnerships, and accountability. It lacked clear definitions and descriptions of different types of abuse, harm, neglect, exploitation, and maltreatment, which are essential to help staff identify signs and indicators. The policy did not specify the required level of safeguarding training for all staff. Overall, the policy lacked sufficient detail and was not fit for purpose.

The service had a designated safeguarding lead. We saw evidence that they had completed Level 3 safeguarding training for children, which is appropriate for their role. However, we did not see evidence they had completed Level 3 safeguarding training for adults.

The service had a Disclosure and Barring Service (DBS) policy which was not tailored to the scope or risks of a patient transport service. It included references to groups and roles that were not relevant, such as teachers, nursery staff, foster carers, childminders, councillors, inspectorates, beauty therapists, retail first aiders, online moderators, and informal personal relationships. These inclusions created confusion and detracted from the clarity of the policy. While the policy did include a definition of regulated activity for adults, including conveying people to and from health or social care settings, this was presented in legal language and accompanied by examples that were not applicable to the service. The policy did not indicate the level of DBS check required for roles employed by the service.

The service provided evidence that all staff had undergone appropriate pre-employment DBS checks after the inspection.

During the onsite assessment, we spoke with the nominated individual, who told us that the service did not convey children and young people. This was inconsistent with information from staff and the registered manager, who reported that the service had undertaken a small number of transfers involving children and young people within the last year.

Staff used body‑worn cameras during mental health transport to help record incidents of aggression and promote the safety of both patients and staff. The service had a policy in place to guide the use of body‑worn cameras during transportation; however, the policy referenced local council procedures and the Traffic Management Act 2004, which were not applicable to the service’s operations.

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

The service used transfer report forms (TRFs), which were initially completed by the telephone controllers over the phone to understand the requirements of the patient. They gained as much information as possible to risk assess patients. Staff always included the date and time the booking was made on the TRF and considered medicines under ‘other information’.

Information provided by the referring service was used to calculate how many mental health transport assistants and what type of vehicle was appropriate for the level of need during the transfer. Risk assessments were completed at the time of booking and then at the time of collection of the patient.

The service ensured that a parent, carer, healthcare professional or chaperone accompanied the patient during transfer if required.

Patient transport discharge and ongoing returns were organised safely. Patients knew what to expect and when they would be next collected. We spoke to two patients during our assessment who told us they felt safe with staff during transportation.

Staff that we spoke with said they could access advice and support from the host NHS trust hospital discharge lounge in cases where unexpected risks were identified.

The service used a range of control and restraint measures, including physical, psychological and mechanical restraint, and the use of spit hoods, masks and guards. However, the provider’s spit mask, hood and guards (SMHG) policy did not reflect relevant legal and regulatory frameworks including the Human Rights Act, Mental Health Act Code of Practice around least restrictive practices. The policy included a sub heading titled ‘’Protecting the vulnerable’’ which stated that staff should consider any known medical issues but did not specify which conditions would negate the use of a SMHG. It did refer to neurodiverse conditions which may include Autism, Mental Health issues, claustrophobia or any other issue which, in the opinion of the staff member, may have an adverse effect on the subject’s health. The policy did not set out what staff should do in the event of an emergency.

The policy also stated that the subject should always be handcuffed before the SMHG is utilised to prevent the patient removing it. The use of handcuffs and use of SMHG are two separate restrictive interventions each carrying distinct risks. They must be individually risk assessed, justified and proportionate to each individual. Pairing of these two restraint interventions is not lawful, does not follow the least restrictive practices and does not align with best practice.

The service had a restraint risk register dated January 2024 which contained five entries. However, none of the entries recorded the type of restraint used. The service told us they did not complete any audits of restraint.

The provider was unable to give assurance that staff had completed training that met the Restraint Reduction Network (RRN) training standards. This lack of assurance is significant because, without evidence that staff have undertaken RRN‑compliant training, the provider cannot demonstrate that restrictive practices are being used safely, lawfully, or in accordance with national standards designed to protect people from avoidable harm.

