Alpha Care Ambulance Service

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 checked that people were looked after in safe environments and protected from avoidable harm, neglect and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At this assessment, we found the service had made improvements since the previous assessment and were no longer in breach of regulations related to safe care and treatment and safe staffing.

At our last assessment, we rated this key question requires improvement.

At this assessment, the rating remained as requires improvement.

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

The service had strengthened several aspects of safety since the previous assessment, including governance arrangements, staff training, incident reporting processes and business continuity planning. Staff understood how to report incidents, safeguarding concerns and risks, and leaders investigated incidents and shared learning to help reduce the likelihood of recurrence. Staff used systems and processes to support safe patient transfers, risk assessment and continuity of care.

However, we identified some areas where oversight and monitoring could be strengthened further. Governance processes did not always identify or address risks relating to safeguarding information, vehicle and equipment readiness, infection prevention and control, medicines management and recruitment records. We also found some equipment and consumables that were not consistently maintained in a state of operational readiness, including expired or non-sterile items. In some areas, records did not consistently demonstrate that checks, monitoring activities and audits had been completed or reviewed effectively. Leaders responded promptly to the concerns identified during the assessment and took action to address them.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had an incident reporting policy that outlined reporting procedures, investigation levels, and timescales. Staff used a risk assessment matrix to assess each incident according to its severity. Staff we spoke with understood how to raise concerns and report incidents and near misses, and their responses were aligned with policy. Staff had access to incident reporting forms whilst working in ambulances and told us they completed these in real time where possible, before submitting them to leaders on their return to base.

Leaders investigated incidents and took appropriate action to reduce the risk of recurrence. We reviewed 6 incidents reported within the previous 12 months, including 1 near miss, 1 case of minor vehicle damage, and 4 minor staff injuries. Leaders investigated incidents and took appropriate action to reduce the risk of recurrence. Three of the staff injury incidents involved patients during care and transfer activities. Learning from these incidents included reinforcing safe moving and handling practices and ensuring correct use of equipment and increasing staff awareness of behaviours that may present a risk, particularly when supporting people living with dementia.

Leaders reviewed incidents to identify trends and themes. Where required, they provided staff with additional training and support to maintain competence. Leaders also shared lessons learned across the team through one-to-one discussion or via their communication channel to help prevent similar incidents from reoccurring.

Staff understood duty of candour, which means being open and honest with patients and their families when something goes wrong. They apologised and provided a full explanation of what had happened. All staff had completed duty of candour training.

Leaders ensured they addressed actions arising from patient safety alerts and monitored progress. They shared relevant information with external partners and gave an example of an alert relating to a medication that the service did not stock but knew it had been prescribed to a child and was being administered by the child's parents. They took appropriate action to support the child's safety by informing the parents of the alert. However, the service did not maintain a record of patient safety alerts or document the actions taken in response to them, limiting the availability of a clear audit trail.

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 was contracted by the local trust to convey non-emergency patients to and from NHS services across Oxfordshire and Berkshire, as well as destinations outside these areas when required. The service also provided ad hoc transport for local social services and transport for children with special educational needs.

The service accepted patient transport requests based on assessments completed by external partners. 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. Once the service accepted a referral, staff ensured that a suitable vehicle and appropriate resources were available to meet the patient’s needs and minimise risk. For example, staff ensured that a child’s harness was available when required.

The service had systems and processes to ensure that staff collected and transferred the correct patients between locations. We accompanied staff on a patient journey between a patient’s home and school and observed them communicate relevant information to the receiving location. Staff transferred the patient safely and in accordance with the patient’s needs.

Staff demonstrated appropriate driving skills and experience. Suitably skilled staff accompanied the patient throughout their journeys to provide support and maintain safety.

Staff planned and coordinated care and support with patients, partners, and other agencies to ensure continuity of care following transfer to the destination. We reviewed a child’s observation sheet that contained clear and comprehensive information about the patient’s transfer and wellbeing during transportation. 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 completed a transfer record for patients transported on behalf of the local NHS trust. This record documented details of the transfer, including any documents, medications, or equipment handed over, as well as journey times.

