Archived: EMED Surrey Heartlands

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 that leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

This is the first inspection for this service. This key question has been rated requires improvement. The service did not ensure relevant staff received the appropriate training in incident investigation. Staff raising incidents did not always receive feedback after investigations were complete. The service did not always make sure there were enough qualified, skilled and experienced staff. However, the service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. They made sure equipment, facilities and technology supported the delivery of safe care. The service assessed and managed the risk of infection. The service made sure that medicines were safe and met people’s needs.

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.

We scored the service as 2. The evidence showed some shortfalls. The service did not ensure relevant staff received the appropriate training in incident investigation. Staff raising incidents did not always receive feedback after investigations were complete. However, the service investigated incidents comprehensively and ensured actions were in place to prevent incidents recurring.

EMED staff tasked with investigating and responding to incidents had not received training on how to apply the Patient Safety Incident Response Framework (PSIRF). PSIRF is important in healthcare because it provides a structured system-based approach to responding to patient safety incidents, fostering learning and continuous improvement to reduce harm. We were not assured EMED followed this mandatory approach to responding to patient safety incidents.

Learning did not always take place in a timely way. A serious incident occurred in December 2024 and January 2025 relating to the use of a winch when one patient fell out of their wheelchair on 3 separate occasions. While the investigation was thorough and highlighted problems with training staff on how to operate a winch properly, there were repeated incidents before action was taken.

Staff reported most events via a dedicated national incident telephone line, for example, vehicle accidents, patient incidents, and safeguarding incidents. Staff receiving incident calls logged them on the company’s risk, quality and compliance software. Team leaders accessed the risk, quality and compliance software and could log incidents themselves. Every step taken relating to an incident was saved on this software, providing an audit trail. A quality and governance manager [LO6] reviewed every incident to ensure relevant incidents were escalated, investigated, and reported externally, if required. Serious incidents were investigated comprehensively and the duty of candour followed appropriately. Staff told us they did not always receive feedback after reporting an incident.

We reviewed data to understand how long the service took to close incidents. The incident reporting and investigation policy outlined patient safety incidents needed to have an immediate review and learning outcomes after 14 days of receipt of the incident. In the last 6 months the service had logged 41 incidents and the average time to close these with an After Action Review (AAR) and learning outcomes was 22.7 days. The service had 8 open incidents with the oldest being from April 2025.

Staff received focused learning through ‘toolbox talks’ following specific incidents (toolbox talks are short, informal discussions focused on safety). We saw the script for a toolbox talk relating to safely transporting patients in wheelchairs. This included the training session itself and the opportunity for staff to ask questions at the end. Team leaders were responsible for logging staff’s attendance at toolbox talks.

Managers shared learning from events via email, as well as an online messaging platform, and the service’s healthcare software platform. The quality and governance team sent out a monthly learning bulletin, which included learning from incidents, complaints, concerns, and safeguarding. The service conducted swarm huddles immediately or soon after a patient safety event to understand how, what and why something happened. Swarm huddles resulted in actions being put in place to prevent recurrence.

The quality and governance team held weekly incident review meetings with all team leaders, operational managers, and regional managers. This meeting included discussions about incidents, complaints, concerns, and safeguarding issues. We reviewed minutes from these meetings which confirmed staff discussed incidents in detail.

We scored the service as 3. The evidence showed a good standard. 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.

Call handlers collated information at booking to help in managing patients’ journey safely. They ensured they completed eligibility criteria check, and collected information about medicines, mobility needs, and other information. Once this had been gathered, allocations to vehicles and crews were dealt with by a planning team. Call handlers signposted patients who did not meet the service’s eligibility criteria to other providers. Once the patients had completed the eligibility criteria, they could then use the online booking system themselves. The service stored patients’ details on their system and reviewed these at every new booking. Anything the planners or crews needed to be aware of was highlighted on the system and crews could access this on their Personal Digital Assistants (PDAs), a handheld computer used by ambulance crews for various tasks. This included, for example, information related to people’s mobility, medicines and communication needs.

Patients called the enquiries line with queries relating to their transport; for example, if the crew was late picking up. The service captured information from calls on a patient log but did not routinely monitor the data for any themes and trends Which could be placing people at risk of harm.

EMED Surrey Heartlands employed Hospital Ambulance Liaison Officers (HALOs) who based themselves in the discharge lounge of the relevant NHS trust. They also employed Patient Safety Liaison Assistants (PSLAs) who worked in the outpatient departments of NHS trusts. HALOs attended trust bed meetings and engaged directly with the wards to gather information on patients due to be transported. PSLAs provided a support role focused on providing administrative assistance for patient transport. We observed HALOs and PSLAs worked together well. We also saw them liaising with hospital staff appropriately and efficiently.

