Torbay and South Devon NHS Foundation 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

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service had processes to investigate incidents and people could raise concerns. People were protected and kept safe. Equipment met the needs of people and was well-maintained. Staff received training to perform their roles. However, not all infection prevention control risks were managed. There was no clear oversight of incidents in subcontracted services. Not all staff had completed training in learning disabilities and autism.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had limited oversight of incidents in subcontracted services. However, 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.

The service subcontracted some patient transports to independent healthcare ambulance providers. However, there was a limited system to review incidents in those subcontracted services. This meant the service could not be assured learning would be shared between providers.

There were systems and processes to investigate incidents and near misses. There were up-to-date policies to support incident investigations. Learning from incidents was identified and shared with all staff through various methods of communication. Staff told us they had confidence reported incidents would be taken seriously and acted upon.

Staff understood the importance of duty of candour (being open and honest when things go wrong). During the assessment of the service, we reviewed records that demonstrated the service followed duty of candour.

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.

There was eligibility criteria to identify people who could use the service. The service operated under the NHS Non-Emergency Patient Transport Service (NEPTS) guidance.

The service had a process to identify patient risks. The service’s booking process captured patient details and risk factors that enabled care planning. Where booking information indicated a higher level of support was required, staff reviewed the entire patient journey to plan safe care.

We observed staff interacting with other healthcare professionals when collecting and dropping off people at their destinations. Staff checked key information about the patient and communicated patient needs to ensure continuity of care.

There were processes to support communication between the patient transport station and vehicles on the road.

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 concentrated 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.

Staff received training in safeguarding adults and children. Managers monitored training compliance with 99% of staff having completed safeguarding adults, and 97% completed safeguarding children training.

Staff understood their role in safeguarding people from abuse and improper treatment. Staff could identify signs of abuse and understood how to raise safeguarding concerns.

The service had up-to-date policies and processes to protect adults and children from abuse and improper treatment. Staff followed safe processes to report concerns. The service had safeguarding information displayed at the patient transport station.

The service carried out appropriate recruitment checks. This included checks with the Disclosure and Barring Service (DBS) for both adults and children lists. There was a process to review risks in recruitment.

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

The service had processes and policies to support patients having a medical emergency. Staff were trained to provide life support until urgent and emergency services arrived at the scene. Staff were confident describing what they needed to do in an emergency.

The service did not manage or directly deploy medical or nursing staff. However, the service coordinated with wards to arrange for other staff groups to travel with the patient as required.

There were plans to respond to vehicle faults when transporting people. The service had access to vehicle recovery support. The service had capacity to attend a broken-down vehicle to collect people and complete patient transfers.

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, facilities and technology supported the delivery of safe care.

There was not a robust process to check the quantities of stock on vehicles. Storage areas on vehicles were clearly labelled with content but there was no guide for staff to check on quantities needed of each item. This meant there was a risk items may not be available when needed. During the assessment of the service, managers introduced a load list to each vehicle. However, first aid boxes had a content list and there was a process to check all items were available.

Staff carried out regular safety checks to ensure ambulances were safe to drive. Vehicles were insured, taxed and had valid MOTs. The service had a process to ensure all vehicles had a full service in line with manufacturer guidelines.

Staff reported equipment defects to managers. The service had a system to ensure defected equipment was removed from use.

The service had a process to check equipment was safe to use. Managers kept records of equipment servicing and monitored when the next service was due. There was a process to check electrical appliances were safe to use. Electrical equipment had a test date displayed.

Staff had access to specialist equipment to support people using the service including child seats, moving and handling equipment, wheelchairs and bariatric equipment. Staff told us they had enough equipment to look after people.

Chemicals or substances hazardous to health (COSHH) were stored securely. COSHH risk assessments had been completed.

The evidence showed some shortfalls. Staff had not always completed learning disability and autism training. However, the service made sure there were enough qualified, skilled and experienced staff who received effective support. They worked together well to provide safe care that met people’s individual needs.

Staff received training to support them to perform their job roles. Managers monitored compliance for mandatory training, which was near 100% complete for every module. However, compliance for training on how to support people with a learning disability and autistic people was significantly lower at 35% in May 2025. Managers told us training required a face-to-face session which was difficult to book staff on to as there was a limited number of spaces on courses.

The service had office staff, support roles and patient transport crews. Managers told us there was enough staff to crew vehicles and plan service delivery. If medical and nursing staff were required to accompany a patient on a journey, then ward staff would take responsibility for the patient on a transport. At the time of our assessment there was no ongoing recruitment within the service.

The booking process identified patient needs which enabled the service to plan how many staff to deploy on each transport. Where demand for the service was higher than the service could meet, they would subcontract work to independent health providers registered with the Care Quality Commission (CQC).

The service had a process to check and monitor ambulance crews’ driving licences. Staff who drove vehicles were required to attend a driver training course prior to transporting people.

Staff received induction to the service. Staff said the induction process worked well and it included working with experienced staff to become confident in their roles. Managers provided annual appraisals for staff which were tracked to ensure completion. Over 96% of staff had received an appraisal within the last 12 months. Staff said that both the induction and appraisal processes enabled them to do their jobs.

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.

Equipment was not always maintained to prevent the spread of infections. The sink in the sluice was rusted which meant cleaning may not have been effective to reduce the spread of infections. During the assessment of the service managers told us they had ordered a new sink.

Healthcare waste in patient transport ambulances was stored in colour coded bags. However, the bags were stored loosely and not in a container during transport. Staff told us they cleaned and immediately disposed of healthcare waste at the hospital.

During the inspection we found out-of-date personal protective equipment (PPE). We also found protective face masks that had manufacturers guidance requiring them to be stored within a temperature range. The storage area was not temperature controlled, and the service could not be assured that the temperature range had been exceeded. This meant that PPE might not be as effective when used. During the assessment the items had been removed after our feedback.

The service had a schedule for deep cleaning and disinfecting vehicles. However, cleaning records were not always completed. Records tracked if a vehicle had been deep cleaned and indicated when a vehicle was not in use, but there were gaps in recording when vehicles had been deep cleaned. This meant the service could not be assured a vehicle had been deep cleaned as required.

The service identified patient infections prior to transport and had systems and processes to reduce the risk of infections spreading.

Staff carried out cleaning in between patient transports to prevent the spread of infections. Vehicles had adequate supplies of cleaning equipment and were visibly clean. Staff received training in infection prevention control.

People using the service told us they felt vehicles were kept clean and were happy to travel in them.

The evidence showed a good standard. The service made sure that medicines were safe and met people’s needs.

Staff followed up-to-date policies and processes to administer oxygen. Staff were trained to use oxygen in an emergency. Staff did not use or carry any other medications. Oxygen cylinders were stored safely on ambulances. Patients’ own medications were transported securely during transport.