HTG-UK East – Norwich

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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 was the first assessment for this newly registered service. This key question has been rated inadequate.

This meant the service were not safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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 1. 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. Lessons were not learnt to continually identify and embed good practice.

Staff understood which incidents needed to be reported and how to report them. However, they did not always feel confident that reported incidents were logged or used to drive service improvement. During our site visit, we saw that a manager had left paper incident reports in a drawer without review or follow-up actions.

Staff told us they did not always submit incidents, even when required, due to a lack of confidence that they would be appropriately addressed.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. The leadership team accepted responsibility for incidents where staff had made an error or had contributed to an incident.

Staff told us they did not always receive feedback from incidents. However, we saw leaders recorded staff feedback from investigations, both internal and external to the service.

Staff did not always meet with leaders to discuss feedback. Leaders told us they were starting to offer listening events for staff. These events offered a space where staff could raise concerns and be heard. However, staff told us they had only had one listening event and did not feel it was useful yet.

Lessons learned were not consistently embedded in practice. While monthly bulletins highlighted key safety considerations, staff continued to be allocated jobs that did not reflect this learning. In one case, a task was assigned where the staff member could not safely monitor the patient. Despite raising the concern and formally reporting the incident, the same task was reallocated the following day with no adjustment to resources.

Staff felt their concerns were not being addressed, and that job allocations were based on operational convenience rather than patient safety. This raised significant concerns about the effectiveness of applying learning to improve safety practices.

Opportunities for staff debriefs were inconsistently applied. Mental health staff told us they were keen to ensure debriefs took place but did not have a suitable space to complete them and a manager was not always available to provide support. However, we did see some examples where staff received debriefs, and appropriate support following serious incidents, which demonstrated some positive practice.

Two serious incidents had occurred in the past 12 months, both of which were investigated and followed by appropriate staff support. Leaders worked collaboratively with external partners to share information.

We scored the service as 2. The evidence showed some shortfalls. 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.

Performance data for renal transport showed overall Key Performance Indicators averaged broadly in line with national figures. However, triangulated evidence from incident reports, referrers and renal staff demonstrated that some patients continued to experience significant delays. Particularly before the correction of data‑transfer errors in appointment times.

These delays directly affected access to time‑critical dialysis sessions. Delays highlighted weaknesses in systems for ensuring continuity of care during service transition. Although leaders acted following escalation from the renal unit, recurring themes indicated that governance and learning processes were not consistently effective in preventing re‑occurrence.

Despite these concerns, staff involved necessary healthcare and social care services to support continuity of safe care for patients, both within the service and following discharge.

We scored the service as 1. The evidence showed significant shortfalls. The service did not 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.

Staff safeguarding training was not up to date. Leaders did not ensure all staff received appropriate safeguarding training. Compliance with safeguarding training for both adults and children was 81% against a target of 95%.

The service had a safeguarding lead and a safeguarding policy; however, despite these structures being in place, there were concerns about how safeguarding was implemented in practice The provider could not evidence whether staff were trained to the appropriate safeguarding levels. Leaders supplied safeguarding certificates that were out of date or belonged to staff who were no longer employed by the service. In the 12‑month period prior to inspection, the Care Quality Commission received 1 safeguarding notification from the service. Several aspects of safeguarding oversight, training, and response demonstrated that the systems were not operating effectively to ensure patient safety.

The mental health lead promoted least restrictive practice, sharing current research and encouraging approaches that reduced the need for physical intervention. While progress had been made, this was not yet embedded consistently across day‑to‑day practice, which created the potential for safeguarding risks if restrictive interventions were not applied in a standardised way.

Staff told us they remained concerned that the de‑escalation training provided was not sufficient to keep themselves or the people they transported safe. They regularly supported individuals with mental health needs, including those detained under the Mental Health Act, and felt the training did not fully prepare them for situations where behaviour may escalate.

National guidance and best practice recommended that staff who may need to use force have appropriate training to support safe, least‑restrictive responses. Staff reported that without more robust training and guidance, they were not always confident in how to respond consistently or recognise when a situation required escalation, increasing the risk of unsafe or variable practice during episodes of escalating behaviour.

