Archived: Health Tech Services Group Limited

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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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for the patient transport and diagnostics services. This key question has been rated Inadequate for patient transport services. We were unable to rate the diagnostics service.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and governance. Governance was not managed at the service, and this left people who used the service at risk.

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 provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was no effective culture of safety and learning. A lack of transparency and openness meant that incidents may be ignored or not reported, and a closed culture more likely to develop.

Systems for reporting safety incidents and complaints were not used appropriately. As a result, the service did not learn from incidents and complaints. The service had an electronic incident reporting system which we were told enabled staff to report incidents without being present at their base. Information provided by the service identified that 4 incidents had been reported. We were not assured staff understood what incidents to report and how to report them and raise concerns, incidents and near misses in line with the service’s policy. Staff said if they had any problems, they would contact the office for advice but were unsure whether incident reports were submitted.

We saw there was a blame culture with staff penalised for errors such as with loss of salary or reduced work opportunities and jobs offered to them. Staff were totally dependent on the company not only for their employment but also their right to remain within the UK. This blame culture made staff fearful to raise concerns and there were ineffective systems to address concerns and errors and improve practice as all incidents were not reported.

We saw records provided by the service which indicated a late pickup had resulted in a patient complaint. The late pickup may mean the patient missed their appointment or treatment and was not recorded as incident although it had resulted in staff disciplinary action. Actions identified following the late pickup stated staff members should regularly check their mobile telephone for a text message and check the portal for information about a patient transfer. Managers did not call staff to confirm their availability or make them aware a message had been sent through the portal.

We saw an incident record which identified a patient required a stretcher, but the property’s hallway was not wide enough for a stretcher. The staff member had called the office for advice and had attempted to move the patient in an evacuation chair which the patient had not been risk assessed for. This caused the person considerable pain and as a result they had refused to be moved using this method. There was no explanation recorded why staff had assessed and considered this person could be safely transported.

We were told actions and subsequent learning were undertaken when an incident was reported. However, information we saw, did not provide assurance learning was embedded, team meeting minutes and the lack of supervision did not support a learning culture. For example, there was an incident that identified problems transporting a person with a spinal injury, and because of this it was highlighted in the risk assessment spinal injury patients should not be transported. However, we saw there had been a recent transportation of a patient with a spinal injury with no reasons why it was considered this patient could be safely transported. We did not see any evidence the service operated a clear inclusion and exclusion criteria for patients being transported so did not support staff to make informed decisions around who they could support.

On the day of the assessment, we found the organisation was trading under a different name to the registered company. We observed the ambulance had decals of a different name to the company, and other records were also in 2 other company names. The inspectors on site could not to find patient feedback regarding the service as feedback was given under a different company name. This also meant people using the service may not be aware of how and to whom to raise a complaint to raise concerns or make complaints as they were unsure of the company to raise concerns about.

We were not assured staff understood the duty of candour and would give patients and families a full explanation if things went wrong. We saw 1 complaint about a failure to move a person safely which the service did not uphold. The reasons given for not upholding the complaint was identified as the person not disclosing the level of pain they experienced when being moved. However, staff had attempted to move the person in a way not previously agreed or assessed.

There had been no serious incidents within the service. We were told that all incidents and patient records were reviewed by a manager.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Safety and continuity were not prioritised throughout the care pathway. The approach to care was not joined up and there was little or no collaboration between people, staff and partners. Systems did not ensure people had continuity of safe care. People using the service or their representative completed the service’s enquiry form, also called the risk assessment. The enquiry form provided some information about their transport needs and minimal information about them and their needs. Whilst staff did call the person to discuss their needs and potential costs, a full assessment of their needs was not undertaken. Twelve patient forms were shared with us, and these did not identify their date of birth, although age was identified, the person’s next of kin or their contact details, their GP or a full medical history and medicines. This meant should the person become unwell during the journey and needed urgent treatment and transfer to an emergency service, full information about them and their needs would not be available and staff would be unable to contact their next of kin. The lack of essential information about the person meant their needs could not safely be met. This was not in line with the service’s deteriorating patient policy which stated “Whilst waiting, complete your PRF (patient record form) so you can handover to the (local ambulance service) crew. On arrival of the responding ambulance, you should complete a handover to the crew member”. Records available would not support staff to undertake these actions and provide a safe and effective handover to the emergency service if or when required.

