1. What the regulation says
Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))
assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))
doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))
ensuring that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way, (Reg 12(2)(d) (premises safety))
ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))
Regulation 15 adds the premises-and-equipment duty that this policy operationalises:
All premises and equipment used by the service provider must be ... clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. (Reg 15(1): the six criteria)
The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/15. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations. Premises and equipment, including patient transport vehicles and the patient-handling equipment carried on them, must also be clean, secure, suitable for purpose, properly used, properly maintained and appropriately located under Regulation 15.
3. Purpose
This policy sets out how the Service keeps patient transport vehicles roadworthy, records pre-shift checks, manages defects and tracks MOT, tax, insurance and patient-handling equipment.
The Service must verify this policy against current Road Traffic Act, MOT, DVSA and CQC source material before adoption. The policy is written for non-emergency patient transport services where each job depends on a safe vehicle, suitable equipment and a crew member who knows the defect process.
4. Sources to verify before adoption
- Road Traffic Act 1988: https://www.legislation.gov.uk/ukpga/1988/52/contents
- Motor Vehicles (Tests) Regulations 1981: https://www.legislation.gov.uk/uksi/1981/1694/contents
- DVSA, guide to maintaining roadworthiness: https://www.gov.uk/government/publications/guide-to-maintaining-roadworthiness
- DVSA, guide to maintaining roadworthiness, current HTML version: https://www.gov.uk/government/publications/guide-to-maintaining-roadworthiness/guide-to-maintaining-roadworthiness-commercial-goods-and-passenger-carrying-vehicles
- GOV.UK, MOT inspection manual for cars and passenger vehicles: https://www.gov.uk/government/publications/mot-inspection-manual-for-class-3-4-5-and-7-vehicles/
- GOV.UK, check vehicle tax: https://www.gov.uk/check-vehicle-tax
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17: https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
5. Scope
This policy applies to:
- all vehicles used for patient transport, high-dependency transfer, bariatric transport and end-of-life transport
- daily pre-shift checks completed by Crew
- vehicle MOT, service, tax and insurance tracking
- patient-handling equipment carried on vehicles, including stretchers, carry chairs, wheelchair restraints, tail-lifts, ramps and oxygen fixtures
- defects identified before, during or after a job
- hired, leased, loaned or temporary replacement vehicles used by the Service
This policy does not replace the manufacturer's instructions, MOT requirements, insurance terms or any operator-licence duties that apply to the Service.
6. Vehicle roadworthiness process
The Service keeps a live vehicle register and uses it to plan, check and evidence roadworthiness.
6.1 Vehicle register
The Fleet Lead maintains a register for each vehicle.
The register records:
- registration number
- make, model and conversion type
- vehicle class and weight category
- MOT expiry date
- service schedule
- insurance cover
- vehicle excise duty status
- patient-handling equipment assigned to the vehicle
- oxygen fixture and cylinder-storage arrangement where applicable
- tail-lift, ramp and wheelchair-restraint service dates
- date removed from service and reason where applicable
The Fleet Lead checks the register before allocating a vehicle to the rota.
6.2 Pre-shift defect check
Crew complete a pre-shift vehicle check before the vehicle leaves the operating base.
The check covers:
- lights, indicators, horn and mirrors
- tyres, wheel fixings and visible damage
- windscreen, wipers and washers
- brakes, warning lights and dashboard alerts
- fuel or charge level
- cleanliness and infection prevention readiness
- stretcher, carry chair and wheelchair-restraint equipment
- tail-lift, ramp and floor tracking
- oxygen bracket, suction bracket and equipment mountings where fitted
- first-aid and emergency equipment assigned to the vehicle
- patient comfort items needed for the planned jobs
Crew record the check against the vehicle, shift, date, time and checker. The platform records the check as an assurance task. Staff record an incident only when the check fails or a defect creates a patient-safety, staff-safety or service-continuity risk.
6.3 Defect grading
The Service grades each defect before the vehicle is used.
- Critical defect: the vehicle is removed from service immediately. It is not used for patient transport until the Fleet Lead confirms repair and release.
- Major defect: the Fleet Lead decides whether the vehicle can complete any current safe movement, such as return to base or movement to repair, before further use.
- Minor defect: the Fleet Lead records the defect, sets a repair date and confirms that the vehicle remains safe for the planned job.
Crew do not override a critical defect because a job is delayed. The Operations Manager arranges a replacement vehicle, subcontracted transport where approved or a safe rebooking route.
6.4 Defect repair and release back to service
The Fleet Lead keeps a repair record for each defect.
