Specialist Medical Transport - North

Independent Ambulance · North East

Overall Rating
Inadequate Last inspected 10 January 2023
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Requires Improvement
Responsive
Good
Well-led
Inadequate

View Full CQC Report

19 must-do actions
1 should-do action

Must-Do Actions (19)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The service must ensure that the service has systems and processes to ensure staff assess and make plans to respond to the risks presented to service users in carrying on the regulated activities.
Regulation 12(1)(2)(a)(b): Safe care and treatment
The service did not have systems and processes to ensure staff assessed and made plans to respond to the risks presented to service users in carrying on the regulated activities. The service did not maintain appropriate records to evidence that service users’ risks and needs were assessed and met prior …
Must Do
Safe
The service must undertake an assessment of patients presenting risks or needs prior to commencing the journey.
Regulation 12(1)(2)(a)(b): Safe care and treatment
Staff did not complete or update risk assessments for each patient to remove or minimise risks. We did not see evidence that staff were made aware of specific risks relating to each individual patient in advance of arriving to undertake the transfer, for example, patients’ mental health risks, including risks …
Must Do
Effective
The service must ensure care is provided with the consent of service users, or ensure staff have the training and experience required to consider and assess capacity for service users whom may lack the mental capacity to consent to their care.
Regulation 11(1)(3): Need for consent
Staff did not support patients to make informed decisions about their care and treatment. National guidance and legislation to gain patients’ consent was not followed. The service had not ensured care was provided with the consent of service users, or ensured staff had the training and experience required to consider …
Must Do
Safe
The service must implement systems and processes to ensure the control of physical or mechanical restraint of a patient is the least restrictive option, is necessary and is proportionate to the risk in order to prevent a risk of harm to service users or others.
Regulation 12(1)(2)(a)(b): Safe care and treatment
Managers could not provide copies of service users’ risk assessments which evidenced the need to apply mechanical restraint or to use the cell area of the vehicles. There was no rationale or decision-making processes adequately recorded. Whilst staff said they took account of a patient’s history they did not complete …
Must Do
Safe
The service must ensure that staff undertake accredited blue light driver training and that evidence is maintained on file for those staff members.
Regulation 12(1)(2)(a)(b)(c): Safe care and treatment
The provider told us five staff were trained to drive under ‘blue lights. However, there was no evidence of accredited blue light driver training on file for any staff member.
Must Do
Safe
The service must evidence that managers have investigated incidents thoroughly and learned lessons from these incidents or recognised potential safeguarding factors in these incidents.
Regulation 12(1)(2)(a)(b): Safe care and treatment
Managers could not evidence that incidents were investigated appropriately or used to identify opportunities for learning. None of the incidents had been investigated appropriately or used to identify lessons learned or to improve the service.
Must Do
Safe
The service must ensure all staff have the training, competencies, supervision and appraisal required to provide safe care.
Regulation 12(1)(2)(a)(b)(c): Safe care and treatment
The service did not provide mandatory training in key skills to all staff and make sure everyone completed it. Managers did not maintain or have access to complete records of training delivered to staff which meant the service could not provide assurance that all staff had the training required to …
Must Do
Safe
The service must implement effective processes to safeguard patients from the risk of improper treatment and/or abuse.
Regulation 13(1)(2)(3)(4)(b): Safeguarding service users from abuse and improper treatment
The service had not implemented effective processes to safeguard service users from the risk of improper treatment and/or abuse. The provider had a safeguarding policy although this was not fit for purpose because it did not provide clear guidance and expectations of the process staff were expected to follow to …
Must Do
Safe
The service must evidence that staff have received the required training in safeguarding to recognise and respond to the risk of abuse and keep service users safe from harm or the risk of harm.
Regulation 13(1)(2)(3): Safeguarding service users from abuse and improper treatment
None of the staff, including managers at the service location, had received training in safeguarding adults or children at level 3 or above. There was no evidence that all staff had received the required training in safeguarding to recognise and respond to the risk of abuse, and keep service users …
Must Do
Safe
The service must ensure that all staff have a valid Disclosure and Barring Service (DBS) check prior to working with vulnerable individuals.
Regulation 13(1)(2)(3): Safeguarding service users from abuse and improper treatment
We saw a member of staff working prior to receiving DBS clearance.
Must Do
Safe
The service must have a clear understanding of who their safeguarding lead is and have a clear process to report safeguarding concerns to external agencies including local authorities and CQC.
Regulation 13(1)(2)(3): Safeguarding service users from abuse and improper treatment
Managers we spoke with did not know who the provider’s safeguarding lead was and were unsure who was undertaking the roles since the last lead had left the service. The service did not have clear processes to report safeguarding concerns to external agencies including local authorities and CQC.
Must Do
Effective
The service must ensure that patients transferring on longer journeys are provided with adequate hydration.
Regulation 14(1): Meeting nutritional and hydration needs
Journeys were not planned or carried out with consideration of patient’s hydration, food and toileting needs particularly where journey times might be long. Managers told us that drinks were not provided.
Must Do
Well-led
The service must have effective governance and systems and processes to identify, assess, record, manage and mitigate risks in the delivery of the service.
Regulation 17(1)(2)(a)(b): Good Governance
The service did not have effective governance and systems and processes to identify, assess, record, manage and mitigate risks in the delivery of the service. Governance systems did not operate effectively to identify the risks found by the inspection team.
Must Do
Well-led
The service must ensure the service has clear criteria or service specification to ensure staff assess whether they are able to meet the needs to service users prior to accepting bookings.
Regulation 17(1)(2)(a)(b)Good Governance
The service did not have clear criteria or service specification to ensure staff assessed whether they were able to meet the needs of the service users prior to accepting bookings.
Must Do
Well-led
The service must maintain records of journeys to evidence patients’ risks are managed and needs are met.
Regulation 17(1)(2)(a)(b)(c): Good Governance
Staff did not keep detailed records of patients’ care. Records were not comprehensive but were stored securely. Managers had audited all of the records that were reviewed, however, the audits had not effectively identified the errors or omissions we found.
Must Do
Well-led
The service must maintain a local risk register specific to the location.
Regulation 17(1)(2)(a)(b): Good Governance
The service did not have a local risk register.
Must Do
Well-led
The service must undertake audits thoroughly and appropriately to identify gaps or omissions and take appropriate action.
Regulation 17(1)(2)(a)(b): Good Governance
The provider did not audit records appropriately to identify gaps or omissions and take appropriate action. Audits were not effective or standardised and did not identify errors or omissions in documentation.
Must Do
Well-led
The service must ensure all staff recruited by the service are fit and proper persons for their roles.
Regulation 19: Fit and proper persons employed
Four of the staff files did not have evidence showing references had been obtained for the staff prior to commencing their employment. Three staff files did not include evidence showing staff had been interviewed. Six of the staff files had no evidence of training records. Most staff files we reviewed …
Must Do
Responsive
The service must ensure that there are systems in place to inform patients how to make a formal complaint.
Regulation 16(2): Receiving and acting on complaints
The service had no clear system to inform patients how to raise a complaint. There was no signage in vehicles or complaint process on the services website.

Should-Do Actions (1)

Recommended improvements to enhance service quality.

Should Do
Responsive
The service should consider providing communication aids and access to translation services for those patients with communication difficulties or whose first language is not English.
Location Details
CQC ID: 1-10682900007
Local Authority: North Tyneside
Region: North East
Inspection Report
Type: Comprehensive inspection
Date: 10 January 2023
Rating: Inadequate
Actions: 19 must-do , 1 should-do
AI-extracted 17 Feb 2026