The provider 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 concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns and appropriately.

The lack of a comprehensive assessment of peoples’ needs, which may include any safeguarding, meant staff would be unable to identify how best to support vulnerable people and identify adults who may be at risk of, or suffering, significant harm.

Modern slavery is an umbrella term for practices in which people are trapped, controlled, and/or exploited in situations they cannot escape because of threats, violence, financial control or someone taking advantage of their vulnerability. The service was not operating in line with the terms and conditions of the contracts it had issued to staff or in line with the sponsorship guidance and terms and conditions of employment. We saw the service and its senior managers had practices which trapped and controlled staff around their continuing sponsored employment and potentially their right to remain in the United Kingdom. Staff told us they had not received their previously agreed salary, and their salary was either not paid, reduced and frequently received late or in instalments. Managers then made it difficult for staff who raised concerns with threats to discontinue their sponsorship.

Staff recruitment practice was not robust and provided limited assurance people would be protected from unsuitable staff providing care and transportation. Most staff had been recruited from overseas and had no work experience within the UK. Whilst staff files did have 2 references there was no check on the authenticity of the references. Several references were not fully completed, did not identify how they knew the applicant and only contained the name of the referee and their job role. There was no acknowledgment by managers that it was a character reference and no system in place to supervise staff when no valid employment references had been provided.

Staff files did include a Disclosure and Barring Service check before the staff member commenced employment. However, given the person had been in the UK for a limited time it may not show convictions from outside the UK. One file seen however did include a police check from the country they had previously lived in.

Staff were trained in adult safeguarding. We were told the service does not transport children, that the service is an adult service only. We saw staff received online safeguarding adults training, and certificates in staff files identified completion of safeguarding adults' level 1, 2 and 3. The registered manager said all safeguarding training was undertaken online with no face-to-face training. However, safeguarding adults level 3 should include face to face training. We were unclear what the actual level staff had attained because certificates were in the company name and did not identify validation dates or module content. We were unclear if staff knew how to make a safeguarding alert or did so when appropriate. Staff said if they any safeguarding concerns they would tell the office. Safeguarding policies were in place for children and adults, although local arrangements were not identified.

We were told that no safeguarding referrals had been made by staff working within the Telford base. We saw no evidence that safeguarding concerns were shared with the team from other areas or any identified learning. The nominated individual was the organisation lead for safeguarding and was trained to level 4 in safeguarding of adults.

The service had a restraint policy although the enquiry form did not include any questions about any circumstances where restraint may be used. Staff were not trained in restraint, and most patients journeys were undertaken by 1 member of Health Tech Services Group staff. The registered manager told us that patients with mental health needs would not be transported, although we saw evidence on the day that this had happened. The policy provided confusing information for staff and may mean a person may be inappropriately restrained which would result in their wellbeing and health being compromised.

Staff received training in the Mental Capacity Act (MCA), but some staff were unclear how this affected the patient, although said they would not transport any patient against their wishes.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive. Risks to individual people were not understood, leaving people exposed to avoidable harm.

The service did not mitigate risks effectively or appropriately. People did not have their needs or risks appropriately assessed and individual risk assessments were not always in place. The risk assessment form did not provide sufficient information about the person; their health and medication needs or their doctor should the person require emergency care and need to be transferred to another service.

Risk assessments did identify some risks but not always mitigating actions. However, 1 mitigation action identified they could not transport a person with a spinal injury, but we saw this instruction had been disregarded with no other mitigating action identified.

Care records were incomplete and did not identify potential or predict foreseeable risks There was a lack of systems and processes to ensure emergencies and clinical risks would be well managed.

We did see incidents when people had refused transport as they felt too unwell and this had been discussed with; managers and family present and the person’s wishes had been respected.

The provider 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 building where the office was located was not usually accessed by patients or their representatives but was primarily accessed by staff. It was evident the Health Tech Services Group office had not been accessed for some time. On the first day of our assessment the route into the office was compromised with boxes and cabinets restricting access. We were made aware this had been the case for some time by other businesses occupying office space. This posed a significant fire risk to any person visiting the office. We met the landlord who said this would be addressed which it had been when we next visited.

There was gated access to the premises and closed-circuit television (CCTV) monitoring both to the outside of the building and office. The use of CCTV within the office did not meet required General Data Protection Regulation (GDPR) and information Commissioners Office (ICO) standards with no signs identifying the use of CCTV.

