Inter-County Ambulance Services 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

This means we looked for evidence that systems were safe, people were protected from abuse and avoidable harm, the service managed risk, the environment was well maintained, the service had enough qualified staff and infection control was managed well.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were at risk of avoidable harm. 

We found breaches of Regulations 13, 12 15 and 17. Staff were not clear about how to report safeguarding concerns or where safeguarding referrals should be sent. There were no documented inclusion or exclusion criteria for people using the service, and no risk assessment process. There was a lack of robust clinical oversight of medicines management and infection prevention and control procedures were not always effective. The provider did not have effective oversight of the cleanliness of the premises or systems to evidence that equipment had been appropriately cleaned.

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 2. The evidence showed some shortfalls. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Effective systems were not in place to identify, report, investigate and learn from incidents. The service had an incident reporting policy which outlined reporting requirements, investigation timescales and arrangements for sharing learning, however there was limited evidence that incidents and near misses were being identified and recorded in line with the policy.

During the inspection, the service told us that 2 incidents had been reported within the previous 2 to 5 years and that no near-miss incidents had been recorded. The service had reported no incidents in the 12 months prior to the inspection. A staff member we spoke with was unaware of any incidents having occurred.

Leaders stated that the low level of incident reporting was due to no unexpected or unplanned events being recorded on the Patient Report Form (PRF), which was completed for every journey. However, we did not see evidence that information recorded on PRFs was routinely reviewed to identify incidents, near misses or emerging themes requiring escalation, investigation or organisational learning.

We were told no formal complaints had been made, and we did not see a policy that referred to the duty of candour. Duty of candour means being open, honest, and transparent with people when things go wrong. However, staff told us they were open and transparent with patients and relatives when the service fell short of expectations, for example when there were delays in attending transfers.

Staff told us relevant information and feedback were shared through informal discussions, which supported day-to-day communication within the service. However, we found limited evidence that incidents, concerns or lessons learned were formally reviewed by leaders or systematically shared with staff to support service improvement. There was no regular or documented process to ensure learning from incidents, complaints or other events was communicated across the service.

Following the inspection, we reviewed minutes from a quarterly management meeting held in April 2026, which included a standing agenda item for complaints and incidents. The minutes recorded there were no complaints or incidents to discuss.

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.

The service did not have clearly defined exclusion criteria to identify patients who may have been too unwell to be transferred safely, which could place patients at risk. Transfer requests were received by email or telephone, and a booking form was completed for each request. The booking process identified whether a standard or trained crew was required, a trained crew would include a technician or paramedic. However, the booking information reviewed did not provide clear guidance on the medical conditions or criteria that would necessitate the use of a trained crew. The service undertook transfers on behalf of hospitals, referred to as High Dependency Unit (HDU) transfers. Between May 2025 and April 2026, HDU transfers accounted for 14% of Inter-County Ambulance's total activity.

Staff told us that patients requiring HDU transfers were usually accompanied by a hospital-employed doctor or nurse, which would help reduce the risks associated with transporting patients who may deteriorate during transit. However, information provided by the service following the onsite inspection showed that between January and April 2026, only 24% of patients transported on HDU transfers were accompanied by an externally employed doctor or nurse.

This meant there was the possibility that patients with complex or higher risk needs may not have been accompanied by appropriately skilled clinical staff throughout their journey.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns quickly and appropriately.

The service's systems and processes did not operate effectively to prevent, identify, and respond to potential safeguarding concerns. Although staff at all grades had completed Level 3 safeguarding training for adults and children, there was a lack of awareness of safeguarding risks and the appropriate actions to take when concerns were identified.

The service had a safeguarding policy in place which set out staff responsibilities for recognising and responding to safeguarding concerns. However, the policy did not specify which external organisation safeguarding concerns should be reported to, and senior leaders were unable to provide this information when asked. Staff were unclear about who held the role of safeguarding lead within the service, as the policy instructed staff to notify the service control room of any safeguarding concern or incident rather than identifying a designated safeguarding lead.

One staff member told us they would raise safeguarding concerns with hospital staff and record them on the Patient Report Form (PRF). However, this was not part of the service level agreement with the hospital and the staff member did not know who to raise the concern with internally. It was unclear whether PRFs were routinely reviewed following patient journeys to identify safeguarding concerns or other issues requiring action. Audits of PRFs focused on the completion of documentation rather than the content of the information recorded. As a result, the service could not be assured that safeguarding concerns were identified, appropriately escalated, or acted upon.

At the time of inspection, the service did not have a safeguarding lead trained to Level 4, as recommended in the intercollegiate safeguarding document. Following inspection feedback, the service acted promptly to address this and provided evidence that Level 4 safeguarding training had been completed.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff therefore did not always provide care that was safe.

The service did not have documented exclusion criteria or formal risk assessment processes for people using the service. Individual risks were not routinely identified, assessed, or recorded by the service. The control room recorded the initial journey booking information and Patient Report Forms (PRFs) were then  completed by the attending staff. However, this information was not used to complete formal risk assessments, for example a risk assessment for managing a stretcher up flights of stairs. This meant the service could not demonstrate that risks associated with individual transfers had been systematically assessed and managed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

We inspected 4 ambulance vehicles and found them all to be clean, well maintained, and suitably equipped to meet the needs of the service. Each vehicle carried pressure-relieving mattresses and patient handling equipment. Specialist paediatric transfer equipment, including a neonatal transport system designed to safely secure babies and a children’s ambulance restraint were also available. The service maintained comprehensive records demonstrating that daily and weekly vehicle checks were completed and that equipment was appropriately maintained. When not in use, vehicles were stored at the service premises and vehicle keys were kept securely.