The service carried out daily vehicle checks at the start of each shift. For example, checks confirming that vehicle tyre pressures were adequate, screen wash levels were sufficient, and clinical waste bins had been emptied. At the end of each shift, staff completed further checks of vehicle equipment, stock levels, and cleanliness. Staff submitted the completed check forms at the end of the shift. However, this process did not provide leaders with assurance that vehicles were safe, clean, and appropriately equipped before being used to transport patients, creating a risk that issues identified during checks were not addressed prior to deployment.

The service's business continuity policy included guidance for adverse weather conditions. All company vehicles were fitted with winter tyres, and the service had access to four-wheel drive vehicles to help maintain service delivery and meet demand during periods of heavy snow. Staff escalated delays by contacting the service and the receiving destination where appropriate. This ensured patients were kept informed of any delays and that healthcare providers were aware if patients were likely to arrive late for appointments.

Bank staff providing medical cover at events also worked in frontline NHS ambulance roles and were familiar with local escalation, pre-alert and handover arrangements. Leaders described how staff coordinated with receiving services when patients required onward treatment.

During the previous 12 months, staff transferred only 1 patient from an event to a local hospital for further emergency and urgent care.

Following the assessment, the service introduced a standard operating procedure to support handovers to emergency departments and clarify responsibilities during transfers of care. As the service introduced the procedure only recently, it was too early to determine whether staff had fully embedded it into practice.

The service did not always ensure that safeguarding policies, procedures, and guidance remained up to date.

The service had safeguarding policies; however, these contained outdated information. For example, the safeguarding policy referenced guidance, procedures, and local safeguarding arrangements from 2017 that were no longer current. The policy did not reflect current safeguarding structures or the multi-agency arrangements delivered through the Berkshire West Safeguarding Children Partnership.

We also found outdated safeguarding information displayed on staff noticeboards and within safeguarding guidance folders kept in vehicles. The information available to staff was dated 2017 and had not been updated to reflect current safeguarding arrangements.

These issues increased the risk that staff could rely on outdated guidance with current local safeguarding pathways. This could lead to delays in escalating concerns, inconsistencies in safeguarding practice, and reduced assurance that safeguarding matters would be managed in line with current legislation, guidance, and local partnership arrangements. It also indicated that the service's governance systems had not effectively ensured that safeguarding information remained accurate, current, and readily available to staff.

Staff completed both adult and children's safeguarding training. Training records showed that 100% of staff had completed Level 3 safeguarding training. The registered manager and administrator acted as the designated safeguarding leads and had completed enhanced trainingto provide them with the knowledge required to undertake this role. The service was unable to provide details of the level of enhanced safeguarding training completed by leaders. As a result, we could not determine whether leaders had completed training at the level required by the relevant intercollegiate safeguarding guidance, which sets out the safeguarding competencies and training requirements expected of healthcare staff.

However, staff demonstrated a good understanding of safeguarding responsibilities and knew how to identify adults and children who were at risk of, or experiencing, abuse or significant harm. They provided appropriate examples of safeguarding concerns and clearly explained the actions they would take to protect patients, including reporting concerns, notifying the commissioning organisation of safeguarding incidents, and seeking support from relevant safeguarding agencies. The service worked effectively with partner agencies and had well-established relationships with external safeguarding teams. Staff told us they would escalate safeguarding concerns without delay.

The service had not reported any safeguarding concerns in the previous 12 months. The Registered Manager was aware of their responsibility to submit statutory safeguarding notifications to CQC when required.

Following the assessment, the registered manager provided evidence that they had completed Level 6 Designated Safeguarding Lead training. They also confirmed that the administrator was scheduled to complete the same training.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments for all patients, including those requiring discharge transport and home assessments. Children using the specialist patient transport service had individual travel packs containing relevant clinical information and sealed medication packs. Staff demonstrated a good understanding of patients' individual needs and risks and took appropriate steps to support them safely. This included ensuring specialist equipment, such as bariatric (a high body mass index) stretchers, was available where required to facilitate safe and comfortable transport.