Staff escalated concerns to leaders when there were safeguarding considerations; however, leaders did not always respond appropriately to the concerns raised. Staff gave numerous examples of identifying potential safety issues. For example, staff raised concerns related to equipment safety, appropriate journey planning, and the need for suitable skills and training.

Staff raised safety concerns and requests for alternative vehicles to support patient comfort and dignity. Staff raised concerns about journey plans that could negatively affect wellbeing, and gaps in the skills required to respond to potential patient deterioration for both child and adult cases.

Staff understood how to protect patients, including those with protected characteristics under the Equality Act.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff 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.

Staff worked with patients presenting with complex needs, including mental health conditions and social vulnerabilities, and demonstrated awareness of protected characteristics. Although there was a clear intention to manage risks in a safe and supportive way, inconsistent implementation, evidenced by only 75% compliance with Basic Life Support training may affect staff confidence and potentially compromise patient safety in critical situations.

Staff communicated effectively with patients, including those experiencing communication challenges, by adapting their approach, for example, involving family members to support neurodivergent individuals. However, we also observed that staff responsible for triaging referrals did not always seek further information to fully understand specific needs, such as those patients with advanced dementia.

Staff told us that in some situations, including when detained patients attempted to abscond, they did not feel their current physical intervention training fully prepared them to manage risks safely. One example involved a male crew restraining a female patient, which staff felt would have been safer with more comprehensive training. We acknowledged that the provider delivered physical intervention training and had procedures in place for patients who were absent without leave. However, staff consistently raised feeling vulnerable, under-prepared, and unsupported, particularly when managing restraint as an all male crew involving female patients. They also felt their safety concerns were not being heard or acknowledged by leadership.

Staff demonstrated an understanding of least restrictive practice and avoiding blanket restrictions. However, staff were concerned about the lack of leadership support for restraint training, which staff felt was necessary in some situations. For example, when patients attempted to abscond and allowing them to do so would be unsafe. While staff documented instances of restraint, and leaders collected data to monitor its use, the absence of appropriate training remained a concern.

Leaders told us that mental health training and support were provided. However, during our site visit, we saw that leadership presence and guidance was not always available in a supportive way. Staff told us they did not feel the training adequately equipped them to manage risks or ensure the safety of themselves or individuals in their care.

We scored the service as 1. The evidence showed significant shortfalls. 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.

We identified several concerns relating to the safety and management of equipment and hazardous substances, which indicated that the systems in place did not provide sufficient assurance of safe practice. Significant lapses in fire safety, electrical safety, and Control of Substances Hazardous to Health (COSHH) management created avoidable risks to staff and patients and demonstrated a disconnect between documented compliance and what was observed in practice.

Fire safety arrangements were inadequate. Fire extinguishers were dusty, poorly maintained, and not serviced in line with required standards; one extinguisher displayed inspection dates as far back as 2013, with the last recorded check in October 2022. Access to another extinguisher was obstructed by a vacuum cleaner, which could delay the ability to respond safely in an emergency. Electrical safety was similarly inconsistent. We found a portable heater with an out‑of‑date test label, overdue for inspection since November 2024, with no evidence of a recent safety check.

Leaders reported that equipment under 12 months old did not undergo portable appliance testing (PAT); however, staff had no reliable way to determine the age or safety status of items in the absence of visible labels or accessible records, limiting assurance that equipment was safe for use.

Despite internal COSHH audits recording 100% compliance from October 2024 to August 2025, our findings did not align with this. Cleaning fluids were stored in a cluttered space among empty boxes, with several containers missing lids. This poor organisation created risks of spillage, contamination, and unsafe chemical exposure, and did not meet safe COSHH storage practices.

We reviewed vehicle safety in response to concerns raised by staff to us. Staff told us they had repeatedly reported issues such as poorly serviced vehicles and unsafe tyre tread but felt their concerns were not acted upon. Some staff provided photographic evidence to support these reports. During our inspection, however, all vehicles we checked were found to be maintained.