The record includes:
- defect description
- person who identified it
- date and time reported
- photographs where helpful
- immediate action taken
- whether the vehicle was removed from service
- repair provider
- repair completion evidence
- person who authorised release back to service
The vehicle returns to service only when the Fleet Lead or delegated competent person records that the defect has been corrected or controlled.
6.5 Patient-handling equipment on vehicles
The Service treats patient-handling equipment as part of vehicle readiness.
Staff check that:
- equipment matches the vehicle and patient group
- stretchers, carry chairs, ramps and tail-lifts are within service date
- wheelchair restraints and tracking are clean, complete and functional
- bariatric equipment is available where the booking requires it
- oxygen cylinders are stored upright or secured according to the local process
- equipment defects are linked to the vehicle record and removed from use where needed
The Service does not dispatch a vehicle where essential patient-handling equipment is missing, damaged, out of service date or unsuitable for the planned patient.
7. MOT, service, insurance and tax control
The Fleet Lead keeps expiry-date control for each statutory and service record.
The Service records:
- MOT expiry date and certificate
- planned service date
- safety inspection date where the vehicle falls within the Service's local safety-inspection programme
- insurance certificate and renewal date
- vehicle excise duty status
- roadside-assistance cover where used
- driver licence category needed for the vehicle
The Service does not allocate a vehicle where MOT, insurance or tax evidence is missing, expired or uncertain. Staff use GOV.UK check routes and the Service's own records to verify the position before a vehicle is dispatched.
8. Response to an unfit vehicle dispatched
If Staff identify that a vehicle was dispatched while unfit for use, they record an incident immediately.
The Registered Manager or Fleet Lead:
- makes the patient and Crew safe
- decides whether the current journey can continue safely or must stop
- arranges replacement transport where needed
- informs the booking facility or receiving facility where the journey is affected
- removes the vehicle from service
- records the defect, decision and patient impact
- considers duty of candour where harm or possible harm occurred
- considers whether DVSA, police, insurer, commissioner or CQC notification advice is needed
- assigns improvement actions to prevent recurrence
The review checks whether the defect was visible during pre-shift check, whether records were complete and whether rota pressure affected the decision to dispatch.
The Service does not set a fixed DVSA reporting threshold in this template. The Fleet Lead checks current DVSA source material, insurance terms and commissioner terms before reporting or ruling out external notification.
9. Responsibilities
- Registered Manager: owns this policy, ensures vehicle governance is in place and signs off annual review.
- Lead Clinician: confirms that vehicle and equipment readiness supports safe patient transport and escalates clinical risk from equipment gaps.
- Fleet Lead: owns the vehicle register, MOT tracking, defect process, repair evidence, service records and release back to service.
- Operations Manager: allocates vehicles to jobs only where the register shows them as available and suitable.
- Crew: complete pre-shift checks, stop unsafe use and report defects before the vehicle leaves base where possible.
- All staff: record vehicle incidents promptly and do not pressure Crew to use a vehicle they have reported as unsafe.
10. Recording requirements
The Service keeps the following records:
- vehicle register
- pre-shift vehicle check
- defect report
- vehicle removed-from-service record
- repair record and release-back-to-service decision
- MOT certificate or check evidence
- service and safety-inspection record
- tax and insurance evidence
- patient-handling equipment service record
- incident record where a defect affects patient safety, staff safety or service delivery
- improvement action record
Records are kept in the Service governance records and are available for internal review, CQC review, commissioner review and external review where required.
11. Audit cadence
The Service uses the following Verivius default audit rhythm unless current DVSA, MOT, CQC, insurance, commissioner or local source material requires a different rhythm:
- Per vehicle, per shift: Crew complete the pre-shift defect check before dispatch. The platform records it as an assurance check and records an incident only where the check fails or a defect is identified.
- Weekly: the Fleet Lead reviews missing checks, open defects, equipment gaps and vehicles removed from service.
- Monthly: the Operations Manager checks whether vehicle allocation matched vehicle availability, crew licence category and patient equipment need.
- Annually: the Registered Manager audits the vehicle register against MOT, insurance, tax, service, defect and equipment records.
Audit findings are recorded as improvement actions with an owner and review date.
12. Version control and review date
The Service keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
13. Related records
- Vehicle register
- Daily vehicle defect check
- Equipment audit
- Incident register
- Risk register
- Improvement action register
- Insurance record
- Vehicle service file
- Patient assessment and journey-planning policy
- Transfer of care and patient handover policy
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.
14. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- Road Traffic Act 1988
- DVSA guidance, including the guide to maintaining roadworthiness
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 15: Premises and equipment
- Manufacturer maintenance and servicing guidance
- Fleet insurance requirements
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
15. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.
16. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.