The service worked with patients to understand and manage risks while supporting them to achieve positive outcomes. Staff met people's needs and helped them do the things that mattered to them, including enabling them to attend appointments on time and supporting safe discharges home.

The service ensured staff had the specialist skills and training required to meet the needs of children and young people requiring tracheostomy care during transport. This included training in suctioning and emergency tracheostomy replacement procedures. Leaders told us this had enabled the service to expand its role and undertake transfers of patients with a tracheostomy on behalf of local hospitals.

For patients who used the service individual risk assessments identified known risks, the actions required to mitigate them and escalation processes to follow should concerns arise. 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 shared relevant information during handovers to promote the continuity and safety of care when transferring responsibility to other services. Where appropriate, they documented handovers within patient records.

Staff also took steps to promote patients’ comfort and wellbeing by ensuring there were suitable arrangements including access to food, hydration and appropriate heating. They told us they would escalate concerns about a patient’s welfare or ongoing support needs to their manager or the receiving healthcare provider, whenever additional support or intervention was required.

Staff had received manual handling, basic life support for adults, and children and young people as part of their statutory and mandatory training.

Staff informed that before accepting an event booking, they reviewed event risk assessments, major incident plans and first aid plans which showed that leaders identified and mitigated potential risks before events took place.

Staff told us they monitored risks throughout events and adapted their response when circumstances changed. Staff escalated concerns appropriately and sought support from external agencies when risks exceeded the scope of the event medical provision.

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.

The service had a code locked stock room that all staff could access. Although most consumable stock was within its expiry date, the service did not operate an effective stock rotation system. Staff stored consumables in individual drawers and marked expiry dates on the drawer fronts using wipeable marker pen. This system did not ensure that stock remained fit for use, as the dates were not always legible and could be removed through normal handling.

In addition, staff only replenished stock when drawers became empty, which did not ensure that older stock was used before newer stock. The service did not have an effective system to identify equipment that was ready for use. Staff told us that equipment bags stored on shelves had been checked and were operationally ready, while bags stored on the floor required checking. However, the service had not implemented a system or signage to distinguish between checked and unchecked bags. This increased the risk that staff could select equipment that had not been checked or was not ready for use.

We identified several concerns relating to vehicle and equipment management. Staff had used a patient transport vehicle for 3 consecutive days despite it being configured for event work rather than patient transport services. We found a damaged single-use neck collar that was not stored in a protective bag, a flow regulator that had not been serviced in line with maintenance requirements, and a defibrillator that had not been checked, with a flat spare battery. In addition, 4 suction catheters had been opened and were no longer sterile, and 2 bags of sterile water had expired in May 2025. These findings showed the service did not have effective oversight arrangements to ensure vehicles were maintained and equipment was ready and suitable for patient use.

However, following the assessment, the service provided evidence that it had replaced the expired equipment and consumables and put in extra checks to prevent reoccurrence.

The service stored clinical waste in a locked clinical waste bin which was located within a communal business car park. The bin was not secured to a fixed structure or enclosed within a fenced area. Although the bin remained locked, the lack of additional security measures meant the arrangements were not in line with Environment Agency guidance and did not adequately mitigate the risk of unauthorised access.

However, following the assessment, the service provided evidence that it had secured the clinical waste bin to a wall in line with relevant guidance.

Staff stored oxygen cylinders correctly in designated cages in an upright position and displayed appropriate hazard signage. However, the staff smoking area was located in close proximity to the oxygen storage area. We reviewed the service's medical gas policy, which stated that staff should not smoke within three metres of stored oxygen. Although the designated smoking area was positioned over three metres from the storage location, the service could not provide assurance that staff consistently remained within the designated area when smoking.

During the assessment, we observed a staff member smoking inside the garage where operational vehicles were stored. This was not within the designated smoking area. This increased concerns that staff may not consistently follow local arrangements for smoking on site.

