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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.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had a stated vision: to be one of the best independent ambulance services in the Northeast of England, delivering high-quality patient care and value for money through dedicated and fully trained staff. It also aimed to be an easy provider to work with and to build long-term relationships with customers and suppliers.

The service had five core values:
• Care – treating patients and staff as the service’s greatest asset
• Respect – regarding each other with respect
• Quality – striving for excellence in all areas
• Confidence – being fair, honest, open, and keeping commitments
• Improve – promoting continual learning and service monitoring

Although the service had a stated mission and set of values, it was unclear how these were achievable in practice. There was no supporting strategy or organisational goals to guide implementation. Staff were not aware of the mission or values, and there were no measurable objectives to demonstrate how managers and staff would enact them.

Not all leaders understood the context in which the service delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service had four directors, two of whom were not actively involved in the operational running of the service. Of the two remaining directors, one was the CQC registered manager (RM) and the other the nominated individual (NI). Non-emergency patient transport service and mental health transport were overseen by a team leader and an office manager.

While staff were aware of these individuals, staff raised concerns that these leaders were not consistently visible or approachable.

People did not feel they could speak up and that their voice would be heard.

The service did not have a Freedom to Speak Up Policy (FTSU policy) or process to support staff to raise concerns.

The service had a whistleblowing policy; however, this consisted of a single page and stated only that staff could raise concerns if they accessed or came into contact with confidential information. The policy advised that concerns should be raised with a line manager, or if that was not appropriate, with a director. However, the policy did not define whistleblowing or explain how concerns would be investigated, nor did it specify any timescales for the process. Additionally, it lacked guidance on employee support and did not signpost to any external agencies.

Staff told us they had witnessed colleagues raising concerns and incidents, only to face disciplinary action or suspension as a result.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Equality, Diversity, and Inclusion (EDI) training was completed by both team leaders and mental health advocates. Other staff members did not undertake EDI training, in accordance with the service’s training policy.

Staff were able to work flexibly. For example, most mental health ambulance staff were retired members of the police force who worked solely on a flexible basis.

We found limited evidence that the service fostered an inclusive culture. There was no clear process for staff to raise EDI related concerns confidentiality.

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 securely with others when appropriate.

We reviewed the provider’s risk register, which listed 15 risks with associated solutions. The document was generic, not specific to the service, and did not function as an active or dynamic risk register. It lacked key governance elements, including review dates, risk ratings, named risk owners, mitigations, and clear escalation pathways. There was no evidence that risks were routinely reviewed, updated, or informed by incidents, complaints, or operational learning. As a result, leaders did not have effective oversight of the risks affecting the service or assurance that appropriate actions were being taken to manage and reduce them.

We also reviewed the monthly management meeting agenda notes from May to August 2025. The agenda focused predominantly on day‑to‑day operational matters, such as vehicle repairs, credit card receipts, recruitment interviews, and enquiries about external training. There was no evidence that key areas, including safety, quality, or regulatory compliance were discussed or subject to structured oversight to ensure ongoing compliance.

In addition, several policies were not fit for purpose and did not accurately reflect the services provided. Many contained incorrect or outdated references consistent with content having been adapted from externally sourced material or from other organisations without being adapted to the service or its regulated activities.

Some policies referred to job titles that did not exist within the organisation or used inconsistent terminology. Many were not evidence‑based and lacked references to relevant legislation or national guidance. There were no clear arrangements for policy governance, and little evidence that their effectiveness or compliance was being monitored or reviewed.

Audit activity was limited and did not demonstrate an effective governance approach. The service did not have a structured audit programme, and there was no evidence that routine audits were being carried out to monitor safety, quality, or regulatory compliance. This meant leaders did not have reliable assurance that standards were being met or that identified issues were being addressed in a timely and effective manner.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service had developed relationships with the local NHS trust and with NHS mental health trusts in the region; however, we did not see evidence that these relationships were being used effectively to support meaningful collaboration.

Although operational staff described informal contact with hospital teams, there was no evidence of a structured programme of partnership meetings involving the senior leadership team. We did not see minutes, action logs, or agreed workplans that demonstrated leaders were working jointly with system partners.

NHS partners provided many positive comments about operational staff, praising their expertise, experience, and the support they had offered.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The service did not have a quality improvement plan or any documented improvement objectives or goals.

There was no evidence of learning being used to promote change in practise. We requested examples through a data request following assessment; the provider did not supply any evidence in response.