Pro Medicus

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the regulation for governance.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Quality Statement Score: 1

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 1. The evidence showed significant shortfalls. Leaders did not demonstrate full oversight of service provision or understanding of regulatory requirements.

The service was led by the registered manager, who was an experienced ambulance technician. The registered manager had been in post since the service opened. The registered manager was supported by an operations manager, a medical director, and administrative staff. The operations manager was a paramedic, who had joined the service since our last assessment.

The registered manager and the operations manager regularly worked operationally. This had resulted in a lack of attention to the management of the service and to governance processes. As a result, there had been limited progress made against the concerns identified at our last assessments in 2022 and 2024.

The registered manager had delegated a significant portion of the day-to-day management of the service to other members of staff. The registered manager expected these members of staff to make him aware of any significant areas of concern. However, this was not formally set out in a framework of accountability, to ensure that staff had clear guidance about when to escalate matters of concern. As a result, leaders had not been aware of a concern regarding bank staff mandatory training compliance, as this had not been escalated to them.

The registered manager was not able to demonstrate full oversight of the service provision. For example, the registered manager was not able to describe the top risks on the risk register, any areas of concern that had been escalated internally for their attention, or the key performance indicators in place. However, the registered manager did demonstrate oversight in other areas, such as the service’s 5-year business plan, complaint and incident themes, and an understanding of the context in which staff deliver care.

Leaders did not demonstrate a full understanding of regulatory requirements. As a result, they were not compliant with their regulatory responsibility to submit statutory notifications to CQC or to display the most recent CQC performance assessment.

Leaders were responsive to the concerns raised during our assessment and took swift action to address the concerns. However, leaders had not identified the concerns prior to our assessment. This demonstrated a reactive rather than a proactive leadership approach.

The service did not always have effective arrangements in place to ensure continued oversight of key areas when leaders were absent from the service. For example, the operations manager was on leave during our on-site visits and other leaders were unable to provide information or answer questions relating to key areas such as key performance indicators or daily vehicle check completion.

There was no infection prevention and control lead within the service. This meant that the service did not have clear roles and responsibilities around infection prevention and control. This concern was raised at our last assessment but had not been addressed.

Staff provided positive feedback regarding the service’s leaders. Leaders were described as visible and supportive.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Quality Statement Score: 1

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this with others when appropriate.

The service did not always have effective governance arrangements in place. Management meeting minutes did not give assurance that all key topics, including performance data and risks, were covered at each meeting. Meeting minutes also showed that actions had not always been identified when areas of concern were discussed. We were not provided with evidence of an action log. However, management meetings were now held regularly and did cover a range of topics, including relating to audit outcomes, staffing, finances and incidents. This was an improvement from our last assessment.

The service had a governance policy in place but this did not clearly set out responsibilities, roles, and systems of accountability.

Leaders told us that there were no staff meetings in place. Leaders stated that a secure messaging platform was used to share relevant information with staff. Our review of this messaging platform demonstrated that this was mostly a one-way method of communication from leaders to staff. Some staff also told us that they did not always read the messages. Staff meetings would have provided an opportunity for staff to discuss and raise any concerns.

Arrangements with partners and third-party providers were not always governed and managed effectively. For example, the service did not provide evidence of a contract or meetings for the patient transport service work undertaken for a local hospital trust. This concern had been raised at our last assessment and had not been addressed.

The service did not have effective processes to monitor performance. Leaders told us that no internal key performance indicators (KPIs) had been set. The meeting minutes that we reviewed did not show evidence of monitoring performance against any KPIs.

The audit process was not always robust enough to determine if the service was doing well and what improvements could be made. The concerns identified during our on-site visits had not been identified through the audit process. Staff told us that the service had increased the range of audits carried out since our last assessment and showed us evidence of this during our on-site visits. However, when we requested evidence of audit outcomes following our on-site visits, we were only provided with evidence of IPC audits, and audits of patient report forms (PRFs) for events work. We were not provided with outcomes from medicines management audits, any PRF audits for non-events work, or any audits relating to the environment or equipment. We were not provided with any action plans for any audits.

The service did not have effective processes for the identification and management of risk and issues. We requested a copy of the risk register following our on-site visits. The risk assessment document provided showed that a range of hazards had been identified, but they had not been given a ‘risk level’, they did not always have an action owner identified, and they did not always have evidence of the risk being reviewed or updated. There was no evidence that risks were regularly discussed and reviewed at management meetings.

Leaders had not identified the areas of concern that we identified during our assessment. For example, relating to medical gases storage and reusable mop heads. Leaders had not ensured that all concerns identified during our last assessment had been addressed. For example, we continued to identify concerns regarding the storage of medical gases, infection prevention and control, and the learning culture. Although an action plan had initially been drawn up in response to the 2024 warning notices, leaders stated that this had been discarded when the member of staff overseeing the action plan had left the service. The discarded action plan was not replaced with a service improvement plan or a process of ensuring improvements were being made and embedded in practice.

There was no formalised process for policy review and approval, therefore policies were not being regularly reviewed. Staff told us that work to review policies had only recently begun at the time of our assessment. During our on-site visits, we reviewed 6 policies in the policy folder on the service’s electronic system. All of these policies had last been reviewed in 2023. Leaders told us that policies should have been reviewed annually. We requested the service’s standard operating procedure for policy review and approval following our site visit, but this was not provided.

The policies reviewed as part of our assessment did not always reflect the service provided. Without clear, tailored guidance that reflects the actual practices and procedures of the service, staff may not be certain on how to respond appropriately in key areas, such as infection prevention and control.

There were not always effective arrangements to ensure that data or notifications were submitted to external bodies as required. For example, the service had identified 6 safeguarding concerns in 2025, but these had not been reported to CQC as required.

As part of our assessment, we requested evidence of any workforce planning undertaken in the last 12 months. The service provided a workforce planning policy. However, the service did not provide evidence that they had completed the workforce planning process set out within the policy.

The service had an emergency planning and business continuity policy in place but this had not been fully completed. For example, to include staff details and other key contacts.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.