The service had completed its own fire risk assessment. Following the assessment, leaders informed us that they had commissioned an independent external fire risk assessment as part of their commitment to continuous quality improvement. They also provided evidence that they had relocated the staff smoking area further away from the oxygen storage area to reduce the associated risk and had reminded staff of the importance of smoking only in designated areas in line with local safety requirements.

However, the service had arrangements for clinical engineering support to maintain and service equipment. The service maintained up to date records of equipment maintenance and servicing schedules.

Staff stored vehicles in a secure area that unauthorised persons could not access, and they kept vehicle keys securely within a key safe located in the stock room.

Staff carried out daily safety checks of specialist equipment and recorded on a white board faulty equipment and vehicles that was displayed in the office. The reporting system was visible to all staff, enabling them to see equipment and vehicle defects that had already been identified.

Staff told us they had sufficient equipment to carry out their roles safely and to meet patients' care and treatment needs.

The service maintained fire safety equipment on vehicles and ensured it was serviced appropriately. All fire extinguishers were securely fastened, checked regularly, and remained within their expiry dates.

Staff stored hazardous substances in a cupboard labelled COSHH (Control of Substances Hazardous to Health) and had access to relevant product information.

The service did not always operate effective systems to ensure staff were suitable for their roles and that appropriate employment checks and ongoing oversight were in place. Leaders had not consistently maintained complete recruitment records or obtained sufficient information to demonstrate staff remained fit and able to carry out their duties safely and effectively.

We identified gaps in the service's recruitment and staff oversight processes. We reviewed 4 staff files and found they did not contain all the information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. Although some staff had completed driving assessments, records did not consistently demonstrate that staff had undertaken associated eyesight assessments. Health declarations were limited and mainly related to COVID-19. One staff file contained a physical health assessment; however, there was no corresponding assessment of the staff member's mental health and wellbeing. In addition, records did not show that leaders had considered whether staff required reasonable adjustments to enable them to perform their role safely and effectively. These omissions reduced confidence that the service had fully assessed and monitored staff suitability throughout their employment.

The service was in the process of recruiting 5 new staff members. Leaders told us they had sufficient staff with the appropriate qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide appropriate care and support. The service declined transport requests when leaders determined that they did not have sufficient staff available to provide the service safely. The service also used bank staff to support workforce capacity when required.

Leaders provided new staff with a structured induction programme that included training and supervised clinical practice until staff demonstrated the confidence and competence required to work independently as part of the team. They supported staff development through annual appraisals and regular clinical supervision. However, at the time of the assessment, the appraisal completion rate for 2026 was 63%. Leaders advised that the remaining appraisals had been scheduled for completion by the end of the year.

The service supported staff learning and development and ensured staff received specialist training relevant to their roles. Leaders identified training needs and provided staff with the time and opportunities to develop their skills and knowledge. For example, the service funded newly recruited staff to complete external First Response Emergency Care (FREC) level 3 training. The service also funded FREC level 4 training for staff who wished to progress after 6 months of working at level 3. Staff who wished to drive service vehicles completed training and assessment with an external paramedic to ensure they were competent to do so safely. Leaders reassessed driving competency where concerns later arose about a staff member's driving ability.

Leaders ensured they deployed staff with the appropriate skills, qualifications and experience to meet patients' needs. The service used a mix of permanent and bank staff, including registered paramedics, ambulance technicians, emergency care assistants, and staff qualified to First Response Emergency Care (FREC) Levels 3 and 4. Leaders ensured that staff skills, qualifications, and competencies were matched to the needs of each event.

Leaders told us that bank staff worked in frontline roles within NHS ambulance trusts. Before staff worked for the service, the service collected and reviewed evidence of their identity, qualifications, professional registrations where applicable, Disclosure and Barring Service (DBS) checks, driving license’s, occupational health information, and statutory and mandatory training records.

Leaders maintained records to demonstrate that staff held the appropriate qualifications and training for their roles. The service also had access to medical staff when required, although the service told us this was rarely necessary for the events they covered.

The service did not always assess or manage the risk of infection.