Despite the provider’s established vehicle checking process. We observed two journeys’ where staff did not use vehicle daily inspection (VDI) sheets in practice. Checks were inconsistently carried out and not recorded. Staff told us they relied on visual checks and did not complete the formal vehicle daily inspection (VDI) sheets. As a result, there was a risk that defects would go unidentified and unresolved. Risks included issues such as faulty brakes or lights, low tyre tread or pressure, expired or missing medicines and equipment, depleted oxygen, inadequate infection prevention supplies, or equipment not secured. The impact could be delayed care, compromised infection control, increased risk of incidents during transport, or lead to avoidable patient harm.

Several staff described ongoing issues with vehicles not being repaired after defects were reported and said that the absence of a make‑ready function had contributed to these problems. Staff also told us they were unsure how to report defects through the fleet management system and typically relied on verbal reporting to the station manager.

There were some areas where processes were implemented appropriately. Oxygen cylinders were stored securely in a cage with clear separation between full and empty cylinders, demonstrating compliance with expected handling and storage procedures.

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.

At the time of the initial site visit, senior leadership presence during routine operations on site was limited. While the provider assigned several leadership roles to the East Norwich site, there was reduced direct oversight and immediate access for staff. Administrative and coordination capacity was also constrained, with one site administrator, four dispatchers, and a small control team. Following the site visits, senior leaders relocated to be on site more consistently. Leaders have since recruited a Station Manager and an additional Deputy Station Manager, to help strengthen governance visibility and day‑to‑day leadership.

Clinical oversight was limited for the level of complexity seen in some of the people transported. Although the service was not expected to employ paramedics, staff transported individuals whose needs occasionally exceeded the staff skill‑mix. There was no clinically trained staff available to offer guidance. Staff told us this meant they were not always supported to recognise or escalate deterioration, and the service lacked a reliable system to identify when a person’s needs were beyond its competencies.

Clinical oversight was limited for the level of complexity seen in some of the people transported. Although the service is a NEPTS provider and not expected to employ paramedics or hold TDDI registration, it transported individuals whose needs occasionally exceeded the staff skill‑mix. Only two staff held FREC Level 4, with the remainder trained to Level 3, and there was no clinically trained staff available to offer guidance. This meant staff were not always supported to recognise or escalate deterioration, and the service lacked a reliable system to identify when a person’s needs were beyond its competencies.

Operational staff raised concerns about their ability to manage clinical situations safely, especially without medical cover or adequate training. While a gold and silver command structure was in place for emergency escalation, this did not substitute for consistent clinical leadership and assurance in routine operations.

Staff told us there was limited out‑of‑hours leadership cover. The mental health team highlighted that there was no out-of-hours provision for escalating concerns. A manager told us they often stayed late to ensure staff had access to someone in a position of responsibility.

Staff were not up to date with mandatory training requirements. In the 12 months prior to inspection, training compliance remained consistently low. In October 2024, mandatory training compliance was 4%, and by August 2025, most areas were still below required thresholds.

Leaders did not ensure staff were compliant with mandatory training. Completion rates for key safety‑critical areas remained below expectations. First Aid reached 75%, Basic Life Support 73%, Safeguarding Adults and Children 81%, and Autism and Learning Disabilities Awareness 80%.

Since 1 July 2022, all registered providers must ensure staff are trained in learning disability and autism. Compliance with the Oliver McGowan Mandatory Training was low among mental health ambulance care assistants, with only 7 of 17 staff having completed it. Staff did not receive supervision linked to this training, despite guidance recommending ongoing support. This raised concerns about the provider’s ability to ensure staff were equipped to deliver safe, person‑centred care for people with learning disabilities and autism.

Leaders did not ensure that staff with appropriate skills, training, and experience were deployed together to safeguard patients effectively. Mental health staff without physical health training were assigned to patients with complex medical conditions, while staff with physical‑health roles but no mental‑health training were tasked with supporting people in crisis. This mismatch in competencies posed risks to patient safety and quality of care.

Staff did not have up‑to‑date supervision or appraisals, which may impact quality and safety. Staff supported vulnerable people, including those with mental health conditions, dementia, and people at the end of life. Without regular supervision, opportunities for reflection, support, and accountability may be missed.

Managers provided a local induction but did not ensure ongoing supervision or regular meetings to review care management. There were no structured opportunities for staff to reflect on practice, receive personal support, or engage in professional development or appraisal.