The service had an IT system that provided live tracking of all vehicles and recorded driver details. This enabled the service to monitor driving activity and ensure that drivers were not driving for excessive periods during longer journeys.

The service premises were not maintained to the same standard as the ambulance fleet. Although people using the service did not attend the location, it was used by service leaders and staff as a base of operations. There were no cleaning or maintenance schedules in place for the premises, and several areas and pieces of equipment, for example trolleys, were visibly dirty.

Hazardous and flammable substances were not stored safely, and information relating to the products found on site was not readily available. Following the inspection, we received evidence from the service demonstrating that the concerns raised had been appropriately addressed.

Within the building, a fire exit was obstructed by staff lockers. Following the inspection, the service submitted evidence confirming that the oxygen storage arrangements had been reviewed and reorganised to address all the concerns identified.

We scored the service as 2. The evidence showed a good standard. The service did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Basic Life Support (BLS) training was delivered either by external providers, including through staff members' employment within the NHS, or by the service's nominated individual, who was based outside the UK. Training delivered by the nominated individual was conducted virtually. The nominated individual told us that participants' skills and competence were assessed remotely. However, the provider was unable to provide evidence of the process used to assess and verify practical competence following virtual training.

We asked the provider for a copy of their training matrix. We reviewed this information and the matrix did not include any Intermediate Life Support (ILS) training for paramedics.

In addition, concerns were raised regarding the effectiveness of the service's Patient Group Direction (PGD) training, which meant we could not fully verify that staff had received appropriate training and competency assessment in relation to the PGDs.

The service had sufficient numbers of appropriately qualified staff to meet its operational demands. Many of the paramedics and technicians working within the service also worked for NHS organisations and were able to provide evidence of externally delivered training.

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 service did not always have an effective approach to assessing and managing the risk of infection. The service did not maintain cleaning schedules or records for the service premises or the equipment stored there. However, the ambulance vehicles were clean, and staff were allocated time to clean them after each use. Records also demonstrated that the vehicles had 2 weekly deep cleans.

The service’s Infection Prevention and Control (IPC) policy did not reference the cleaning product used on ambulance vehicles. Information about the product was not readily available to demonstrate its effectiveness for infection control purposes or to confirm how long it remained effective once diluted. The cleaning solution bottles were not labelled or dated to identify what the cleaning solution was, any chemical hazards, or the use by date. Following the inspection, the service provided evidence that the product had been replaced with an alternative cleaning agent supported by appropriate product information.

The service was using orange clinical waste bags to store white salts, which are not classified as infectious clinical waste. We also observed yellow clinical waste bags being placed inside orange waste bags before disposal in the yellow clinical waste bin. This did not support clear segregation of waste streams and created uncertainty regarding the appropriate level of waste management required. The yellow clinical waste was also unlocked.

During the onsite inspection, we found 2 yellow sharps bins on ambulance vehicles that contained clinical waste, including gloves and paper hand towels. Two sharps bins in use had not been labelled or dated in accordance with the guidance ‘HTM 07-01: Safe and Sustainable Management of Healthcare Waste’ or the service’s infection prevention and control policy.

Equipment on the ambulance vehicles was clean; however, some equipment stored at the service location was visibly dirty. We also found no clear system on the vehicles or at the service location for identifying whether equipment had been cleaned after use, such as the application of "clean" labels or stickers.

The kitchen and storeroom at the service location were visibly dirty, with the presence of cobwebs and accumulated black dust. We observed a broken wall tile in the kitchen and what appeared to be black mould on the ceiling.

We scored the service as a 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We identified gaps in the systems and processes used to support the safe management of medicines. The service did not have a suitably qualified, UK‑registered clinician providing clinical oversight. The nominated individual (NI) assessed staff competencies despite not holding a current healthcare qualification, which did not provide adequate evidence that competency assessments were robust and effective. Interim arrangements were not sufficient, as the acting clinical lead did not hold a recognised UK registration. Leaders had attempted to appoint a medical director, but this had not been finalised, leaving gaps in clinical governance.

The service did not manage Patient Group Directions (PGDs) in line with national guidance. PGD’s are a written legal framework that allows specified registered healthcare professionals to supply or administer prescription only medicines directly to patients without needing a doctor’s individual prescription.  There was no evidence that managers had confirmed staff eligibility and competency to work under a PGD. PGDs had not been appropriately authorised by a senior doctor, pharmacist, or governance lead, and there was no clear involvement from relevant professional groups. This meant that medicines could potentially be administered to patients by staff without the competency or the correct legal authorisation in place

The service did not comply with controlled drugs legislation. It did not hold a Home Office licence to possess or supply controlled drugs, including diazepam, which is required under the Misuse of Drugs Regulations 2001. Although medicines had previously been obtained under a former medical director, leaders could not demonstrate that current arrangements were in line with legislation. The service informed us that following the inspection, all controlled medication had been removed, and the service no longer stored or administered controlled medications.

Staff stored medicines in a locked room with restricted access; however, they kept stock medicines in a filing cabinet, which did not align with national guidance. Medicines bags and oxygen cylinders kept on vehicles were stored securely.

The service completed regular date and stock checks of medicines available in the service. Medicines were in date and medicines bags had tamper seals. The service rarely administered medicines but used patient report forms to record administration when they did.