The service had 1 ambulance. We were initially told the ambulance was stored outside the office but later discovered the ambulance was stored outside the ambulance driver’s property which was not secure and may represent a risk to the vehicle being tampered with.

The ambulance appeared well maintained and had in date vehicle tax and a current MOT test. The service used a high street provider to make responsive maintenance to the vehicle.

The ambulance equipment was appropriately maintained and last serviced in February 2026.

The provider 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.

Most staff (23 out of 25) were employed from overseas under sponsorship arrangements. The company had not fulfilled the requirements of the sponsorship licence which had been revoked by the Home Office for noncompliance due to failure to pay staff the agreed salary.

The Home Office identified the service had unethical international recruitment practices. Information we saw during our assessment confirmed this. Staff did not receive their agreed salary and were not always paid for all work they had undertaken. Staff were expected to be available from 9.30 to 5.30 daily even though they were not being paid and work was not available. The director has now applied for Judicial review, which is a court procedure used to assess the lawfulness of a decision made by a public body.

We saw information from The Secretary of State for the Home Department (SSHD) which identified whilst the service could no longer recruit sponsored workers under the work routes of the Points Based System, they may still employ UK nationals, as well as European Economic Area (EEA) and non-EEA nationals who hold the right to work in the United Kingdom. The registered manager was also employed under sponsorship and the SSHD identified this was a byproduct of the individual being placed in the role. Without a registered manager the service would not be compliant with CQC regulations.

We were initially told there were 2 staff working for the Telford office. However, records showed there had been 17 staff, all employed under sponsorship arrangements, who had undertaken work at the location. Staff told us most journeys were undertaken by 1 staff member, the ambulance driver. However, if the person required assistance and no family or carers were available a second staff member would also be booked to support this person.

Recruitment practices were not robust and failed to protect people from unsuitable staff working for the service. We found staff to be doing references for other staff.

We saw all staff received training, which was appropriate for the service. We found that some, but not all staff were expected to fund this training prior to employment commencing. We saw contracts of employment were not issued until the training service led agreement was fulfilled. Staff were tied into a service level agreement for 12 months which required them to pay for their own training. Some of the training that was being charged for was available free of charge on social care websites.

Staff received annual basic life support training. Information provided confirmed 12 out of the 17 staff files we looked at had received this training.

There was no structured approach to monitor staff performance with no individual conversations recorded in 17 staff files. Staff supervision and appraisal did not meet requirements. This was of particular concern given employment references were mainly character references. The 2 1:1 meeting we saw were used to address staff conduct. In the 17 staff files we looked at, there was 1 recorded appraisal which identified personal improvement in the role was required but there was no ongoing follow up. Staff said they did not have any formal individual meetings with managers nor had any records of meetings. Of the 17 staff files reviewed we found 5 staff were no longer employed.

We requested confirmation of the enrolment or completion of the registered manager level 5 Diploma in Leadership and Management for Adult Care. We were supplied with a level 5 placement employer supervision agreement the date of commencement stated 25 November 2023, but the director signed this off on 5 May 2026.We remain unsure and unclear of the date of the enrolment or whether the enrolment had taken place.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it visibly clean. The ambulance was visibly clean, maintained and had required furnishings were easily cleanable, however there were no stickers confirming when equipment and ambulance were last cleaned. Staff were expected to clean the ambulance daily and after each patient transport, but we were not provided with evidence this had been undertaken. The registered manager said staff video called him to check the ambulance was clean.

The ambulance was deep cleaned 8 weekly by an external company and records confirmed this. A deep clean of the ambulance was last undertaken on 29 April 2026. The deep clean confirmed areas which were deep cleaned also results of swabs taken before and after the deep clean for any microorganisms present.

We requested infection control audits for the last 12 months. However, none were provided, and 1 hand hygiene audit was offered instead. The hand hygiene audit identified 4 staff had been checked by the registered manager; the registered manager was included in the audit. The audit identified all staff were fully compliant. This included observations of arms bare below the elbows, hand washing techniques, cuts and grazes covered by a waterproof plaster, and paper towels disposed of without touching the waste bin. Hand cleaning gel was available on the ambulance for use when handwashing sinks were not available

All staff had received infection prevention and control training in the last 12 months.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.