We found shortcomings in the service's oversight of vehicle cleanliness. We found vehicle A2 unlocked and displaying a sign indicating it was ready for use. During our assessment of the vehicle, we found the patient trolley visibly dirty.

Although staff completed cleaning records, leaders had not implemented effective oversight arrangements to verify that cleaning had been completed to the required standard. As a result, leaders could not be assured that patients would always be transported in a clean environment.

Staff told us they often carried out enhanced cleaning more frequently than required, particularly after transporting patients with significant healthcare needs or increased infection risks. However, cleaning records did not consistently reflect this practice. Consequently, leaders could not be assured that vehicle cleaning and decontamination processes were completed in accordance with organisational policy, as the documentation did not provide an accurate record of activity.

However, the service provided staff with access to a local infection prevention and control policy and hygiene guidance which describes procedures for managing infection risks, including transmissible infections. Staff completed IPC training as part of the annual mandatory training programme, and training compliance was 100%.

Staff followed hand hygiene requirements and used personal protective equipment (PPE) in accordance with the service's PPE standard operating procedure. Staff also understood the process for managing body fluid spillages.

The service maintained a stock of PPE in a range of sizes, which it stored centrally. Staff signed equipment in and out, and an on-site first aid kit was available. The service also used a colour-coding system for mops and buckets to reduce the risk of cross-contamination when cleaning vehicle interiors.

Staff disposed of clinical waste safely within vehicles and storage areas. They segregated and labelled waste in line with local policy.

The service did not always have robust oversight of medicines management, which meant leaders could not fully assure themselves that medicines were stored, recorded and monitored safely.

At the previous assessment, the service did not monitor the temperature of the room where medicines were stored. Since then, leaders had implemented a temperature-monitoring system within the medicines stock room. This enabled staff to ensure medicines were stored within the recommended temperature range and remained safe and effective for use.

The service did not own, purchase, stock, or routinely store controlled drugs. Any controlled drugs used during the provision of care belonged to individual registered paramedics as part of their professional supply and were not the property of the service.

During the assessment, we checked a paramedic's bag, which was secured with an anti-tamper seal, and found a Schedule 5 controlled drug stored within it. We also inspected the controlled drugs safe located in the stock room and found a Schedule 4 controlled drug belonging to the same paramedic who was not on duty at the time. The service could not provide a register demonstrating that these controlled drugs had been signed into storage. As a result, leaders could not readily identify who had placed the drugs into storage, when they had been stored, or whether a complete audit trail had been maintained. This meant the service could not fully assure itself that all controlled drugs stored on the premises were appropriately accounted for and managed safely.

Following the assessment, the service provided evidence that it had introduced a formal process for recording the signing in and signing out of controlled drugs while they were stored on the premises.

Staff had not labelled and dated sharps containers in line with national guidance, which reduced the service's ability to monitor their safe use and timely replacement.

However, staff carried out regular checks of medicines to ensure they remained available for use, were fit for purpose and had not expired. During the assessment, we found several medicines stored in the stock room that were due to expire on the day of the assessment. Staff were aware of the impending expiry dates and informed us that replacement stock was scheduled for delivery later that day.

The service stored medicines securely and in accordance with its local standard operating procedures. Staff checked and documented medicines held on vehicles to ensure stock levels remained accurate and all medicines could be accounted for.

We reviewed patient assessment documentation, which captured information about patients' take-home medicines with any requirements for refrigeration, and whether patients were transporting controlled drugs. Recording this information helped staff ensure medicines were transported safely, maintained their effectiveness during transit, and reduced the risk of medicines being lost, damaged, or improperly managed. It also supported continuity of care by ensuring receiving services were aware of any medicines accompanying the patient.

The service used oxygen on its vehicles and stored oxygen cylinders safely. The service's medical gases policy included information on the hazards associated with oxygen use, the causes of oxygen-related fires and explosions, safe storage requirements, and incompatible materials. At the previous assessment, not all staff had completed training in the administration and safe handling of medical gases. Records now showed that all staff had completed this training within the previous year.

Staff completed medicines management training, and compliance with this training was 100%.