Managers provided a learning programme and development opportunities; however, staff consistently reported that some training was insufficient. Sessions scheduled for 3 hours were sometimes condensed into an hour and described as resembling a sales pitch for the trainer’s merchandise. In some cases, staff were directed to leaflets instead of receiving structured training, and they did not feel adequately prepared to work safely.

Leaders provided staffing data indicating a workforce of 113 employees, comprising 94 full‑time and 19 part‑time roles. The workforce included 66 ambulance care assistants, 17 mental health ambulance care assistants, and a small number of clinical staff including 2 Emergency Care Assistants (ECAs), 5 ECAs Plus, and 2 First Emergency Response Care (FREC 4) staff. FREC 3 and 4 staff were listed on the risk register, and additional training was scheduled for September and November 2025 to enhance skills and ensure patient safety.

When required, managers used agency staff to maintain safe staffing levels. Leaders told us that agency staff familiar with the service were used to maintain consistency.

When agency staff were used, they received an induction and were familiar with the service.

Staff had access to a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) flowchart, which instructed them to call 999 and follow emergency service guidance. Staff were also required to report the incident to the control room and complete an incident form. This demonstrated that the service had a structured approach to DNACPR situations with clear escalation and reporting procedures.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The provider could not evidence the service had effective systems in place to manage the risk of infection.

Staff reported concerns about the cleanliness of equipment used to clean vehicles. Buckets used for this purpose were visibly dirty, and there was no clear process in place to record that they had been cleaned between uses. This posed a risk of cross-contamination.

Staff told us that appropriate disinfectant products were not always available at weekends. This restricted their ability to clean vehicles thoroughly and safely, which could increase the risk of infection transmission.

An eye wash station was available; however, it was kept in a room that was untidy and visibly dirty, compromising both accessibility and hygiene. Although two bottles of eye wash solution were present, there was no applicator or dispensing mechanism to enable safe and effective administration in the event of an emergency.

This indicated a lack of oversight in maintaining essential equipment and ensuring it was fit for purpose. The environment and absence of appropriate accessories posed a risk to staff safety and did not reflect good infection prevention and control practice.

The building showed visible signs of aging. While staff areas were generally maintained, we observed that floors in both staff and office areas had not been cleaned, which did not demonstrate good hygiene practice.

Staff raised concerns about the lack of appropriate washing facilities. As part of their role in patient transport, staff frequently encountered situations involving bodily fluids such as vomit and faeces. Staff described situations where they lacked access to suitable washing facilities following such incidents and were instructed to hose themselves down outside. This posed a serious health and safety risk and highlighted inadequate infection control measures.

Mobility equipment, including stretchers and wheelchairs, was stored in a room with cracked and visibly dirty floors. We observed an unidentified brown fluid running down a mirror, bird faeces and the sink in the store area was filled with rubbish. Bins were overflowing, and the floors were littered with dirt and debris, creating an unhygienic and unsuitable environment for storing equipment intended for patient use.

We raised these concerns with the registered manager, who did not recognise the environment as an issue. This response indicated a lack of adequate oversight regarding infection prevention and control risks.

Exterior vehicle cleaning audits reported high compliance scores between October 2024 and August 2025, ranging from 95% to 100%, with one month showing 98% and one instance of missing data. Despite these strong audit results, our inspection found that the exterior of vehicles was visibly dirty. This may indicate a gap between reported compliance and actual conditions observed on site.

Vehicle interiors were clean and well maintained. Staff had access to hand gels, wipes, and appropriate personal protective equipment (PPE), supporting effective infection prevention and control practice during patient transport. Daily cleaning was carried out, and infection prevention and control audits were in place. Where gaps in compliance were found, actions were documented.

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

Staff did not store, prescribe or administer any medicines. Where patients were transported with their own medicines, these remained the responsibility of the individual and stayed on their person or in their bag.

Staff carried medical gases, such as oxygen to support patients that were prescribed medical gases. There was a policy in place to provide guidance for the safe transportation of medical gases.

Staff arranged access to oxygen based on clinical need and as the patient required oxygen therapy during transfer. Staff ensured that eligibility criteria were met and that appropriate arrangements were in place to maintain patient safety throughout the journey. Portable oxygen was provided and secured, and the prescribed flow rate was maintained in line with clinical guidance.