Pro Medicus

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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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 was in breach of the regulation for safe care and treatment.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 1

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have an effective local incident reporting system in place and the provider's policies did not support safe incident reporting systems and processes. We did not always have assurance that the provider thoroughly investigated incidents, or that complaints were responded to in line with the provider's policy.

We remained concerned that the service did not have an effective local incident reporting system in place. Only 1 incident had been reported within the service in 2025. None of the staff that we spoke with had experience of reporting an incident at Pro Medicus since our last assessment. During our conversations with staff, they described events which had occurred since our last assessment, such as data breaches, which had not been reported as incidents. This raised concerns that staff did not always know what incidents should be reported. Leaders had identified concerns regarding low levels of incident reporting and had implemented a QR code system in response. The QR codes were placed in strategic locations across the service. Staff were able to scan the QR code to report an incident through the incident report form. Staff demonstrated an awareness of the QR code system and how to use it to report an incident. Leaders stated that the QR code system had resulted in an initial increase in the number of incident reports, which had subsequently dropped back down again.

We did not always have assurance that the provider thoroughly investigated incidents. As part of our assessment, we requested any documentation relating to the last 3 incidents that staff had reported, including the incident report form, any investigation documentation and any associated action plans. This was not provided.

We were not assured that the provider had robust policies to support safe incident reporting systems and processes. Leaders had not taken action to update their incident policies after we raised concerns regarding the policies during our last assessment. This meant that we remained concerned that there was a lack of clear guidance about how incidents should be investigated and there was no guidance about grading the level of harm associated with an incident.

We did not always have assurance that complaints were responded to in line with the provider’s policy. During our on-site visit, we reviewed a complaint received in January 2025. A statement had been gathered from a member of staff but there was no evidence of a complaint response or outcome. We requested this information following our on-site visit but this was not provided. However, we reviewed another complaint, which had been received by the provider in 2024, which had been thoroughly investigated. Actions had been identified in response to the concerns raised and learning had been shared with all staff. Contact had been made with the complainant to discuss the findings of the investigation and share the learning identified.

Staff understood the principles of duty of candour but had not had experience of putting this into practice. They were focused on being open and transparent, and giving patients and families a full explanation if and when things went wrong.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Quality Statement Score: 2

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 2. The evidence showed some shortfalls. The service could not always provide assurance that staff had received training for the safe operation of premises and equipment. We could not be assured that environmental risks were being effectively monitored and managed.

The service could not always provide assurance that staff had received training for the safe operation of premises and equipment. Leaders and staff told us that equipment training was provided. However, the service did not send us training compliance data for equipment training when this was requested as part of our assessment. We therefore could not be assured that all staff had received training on all the equipment that they would be expected to operate as part of their role. The service could not provide evidence that blue light driving training was re-assessed annually, in line with their policy.

We could not be assured that environmental risks were being effectively monitored and managed. Staff had completed a risk assessment document which included a range of environmental risks. However, the risk assessment document had not been fully completed to include a risk level, action owners for each risk, and evidence of the risk being reviewed or updated.

Leaders carried out audits to monitor compliance with processes related to the environment and equipment. Staff showed us evidence of audits during our on-site visits. However, following our on-site visit, we asked to see audit outcomes and any associated action plans. This was not provided. This meant that we could not review how well the service performed in these audits or whether they acted in response to any learning from audits.

A process was in place to record the serial number of tamper proof tags on kit bags. This was an improvement from our last assessment.

Staff completed electronic daily vehicle checklists before use. The records of daily vehicle checklist completion that we reviewed demonstrated that checks were being regularly carried out. The operations manager could access the detail to carry out compliance checks.

A system was in place to monitor when vehicles needed to be serviced and all vehicles had regular safety service. The vehicles also had up-to-date MOT certificates and tax records.

The emergency and urgent care vehicles reviewed during our assessment were in a good state of repair. Fire extinguishers on vehicles were up-to-date for servicing. All of the consumables reviewed during our assessment were within their expiry date. Processes had been implemented for auditing expiry dates of consumables. This was an improvement from our last assessment.

The service had registers to monitor the calibration, servicing and testing of equipment. The registers showed that all equipment was up-to-date for calibration, servicing and testing.

Quality Statement Score: 2

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that staff were up-to-date with mandatory training. We could not always be assured that training was delivered by competent staff.

We could not always be assured that the staff providing care or treatment to service users had the competence and skills to do so safely. Bank staff were overdue for mandatory training but were continuing to work for the service. Training compliance data from June 2025 showed that 2 members of bank staff were overdue for all mandatory training courses and 1 member of bank staff was overdue for 10 out of 12 mandatory training courses. Leaders took immediate action to stop these members of staff from working for the service until they became compliant with their mandatory training. All substantive staff were up-to-date for mandatory training.

We could not always be assured that training was delivered by competent staff. The service’s Education and Training Policy stated that some statutory and mandatory training courses were delivered in-house. This included manual handling and basic life support training. We requested evidence of any staff qualifications to provide in-house training. The evidence provided did not demonstrate staff competence to deliver manual handling or basic life support training.