The service 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 or that there was appropriate mitigation of the risk.

The service had a fleet of ambulance vehicles kept within a secure and monitored compound. Vehicles were stored in a safe area and could not be accessed by unauthorised persons. Keys to vehicles were securely stored.

Staff carried out daily safety checks of the vehicles. These included checks of the physical condition of the ambulance and the equipment utilised on the vehicle, such as oxygen, carry chair, mobile phone and vehicle radio.

We inspected four vehicles and found that resuscitation equipment was limited. None of the vehicles carried a defibrillator, which meant staff would not have access to this equipment in the event of a cardiac emergency.

Vehicles used for the transport of patients who were detained under the Mental Health Act were appropriate and safe.

The service did not always 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 always work together well to provide safe care that met people’s individual needs.

The provider employed approximately 50 staff across its patient transport and mental health transport services. The patient transport service employed 22 staff, while the mental health transport team employed around 30 staff, the majority of whom were on zero-hour contracts. Eight staff members were dual trained to work across both provisions. The service was led by two directors, one of whom was the registered manager and the other the nominated individual. Operational oversight was provided by team leaders assigned to each service, supported by an office manager and three telephone controllers.

The service had a training policy in place that outlined mandatory training requirements for different staff groups, including patient transport and mental health ambulance care assistants, telephone controllers, mental health advocates, and team leaders. Training covered core areas such as safeguarding, infection control, emergency first aid, moving and handling, mental health awareness, and driver assessment. Role specific modules were also included, such as Level 2 medical gases and physical restraint. The policy set out the induction process and a phased training schedule over the first six months of employment. However, the provider could not demonstrate that this policy was being implemented consistently across the workforce.

We reviewed a sample of staff files during the site visit and found that those staff had completed training in line with the provider’s policy. Following the inspection oversight of all training undertaken by staff was provided. However, we were concerned about the adequacy of basic life support (BLS) training, as staff had only completed the e‑learning module. There was no evidence that staff had undertaken any practical or observational training to demonstrate competence in basic life support techniques.

We reviewed a sample of staff files, which included evidence of mandatory training. We were concerned about the adequacy of basic life support (BLS) training, as staff had only completed the e‑learning module. There was no evidence that staff had undertaken any practical or observational training to demonstrate competence in basic life support techniques.

The service assessed and managed the risk of infection.

Staff adhered to infection control principles, including handwashing and wearing personal protective equipment (PPE).

The service had a programme in place for deep cleaning vehicles every six weeks, with additional cleaning carried out when required. However, there was no formal process in place to monitor or audit the completion of deep cleans. This meant the provider could not demonstrate that cleaning schedules were consistently followed or that vehicles were maintained to the required hygiene standards.

The service had completed an annual infection protection and control (IPC) audit dated June 2025 which identified good IPC practices overall. The audit covered key areas such as hand hygiene, PPE, waste disposal, body fluid spillages, care equipment, linen, and the care environment. However, there was no evidence of deep clean audits for vehicles, despite a stated six-week cleaning programme.

During the assessment we observed that staff maintained the cleanliness of their vehicle during a shift. For example, we observed, they cleaned down surface areas used by patients or others onboard between journeys.

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

The service only used oxygen onboard PTS vehicles.

The service had a transportation of medicines policy that covered general medicines, controlled drugs and medical gases. The policy outlined the responsibilities for both transport and hospital staff. However, there was no separate policy in place for the management of oxygen. This meant there was no documented guidance on the hazards associated with oxygen use, the causes of oxygen-related fires and explosions, appropriate storage requirements, or incompatible materials, as required by relevant regulations.

We reviewed a sample of staff training files onsite and found some evidence of completion of Safe Handling and Administration of Medical Gases – Level 2. However, although we requested Medicines Training and Competencies and current Mandatory Training compliance for all staff, these were not provided. We could not be assured that all staff had received the required training necessary to safely carry out their roles.