Every vehicle had in-cab closed-circuit television (CCTV) and displayed stickers to alert patients to this. Staff informed patients of CCTV being in use at the beginning of their journey. CCTV could be used to support investigations in the event of an incident. It was also used to monitor drivers’ behaviours.

The provider used a fleet management software system to track their vehicles. Team leaders told us this could be used in cases where patients called when their transport was delayed and the service could indicate how far away the vehicle was.

We scored the service as 3. The evidence showed a good standard. The service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Once safeguarding issues were identified, they shared concerns quickly and appropriately.

The service displayed posters regarding who staff needed to contact in the event of a safeguarding concern. We heard they reported safeguarding concerns to the national control room. This safeguarding telephone line was manned 24 hours a day. Central staff logged all concerns on the risk, quality and compliance software programme. They reported the concern to the local authority if necessary.

The local quality and governance team had oversight of all safeguarding concerns/incidents. Part of their role was to ensure relevant referrals had been made to the local authority.

The provider had a comprehensive and up-to-date adults and children safeguarding policy in place. This clearly outlined definitions of safeguarding and the role of staff in relation to safeguarding. The policy contained clear processes of what actions to take should staff come upon a safeguarding situation.

All crew members received level 1 and level 2 safeguarding training. Quality and governance managers received level 3 safeguarding training, and the medical director was trained to a level 4.

Call handlers received a 2-day face-to-face training programme conducted by the incident reporting team. This was aimed at learning how to pick up any safeguarding concerns during telephone calls.

We scored the service as 2. The evidence showed some shortfalls. The service did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service worked with people to understand and manage risks.

The service had identified a separate team and dedicated fleet to transport dialysis patients. This was introduced as dialysis is a time critical treatment. However, we heard from patients and saw from the data that patients faced delays getting to appointments and being brought back home after their appointment. The service was aware of these concerns and was working to strengthen the dedicated team and was reviewing how journeys were planned.

The service ensured they gathered relevant information from patients to plan safe journeys. For example, call handlers asked patients about their mobility so appropriate equipment could be organised. Crews received training in supporting people who required oxygen, and this was provided on all vehicles.

HALOs and PSLAs based within the hospitals ensured they informed EMED staff of any information regarding patients who were transported home. Equally, they ensured patients waiting for transport were safe and their needs were met whilst waiting.

EMED provided training for hospital staff on how to use the PTS booking system appropriately to ensure relevant information about patients was captured. This was important so crews knew how to assist patients and what equipment was needed to transport patients.

Call handlers encouraged patients to bring food/drink in case of delays. This was particularly important for renal patients following their appointment.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed internal and external vehicle checks daily, to ensure they were safe to use. These checks were comprehensive and included the recording of expiry dates of equipment, the presence of required equipment, and vehicle damage with photo evidence. Team leaders conducted spot checks on vehicles and recorded these. They carried these out randomly before and after shifts. We reviewed 5 records and saw staff had completed them fully. The provider ensured vehicle checking was part of the induction process.

The service had a dedicated regional fleet manager who was responsible for vehicle-related matters. They used an online platform to record all aspects relating to vehicles; for example, dates of MOTs, servicing, Vehicles Off Road (VORs).

The Estates and Facilities department ensured regular checks of ambulance stations and equipment were conducted. This included checking fire alarms, fire extinguishers, roller doors, and the roof of the building. Staff recorded the outcome of the checks in a report. The provider used an outsourced company to make any repairs required.

Team leaders carried out daily audits of sites to check cleanliness, tidiness, and any stock requirements.

There was a safe system to ensure those vehicles not safe for use were not accessible to staff. Vehicles needing repair and taken off the road had a Vehicle Off Road (VOR) sign placed on the dashboard. In addition, the steering wheels were locked to ensure nobody could misunderstand and take a faulty vehicle on the road.

Ambulance keys and PDAs were stored securely, with controlled access, when not in use.

The service transported children and adults. They had suitable equipment for children to keep them safe and secured during transit, and crews received training in how to use the equipment.

The service had use of bariatric vehicles, which included bigger trolleys and wheelchairs. We understood from dispatchers that no specific training for the use of bariatric equipment had been offered to staff by the provider.

We scored the service as 1. 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.

Staff did not always receive the support they needed to deliver safe care. Annual appraisal uptake was low and there was no formal supervision although this could be requested on an ad hoc basis. New staff probationary reviews were not consistently undertaken as described in the policy and staff did not always receive support to complete the required training.

The provider’s policy outlined new members of staff should receive probation reviews at 4, 8, and 12 weeks; however, we heard not every member of staff had these. Team leaders did not always manage to complete crew-related processes as they told us administrative pressures prevented this at times.

Current figures for annual appraisals stood at 4 per cent (6 out of 153 staff had had an appraisal). Managers told us appraisal rates were low due to the high number of new starters. Each new starter had their first appraisal 12 months after starting at EMED. A review of 6 appraisal examples highlighted a lack of detail and incomplete appraisal forms. Appraisals are important as they help staff reflect on their work and identify areas for improvement and development needs.

