HTG-UK East – Norwich

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant people’s needs were not always met.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Staff did not consistently have the information needed to work in partnership with people when responding to changes in their needs. Although frontline staff gave examples of being conscientious and patient‑focused, they told us they did not always receive the necessary risk information or resources to deliver high‑quality, individualised care. This limited their ability to provide consistently person‑centred support.

Leaders did not have a sufficiently robust system in place to ensure that control room staff gathered and shared all relevant risk information needed to help frontline staff keep people safe. As a result, leaders did not always recognise opportunities to strengthen systems and support arrangements that would enable staff to deliver more personalised, responsive care.

Staff were also not consistently equipped with the knowledge, skills or ongoing supervision required to understand and respond to the individual needs of people, including those with learning disabilities and autism. Without appropriate training and clearer processes, staff were not always enabled to deliver care that was fully tailored, respectful and responsive to people’s needs.

We scored the service as 2. The evidence showed some shortfalls. There were some shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Leaders did not demonstrate sufficient understanding of care provision, integration, and continuity, as evidenced by the recurrence of incidents affecting the timeliness and coordination of renal transport services. Persistent delays, capacity challenges, and communication failures indicated that risks were not adequately mitigated, and oversight remained weak.

Systemic issues directly affected care outcomes, particularly for patients requiring time-sensitive treatment, and hindered services from working in a coordinated and responsive manner.

The lack of flexibility in transport arrangements, long travel times, and poor coordination with hospitals and social care services further disrupted continuity of care and restricted patient choice, negatively impacting wellbeing and timely access to support.

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider submitted 6 notifications in the 12‑month period prior to our inspection, which was low given the volume of activity.

Leaders did not ensure that information shared with patients, staff or partner organisations was consistently appropriate, accurate or tailored to individual needs.

Leaders could not demonstrate that there were a system or resources to ensure information was provided in accessible formats.

Control room staff did not always gather or pass on the full range of risk information required to support frontline staff. As a result, frontline teams sometimes began journeys without key details needed to plan safe, person‑centred care. Staff told us this limited their ability to respond effectively to individual needs and to keep people safe.

Leaders ensured information governance systems were in place, and these systems protected the confidentiality of patient records.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did not always involve people in decisions about their care or tell them what had changed as a result.

Between 1 January and September 2025, staff recorded 28 complaints. These mainly related to cancelled transport (8), late inbound collections (6), late outbound collections (5) and staff behaviour (5), alongside additional concerns about communication, safeguarding and other issues. Of these complaints, 11 were upheld, 7 were partially upheld, 5 were not upheld and 5 remained under review.

We compared wider incident data and feedback from external partners; the volume and nature of complaints understated the scale and persistence of service issues. Incident reports from hospitals and commissioners highlighted recurring delays, capacity gaps and communication failures, particularly affecting patients requiring time‑sensitive renal treatment. Peaks in incidents during October and November 2024, and again in August and September 2025, suggested these problems were systemic and ongoing rather than isolated or resolved through individual complaints handling.

Leaders did not use complaints or incident data effectively to drive improvements, nor did they take a proactive approach to understanding or addressing the cumulative impact of these issues on people’s experiences and outcomes. The recurring themes of lateness and delays across both complaints and incident reports highlighted a disconnect between the provider’s internal response and the broader challenges affecting patient care and service coordination. Although the nature and volume of complaints mirrored concerns raised by external partners, this did not appear to prompt sufficient action to mitigate ongoing risks or improve service reliability.

Despite these shortfalls, the service had a complaints policy and process in place, supported by a central patient experience team. The policy was shared with staff, and details of the patient experience team were available on the provider’s website.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Incident volumes rose significantly in October 2024, which was anticipated as this marked the start of the new contract and required a bedding in period. The highest number of incidents occurred in November 2024, with 40 reported issues. Although volumes reduced between December 2024 and July 2025, a further rise was observed in August and September 2025, with 29 and 28 incidents respectively. Most incidents (88) were associated with delays and lateness. Additional issues included capacity and resource constraints (12) and communication challenges (12), reflecting broader challenges in service coordination and patient engagement.

Discharge planning was compromised by transport delays, impacting timely access to medication and social care support. Discharges were frequently delayed for non-clinical reasons, particularly transport issues, contradicting expectations for timely discharge.

Staff supported patients with mobility needs by providing equipment such as stretchers and wheelchairs.

We scored the service as 2. The evidence showed some shortfalls. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Leaders and staff did not always listen to or act on information about people most at risk of experiencing inequality in care experience or outcomes. Despite repeated concerns raised by patients, staff, and external partners, there was limited evidence that services were adapted to meet the specific needs of vulnerable individuals.

Leaders failed to address ongoing delays in patient transport, particularly individuals requiring time-sensitive renal treatment. Incident data showed consistently highlighted issues with timeliness, capacity, and communication, yet these themes persisted throughout the year, peaking again in August and September 2025. This suggested that feedback and incident trends were not used to drive service improvements or adapt care delivery.

Local partners expressed concerns about delays affecting hospital discharge, access to medication, and social care support; issues that disproportionately impacted people with complex needs.

Although leaders engaged regularly with commissioners and local hospitals to address transport issues, progress was inconsistent. Despite offers of support, some collaborative efforts were not always received constructively, which limited the effectiveness of joint problem-solving and prolonged difficulties in delivering timely, coordinated care.

Staff deployment did not align with patient needs. Mental health staff were assigned to patients with complex physical health conditions, and vice versa, creating safety risks due to mismatched skills and competencies. This reflected a lack of focus on individual requirements and a failure to adapt to care clinical complexity.

Overall, the evidence indicates that leaders and staff did not consistently act on information about those most at risk of poor outcomes. As a result, care was not reliably tailored to individual needs, leading to avoidable delays, increased risks, and disruptions to people’s wellbeing.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff worked regularly with patients receiving end-of-life care. Where appropriate, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were in place and clearly documented. Conversations with staff confirmed that care planning was sensitive, patient-centred, and aligned with best practice, enabling individuals and their families to make choices that reflected their wishes and clinical needs.