Isle of Wight NHS Trust

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Trust policies and procedures provided staff with guidance on reporting, managing, investigating and learning from incidents. The incident reporting and management policy, published on the trust’s website, aligned with the requirements of the National Patient Safety Incident Response Framework (PSIRF), which promotes a learning-focused approach to improving patient safety. In line with PSIRF, the trust also published a Patient Incident Response Plan outlining identified safety priorities and how these would be addressed.

Between October 2025 and February 2026, the service reported 3 incidents, all occurring in December 2025. Two incidents were assessed as causing no harm and one as moderate harm. The moderate harm incident involved a patient who was unable to return to the Isle of Wight as planned following treatment at a neighbouring trust. A review conducted using PSIRF principles found that treatment delays and communication issues outside the control of the Patient Transport Service resulted in the patient missing their scheduled transport home. This required alternative travel arrangements and caused distress to the patient. Staff told us there were very few incidents within the service. Managers stated all reported incidents were investigated, and learning was shared, including with other healthcare providers when related to pathway failures.

The service used incident reporting data to identify recurring themes. Investigators reviewed every reported issue to identify root causes and contributing factors, focusing on repeated patterns such as transport delays, communication failures, and equipment problems. Once managers identified these issues, they updated Standard Operating Procedures (SOPs), adjusted workflows, and amended communication protocols. A SOP is a guideline for staff that explains how to perform routine tasks.

The service supported learning by gathering feedback from frontline staff. For example, managers arranged a dedicated patient transport service training day every 5 weeks. We observed posters in the staff room outlining how staff could access the trust’s reporting system. Teams had daily morning briefings Monday to Friday to discuss the previous day’s issues, highlighting upcoming daily challenges, and distribute a summary newsletter every month. These combined communication channels, alongside shift handovers, supervisor updates, and Ambulance Quality Meetings, helped to ensure safety lessons reached all staff.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff managed patient safety effectively by using a multi-layered risk assessment process before any journey began. The Patient Transport Service (PTS) Dispatch Desk acted as the initial safety filter, triaging patients to ensure they were appropriate for transfer. By using a recognised assessment tool, staff could ensure only medically stable patients entered the non-emergency PTS. This screening process helped to prevent inappropriate allocation of unwell patients to crews who did not have the specialist equipment or scope to treat them.

We observed a journey where the crew collected 3 patients (1 patient on a stretcher and 2 patients using a wheelchair). The crew used a handheld device to track bookings efficiently and used a vehicle ramp to load the patient on a stretcher safely onto the ambulance. The service had a policy where 2 crew members always accommodated patients on a stretcher, which allowed one member to drive while the other remained in the back to monitor the patient. The crew collected a patient using a wheelchair with dementia from the hospital. While crews did not always know the severity of a patient’s dementia until they met, staff normally briefed them on how to support the person’s individual needs. In response, the crew told us they would regularly conduct an ‘on the spot’ risk assessment.

To protect patients’ wellbeing and safety, the service had policies to support safe transfers. For example, they never mixed other passengers on a journey if a patient was known to display behaviours that could challenge, and they always assigned 2 staff members to journeys involving patients with dementia. This approach to staffing and risk assessment directly supported a safe and dignified transport environment for vulnerable individuals.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service ensured all staff met safeguarding training standards and had up to date guidance. All staff members completed mandatory safeguarding training and had access to the trust’s safeguarding policy. Records provided by the service showed 100% of patient transport staff had completed level 2 adult and child safeguarding training. This met the trust’s target of 85%.

Staff completed Oliver McGowan training to gain the skills and knowledge needed to deliver safe, compassionate, and informed care to autistic people and people with a learning disability. This training helped staff recognise indicators of poor health within this group, which helped to reduce the risk of unmet needs, neglect, or inappropriate treatment. While 100% of the staff completed Oliver McGowan tier 1 training, the completion rate for the tier 2 training stood at 0%. To address this, the service added the part 2 face to face training to ambulance profiles in January 2026. Managers worked with the local trust, which includes learning disability services, to ensure they could deliver this training by September 2026.

Staff identified vulnerable patients and followed the correct channels to escalate their concerns. All staff we spoke with demonstrated a good understanding of safeguarding by identifying risks, such as unsafe living conditions. Staff explained they would contact their line manager in the first instance or dial 999 for immediate concerns.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The crews maintained safety during transit by conducting dynamic risk assessments. A dynamic risk assessment is a quick, real-time assessment of risks that enables staff to act safely in changing situations. Upon arrival, crews evaluated the patient’s immediate mobility, manual handling risks, and environmental hazards like stairs or cluttered spaces. When a crew identified a patient had deteriorated or was no longer suitable for transport, they followed an escalation pathway. This involved contacting their Patient Transport Service (PTS) Dispatch Desk immediately. This ensured patients received the correct level of clinical response, without unnecessary delay.