There was an inconsistent approach to the service’s requirements for driving assessments. The provider’s Learning and Development policy outlined requirements for driving assessment. This clearly indicated new starters had to take part in driving training and assessment during their induction period. However, we heard conflicting information. Some staff told us they did not receive specific driver training as all they needed was a full, manual driving license. Others said they had received one or 2 assessments on joining the company. The service ensured they reviewed staff’s driving licenses annually and recorded this on the HR online platform. During onboarding of new crew, staff were required to complete an initial driver risk assessment on the service’s online HR platform.

Team leaders had responsibility for organising shift rotas. At the time of this assessment, team leaders told us they did this on a 4-weekly basis. However, there was a discrepancy between what staff said. Frontline staff said they did not receive their shifts until one to 2 weeks in advance. The provider planned to introduce an annual rota in the future.

Team leaders managed rotas and used contingencies to maximise resources and performance, which included mobilising team leaders and operational managers and asking existing crews to extend shifts. The service had almost concluded a staff integrated rota consultation period. This included open days and specific one-to-one meetings with the aim of implementing a new and more accurate rota.

If demand outstripped resources, planners raised this with the operational teams in terms of how to manage the situation. However, we also heard of journeys being added at short notices and patients arriving late for appointments and waiting over 2 hours to be collected. Therefore, it was unclear if the service had the required number of staff to deliver a safely planned service.

Staff received a mix of face-to-face and online mandatory training. The training records showed 91 per cent of staff were compliant with their mandatory training. Staff received training on learning disability and autism as part of their mandatory training. The customer care team had responsibility for ensuring all staff were up to date with their mandatory training. If staff did not attend relevant training, they would be reminded; any further nonattendance led to a formal performance process.

The provider used a variety of social media sites to advertise job openings. They also used one recruitment agency, with the aim of employing agency staff to become permanent members of staff. The provider had established a partnership with a job centre in Surrey to employ people over the age of 50 who found themselves out of work. They also ran a scheme called “refer a friend” where staff received a monetary reward if they helped to recruit somebody they knew. A weekly catch-up meeting between the recruitment and operational team was held to keep abreast of recruitment gaps. The provider employed 27 staff to work within the renal part of the service, with 3 new staff due to start shortly. The provider used approximately 5 per cent bank staff to fill shifts.

The provider had 138 frontline staff. Posts that were currently filled by agency staff were not classified as vacant because this group of staff would become permanent staff soon.

The provider used safe recruitment processes during their hiring of new staff (safe recruitment refers to a set of practices designed to ensure that individuals hired to work with vulnerable people are suitable and pose no risk of harm). The safer recruitment & selection process policy outlined what documentation was required from candidates, such as right to work in the UK, proof of address, professional registration, and Disclosure and Barring Service (DBS) checks.

On joining the company, each member of staff attended a 2-week induction and training period. This included, for example, first aid, manual handling, cardio-pulmonary resuscitation (CPR), fire safety, dementia, infection prevention and control (IPC). Each new member of staff completed a “journey to performance” booklet during their first few months with the company. This included, for example, evidence of completing manual handling training, site-specific induction, oxygen therapy, vehicle safety. The records showed 80 per cent of new staff had completed their journey to performance booklet, which was below the target of 85 per cent. Mentors supported all new starters through the induction process. All agency staff attended the same induction. Staff told us any training which did not form part of mandatory training had to be completed in their own time. Once they had completed their probationary period there was no further review of their competency and team leaders did not accompany crews to check their competency.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The provider had an up-to-date and comprehensive infection prevention and control (IPC) policy in place.

Ambulance stations were clean and tidy.

We checked 6 vehicles, and they were all clean and tidy. Staff had access to personal protective equipment, such as gloves, masks and aprons.

Staff cleaned their vehicles using environmentally friendly sanitising products. Every day staff cleaned vehicles using a dry mist cleaning process. During the day, staff used wipes to disinfect and clean vehicles. Some staff started and ended their day from home. Managers monitored the completion of cleaning of these staff’s vehicles through electronic records.

All vehicles underwent a deep clean every 13 weeks. This was outsourced to a third party.

Vehicles had spill kits secured away in cupboards. These could be used to clean up after patients had been sick, for example.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines were safe and met people’s needs, capacities and preferences.

All vehicles carried oxygen. Warning stickers were seen on vehicles for oxygen and flammable gas. We looked at 6 vehicles and saw all oxygen cylinders were secured properly. The provider had a comprehensive and up-to-date storage of medical gases policy in place. EMED crews could administer oxygen up to 15 litres; if patients required a higher dose, the planning team had to ensure they allocated the correct level of crew. A standard operating procedure (SOP) was in place outlining who could administer oxygen and what level of training was required to be able to carry out this task.