Cornwall & The Isles of Scilly – Bodmin

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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration.

At this first assessment the rating was good. Patients were safe and protected from 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 had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. The service had an incident reporting policy which outlined incident reporting procedures. Staff told us how they raised concerns and reported incidents and near misses, which was in line with this policy. Managers investigated incidents and shared lessons learned with the whole team and across the wider organisation.

We saw evidence of incidents having been investigated, and action taken to reduce the risk of recurrence. We looked at the system for managing incidents which was electronic. From March 2025 to February 2026. This location had reported 41 incidents. There had been no reported serious adverse events in this timeframe.

Staff understood the duty of candour. When things went wrong, staff apologised and gave patients honest information and suitable support.

The service provided mandatory training in key skills to all staff. Managers monitored mandatory training and alerted staff when they needed to complete updates. The data showed an overall completion rate of 90%. However, in some subjects, compliance was low.

The provider outlined expectations around staff’s statutory and mandatory training. New starters had an 8-day face-to-face induction course comprising of 6 days classroom training covering all mandatory modules and 2 days of driver training. All staff had completed training on recognising and responding to patients with for example, patients with mental health needs, learning disabilities and dementia.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care between providers.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed at booking prior to arranging their transport needs. There was a clear criterion for accepting patients as suitable for the available vehicles and resources. These criteria set out where they had limitations in services and therefore minimised risks by excluding some patients.

There were systems and processes to ensure the correct patients were collected and transferred between locations. We accompanied staff on 4 patient journeys between home and the dialysis unit and from the hospital to home. We observed staff checking patient identification and passing on information to the receiving location, as well as obtaining information from staff prior to taking the patient home.

The transfer of patients between locations was done safely. Staff had the driving skills and experience required. Suitably skilled staff accompanied patients during the journey and safety equipment was used throughout.

In the event of a patient’s health deteriorating during the journey, staff followed the Deteriorating Patient procedure and telephoned 999.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve it. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. They understood their responsibilities for notification of safeguarding incidents to the contractor of services. The service had well established working practice and contacts around safeguarding. Safeguarding cases were reported directly to the local authority.

Staff received adult and children's safeguarding training, and data showed 100% of staff were trained in both. There were current safeguarding policies, and these reflected the national guidance for adults and children. From July 2025 to January 2026, staff at this location made 10 adult and no children’s safeguarding referrals.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff from Monday to Friday, including out of hours and staff knew how to contact them. The safeguarding leads for the provider were trained to level 4.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

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

Requirements relating to the patient’s journey were confirmed at booking to ensure any associated risks were identified and effectively managed. The service used electronic records which were initially completed by the booking office and transferred to staff through their hand-held electronic devices. Station managers visited new patients’ homes to complete risk assessments about transfer, when required.

The service worked with patients to understand and manage risks. Patients' needs were met in ways which were safe and supportive and enabled them to do the things which mattered to them. This included for example, ensuring pick up following appointments was not delayed.

Discharge and on-going return journeys were organised safely. We spoke to 4 patients during our assessment. Patients knew what to expect and when staff would collect them. There were key performance indicators (KPI) for the service to achieve. For example, for renal patients the KPI was an hour. This meant patients knew they would be conveyed to the dialysis unit within an hour of their treatment starting and picked up, up to an hour after treatment finished.

Staff we spoke with said they could access advice and support from senior leaders in a prompt manner in cases where unexpected risks were identified. The service did not transport high-risk or mental health patients.

Staff could accommodate bariatric patients under the maximum limit of their heavily weighted wheelchair. They could assign an extra crew member, or a second crew to these jobs if needed.

Staff completed basic life support and resuscitation for adults and paediatric patients as part of their statutory and mandatory training. However, only 60% of staff had completed this. However, poor training compliance was not discussed at governance meetings.

Drivers used a dash camera during shifts to ensure full vehicle compliance. They used an employee time tracking app for clocking in and out of shifts.

Staff followed the service’s health and safety policy which outlined the risk assessment process, including manual handling.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

We inspected 2 ambulance vehicles. Vehicles were equipped for the type of services provided, this included safety seatbelt straps and child seats. Records of equipment maintenance and schedules were available. 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 specialist equipment. There was a system for staff to report faulty equipment and vehicles. A formal record was made of action taken to address the fault/s.

Station managers maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff with results posted on the staff notice board. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients.

Staff disposed of clinical waste safely, both inside vehicles and outside the storage areas. Waste was segregated and labelled in accordance with the local policy. Cleaning chemicals were stored as correctly.

The service usually made sure there were adequate numbers of skilled and experienced staff. Staff did not always receive supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough staff with the right skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and support. Staff were made aware of their shifts in advance and could make requests. Patient pathways and their discharge were not delayed because of a lack of staff.

New staff and temporary bank workers had a full induction tailored to their role before they started work. However, managers did not always support staff to develop through constructive recorded, annual appraisals of their work. Only 20% of 30 active staff had completed a recent appraisal at the time of our assessment. However, poor appraisal rates were not discussed at governance meetings.

Managers reviewed the number of staff needed for each shift based on activity. Managers could adjust staffing levels daily according to the needs of patients and changes in activities. Managers could use bank or agency staff if required.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information shared by email and on the station noticeboard.

The service usually assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service managed infection risks well. Staff used equipment and controlled measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

There was easy access to the providers infection, prevention and control policy (IPC) and supporting guidance was accessible to staff. Staff received training on IPC. However, data supplied showed only 43% compliance with IPC training with 4 staff out of date since December 2024. However, poor training compliance was not discussed at governance meetings.

There was guidance to support staff to respond to infection prevention and control risks such as transmittable infections. We saw staff were following infection control principles including handwashing and the use of personal protective equipment (PPE) despite the poor compliance training figures. Staff understood the process for managing spillage of body fluids.

Staff supported infection prevention and control measures by following the uniform policy. Staff cleaned the interior of vehicles and equipment routinely. A record of cleaning was retained within the electronic hand-held devices and the main computer, and an outside contractor was responsible for regular deep cleaning of the vehicles.

Oxygen was used onboard vehicles and cylinders were suitably restrained. Cylinders were stored safely in the depots, clearly marked and safely stored. All staff were trained and had completed medical gas administration training as part of their induction and a refresher every 3 years.

The service had an oxygen policy and Standard Operating Procedure which staff told us they followed when administering oxygen in an emergency and when a patient had already been prescribed it during conveyance.