The service ensured the safety and dignity of vulnerable individuals by capturing patient information during the booking process. The system required specific information, such as dementia or learning disabilities, resuscitation status, or infection control. Dispatchers used this data to make informed decisions about shared travel arrangements, such as ensuring patients with an infection travelled alone and grouping patients with compatible behaviours. This process helped to protect vulnerable patients from harm and ensure shared transport was only used when appropriate for everyone on board.

Staff ensured patients with mental health needs received appropriate supervision by enforcing a mandatory escort policy. For example, any staff involvement with patients with mental health needs required a clinical escort, such as a mental health nurse or support worker. Additionally, the service used a framework to guide staff on communication strategies and de-escalation techniques for patients with dementia and autistic people. This provided staff with the necessary tools to manage people’s needs, resulting in a safer and less distressing environment for the patient during transit.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service maintained a safe and compliant environment by integrating local risk assessments with trust-wide health and safety frameworks. Managers supported this by using up to date evidence relating to fire and electrical safety and equipment compliance. This meant managers were assured the service met statutory and regulatory requirements for staff and patients.

The base facility demonstrated good standards of fire and electrical safety through documentation and visible safety markers. For example, staff maintained detailed logs for fire alarms, emergency lighting, extinguishers, clear fire exit signs, and fire doors for storerooms. By following these protocols and maintaining a complete Portable Appliance Testing (PAT) register for clinical equipment, the service minimised the risk of fire or electrical failure, ensuring a secure physical environment.

The design of the environment followed national guidance. The environment of the operating station was properly designed, maintained, and well ordered. Staff carried out daily safety checks of specialist equipment. The service had enough suitable equipment to help them to safely care for patients.

Managers we spoke with could explain the process surrounding vehicle servicing and repair which was through a local garage. We inspected 4 vehicles. All vehicles had evidence of daily checks of equipment. Bariatric equipment was available. All the vehicles had up to date supplies of consumable items. During the inspection we checked consumable items and all were found to be in date.

The frontline crews ensured vehicles were roadworthy and safe for every shift. Drivers completed mandatory vehicle daily inspections using a mobile data terminal. This included checking fuel levels, tyres and lights before patient assignments. These routine checks, supported by the recent addition of a clutter-free (one-bag per-patient policy), helped to reduce transit risks and improved overall safety of the mobile working environment.

The service ensured the reliability of medical devices using an asset register and a servicing schedule. The service arranged for engineers to perform annual and twice-yearly maintenance. Equipment was clearly tagged with service dates and unique reference numbers, which meant staff could identify safe tools. This helped to reduce the likelihood of equipment failure during patient care.

Staff maintained a clean and organised clinical environment by following Standard Operating Procedures for vehicle and equipment cleaning. The base had a locked Control of Substances Hazardous to Health (COSHH) cupboard for hazardous substances in the sluice area and provided separate locker rooms for male and female staff. These measures helped to maintain infection control, workplace hygiene, and staff wellbeing.

Crews conducted patient transfers safely by using appropriate moving and handling equipment, such as slide sheets. Staff correctly used secured stretchers with floor brake systems and strapped in wheelchair users to prevent movement during transit. This adherence to best practice handling techniques helped to prevent injuries to both staff and patients during manoeuvres.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers demonstrated safe and effective forward-planning by having awareness of their upcoming workload and ensuring there were enough staff to meet this need. The Patient Transport Service (PTS) had a budgeted establishment equivalent to 20.12 whole time equivalent (WTE) road staff. Of these, 12.24 WTE were permanent posts, representing 55% of the road workforce. The remaining 7.88 WTE were maintained as bank staff positions to provide flexibility and enable the service to respond to daily changes in demand and system pressures. Management, leadership and dispatch roles were permanent positions.

During our visit, bank staff told us they enjoyed the flexibility of their roles and the permanent staff felt there were always enough people to complete the work that needed to be done. This meant the service could prepare for transfers to the mainland and carry these out safely. Where demand increased, such as for last-minute or urgent transfers, all staff we spoke with said the team responded quickly and rarely encountered problems.

The service prioritised flexible leadership instead of fixed schedules. For example, the team leader worked a rotating 4 day week, and the 2 transport liaison officers split the week with a shared overlap day. By coordinating these schedules, the service ensured managers were always available and the team remained well supervised even during staff leave, which removed the need to hire temporary cover.