The service had enough staff. The service employed 9 substantive staff, who worked based on their personal contracts and availability. In addition, bank staff were employed on an ad-hoc basis. The service operated on a flexible basis, responding to requests by contracting providers. This determined how many staff and the number of vehicle hours needed per day.

Quality Statement Score: 2

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service’s base location provided staff with access to vehicle and equipment cleaning facilities. However, the processes in place for cleaning vehicles and equipment demonstrated that staff and leaders did not always have a clear understanding of infection prevention and control (IPC) principles. For example, we observed that reusable mop heads were reused on multiple occasions and between different vehicles. We also observed that the same mop colour coding was in use for ambulances and in the office area. This was not in line with national guidance and created a risk of cross contamination. Following our site visits, leaders implemented a new colour coding system for mops and implemented a new process for cleaning reusable mop heads after each use.

The service had an informal agreement with an external company to deep clean vehicles every 6 weeks. The deep cleaning records reviewed during our assessment demonstrated that cleaning had not always been completed at the 6-weekly frequency agreed with the external company. Leaders stated that this was due to the availability of the external provider, which had been reduced due to staff turnover.

As part of the deep cleaning process, swabbing was undertaken to monitor the cleanliness of surfaces. However, staff did not have access to guidance to indicate when action should be taken and what action should be taken in response to swabbing results. Staff recorded swabbing results on a spreadsheet, but they had not recorded what action had been taken in response. However, we saw evidence that leaders had shared the results with staff through a secure messaging system.

Leaders regularly carried out a range of audits to monitor compliance with infection prevention and control processes. Audits mostly demonstrated high levels of compliance. This was an improvement from our previous assessment. However, the audits had not been robust enough to identify the areas of concern that were identified during our assessment. In addition, where areas of concern were identified through audits, these were not always addressed in a timely manner to prevent reoccurrence. For example, the audit of the office area had identified that the waste bin was not foot operated for 3 months in a row, before a replacement was eventually sourced.

The service’s IPC policy did not always reflect the processes in place at the time of our assessment. For example, the IPC policy still stated that deep cleans were carried out by internal staff, every 4 weeks. The policy had not been updated to reflect that the service had begun using an external company for deep cleans, every 6 weeks.

Staff said that there was no infection prevention and control lead in the service. This demonstrated that the service did not have clear roles and responsibilities around infection prevention and control. This concern had been raised at our last assessment and had not been addressed.

Staff did not label equipment to show when it was last cleaned. For example, through the use of ‘I am clean’ stickers. These stickers were available within the service but we did not observe them in use.

The office and equipment storage area of the ambulance base was cleaned on a weekly basis by administrative staff. The cleaning was not documented, which meant that we could not be assured that cleaning had been carried out as required.

Staff had access to handwashing gels and wipes in all vehicles. 

All vehicles and equipment reviewed during our assessment were visibly clean. This was an improvement from our last assessment.

Cleaning of the vehicle and equipment was carried out by ambulance crew members. Staff said that vehicles were cleaned daily and after every patient transfer. Staff recorded the cleaning through their daily vehicle checks. Data reviewed following our on-site visit demonstrated that daily vehicle checks were being regularly carried out. This was an improvement from our last assessment

Quality Statement Score: 2

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe.

The service did not always ensure that medical gases were stored in line with national guidance. Medical gases were being stored in an equipment room within the office area. This room was not well ventilated and there were potential sources of ignition. The room did not have warning signs in place to alert people to the presence of potentially hazardous gases. Staff moved the oxygen cylinders to a different room when we raised these concerns with them. We did identify improvements in the storage of medical gases in other areas of the service.

Staff did not always maintain accurate records regarding the use of medical gases. The records kept of the number of expired oxygen cylinders in the garage area did not accurately reflect the number of expired oxygen cylinders observed during our site visit. However, the service had implemented improved processes for the use of medical gases since our last inspection. For example, a process was in place to monitor and identify when oxygen cylinders required replacement.

Medicines were not always stored securely. The key to the medicines room was not being stored securely during our first site-visit. This meant that there was a risk that unauthorised members of staff could access medicines. However, by the time of our second site-visit, this concern had been addressed.

Leaders carried out audits to monitor compliance with medicines management processes. Staff showed us evidence of audits during our on-site visits. However, following our on-site visit, we asked to see audit outcomes and any associated action plans. This was not provided. This meant that we could not review how well the service performed in these audits, or whether they implemented action in response to learning from audits.

Tamper-evident seals were used on medicines bags, with serial numbers recorded and audited to confirm integrity prior to use. Medicines bags included oral syringes to support the administration of liquid medicines. This was an improvement from our last assessment.

Regular temperature monitoring was in place across all medicine and medical gas storage areas. This was an improvement since our last assessment. The provider told us they would consider conducting a risk assessment to ensure compliance with manufacturers' storage recommendations.

We observed that staff consistently recorded individuals’ medical histories and current medicines. Records included details of medicines administered by staff, including the use of medical gases.

Staff received regular training in medicines management, including the use of medical gases, and had access to supporting information to promote safe practice.