The service ensured all staff had essential training to ensure their safety and the safety of patients. Mandatory training topics included safeguarding adults and children, equality, diversity and human rights, conflict resolution and training about learning disabilities and autism. Staff said they were allocated time to complete mandatory training. Records provided by the service showed overall PTS staff were 84% compliant, which was slightly below the trust target of 85%. The service considered this to be positive due to recent organisational changes to training requirements implemented in January 2026, which aligned all training profiles with those of a nearby trust. Further planned improvements were in motion to improve their compliance, such as twice-yearly protected training days for all PTS staff.

The service planned staffing levels in line with demand and used flexible deployment to manage activity across the system. Managers had oversight of staffing and capacity through daily operational reviews and forward planning meetings, which supported timely decision-making. At the time of the assessment, the vacancy rate for permanent road staff posts was 37.2%. The service told us these posts were intentionally left unfilled to maintain a flexible workforce and respond to changing demand. However, this vacancy rate was high and required ongoing management.

Managers used a range of measures to mitigate this risk, including flexible staffing arrangements and close monitoring of capacity and demand. Staff told us there were generally enough staff to carry out their roles safely, although pressures at times impacted the timeliness of collections and arrivals. The service worked proactively with system partners, including the clinical coordination centre, to plan activity over the short to medium term. This approach enabled managers to anticipate pressures, adjust resources and prioritise journeys based on clinical need. This demonstrated that, while the service faced workforce and demand pressures, managers had oversight of risk and took action to support safe care delivery.

The service aimed for a 90% appraisal rate to ensure staff had protected time to reflect on their role, discuss challenges, and identify any support needed. During our review, 100% of staff had received an annual appraisal. The sickness rate for the past 12 months was 4.7% and the turnover rate was 25.3%. As a result, managers investigated exit patterns and their workforce demographics. They found this was mainly due to staff retiring rather than staff being unhappy. All staff consistently told us their bank staff were reliable and had been assessed as competent to fill gaps in rotas.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service managed and controlled the risk of infection effectively. An up-to-date infection prevention and control (IPC) policy clearly outlined staff roles, responsibilities and legal frameworks. Managers validated this policy through quality assurance audits, which included direct observations of the crew’s hand hygiene practices. In February 2025, the service achieved a 94% compliance score in these audits. Furthermore, managers conducted unannounced hand hygiene audits while staff worked inside hospitals to ensure an accurate reflection of everyday practice. This oversight provided reliable assurance staff consistently maintained good infection control standards during routine clinical activities. All transport staff completed mandatory IPC training. Managers reinforced this training with regular daily and weekly briefings, particularly during periods of heightened IPC risk.

The service maintained a clean and safe environment for patient care. Staff followed the Ambulance Service Vehicle and Equipment Cleaning Standard Operating Procedure. Staff told us they could access an ‘A–Z of Infectious Diseases’ guide, which specified required decontamination levels and personal protective equipment for specific infections.

We observed clean and tidy laundry rooms, hand gel stations and laminated posters, and saw evidence of deep cleans for vehicles. Crews appropriately managed medical supplies and waste. They used disposable slide sheets, changed waste bags routinely, and used red bags for soiled linen between each patient. Staff disposed of clinical waste safely.

We saw crews using hand gel and cleaning equipment, wheelchairs and stretchers between patients. This helped to prevent cross-contamination and protect patients and staff from the spread of infection.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

The service managed patient medicines safely and maintained clear boundaries around staff responsibilities. Patient Transport Service (PTS) crews did not administer medicines, as this was outside their scope of practice. Instead, staff supported safe self-administration by checking medicines belonged to the patient, were correctly labelled, and were suitable for the journey. Crews monitored patients for any adverse effects but did not administer medicines, escalating concerns to the Clinical Support Desk or emergency services where required.

The service managed medical oxygen as a continuation of prescribed care. Where patients had a prescription for oxygen, crews transferred oxygen between cylinders without altering the prescribed flow rate. If a patient showed signs of deterioration, crews were required to stop safely and seek immediate support from emergency services.

Staff we spoke with understood their roles and responsibilities. These arrangements ensured staff worked within their competence while maintaining continuity of care for patients requiring oxygen therapy.

During the inspection, we reviewed the storage of medical gases at the station. Medical gases were stored safely in accordance with national guidance, including the Health and Safety at Work Act 1974 and Health Technical Memorandum. Staff we spoke with told us there were sufficient full medical gas cylinders available to replace empty ones.