Archived: Head Office

On this page

• 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patient who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, and person-centred.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant patient’s needs were met through good organisation and delivery.

We found a breach in good governance.

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 clear to staff. Staff did not always understand how their behaviours aligned with the organisational strategy.

The service did not have a written vision or values; however the organisational strategy was aligned to attaining the International Organisation for Standardisation (ISO) accreditation. The ISO set guidelines to implement consistent standards and specifications.

Staff were focused on the needs of patients receiving care and delivering a high quality of service. However, they were not aware of how their work contributed to the service achieving the strategy of attaining the ISO accreditation.

Staff felt respected, supported and valued. Staff reported the leadership culture to be inclusive and spoke about feeling valued and respected. Relationships between staff were positive, with strong teamwork and collaboration. Examples of collaborative work included, responding to staff needing a more comfortable staff area and being supported when needing to finish a shift early due to a personal emergency.

Team and individual staff achievement, and success was recognised and celebrated through the staff recognition programme and the excellence award given by the executive team. We saw evidence of positive feedback published in the new quarterly newsletter sent to staff.

Staff were thanked for their work and compliments were feedback to them directly if they were named by members of the public.

All staff had received training in Equality and Diversity, and this helped and enabled them to deliver high quality care to the community.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively.

The service was led by the registered manager, who was an experience paramedic. The registered manager has been in post since 2013. The registered manager was supported by 2 other executive directors and 5 non-executive directors. The service had recently appointed a director of operations and group clinical director to support the registered manager with operations for frontline work as well as events.

The registered manager and leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for staff. The registered manager was also the chief quality officer, ensured they were visible by working at events and visiting the Head Office base once a week for tasks such as stock reviews or cleaning. The director of operations was based at Head Office which ensured staff had access to senior management.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders undertook patient facing activities to assess for themselves how the service was running. We saw evidence of staff communications sent in response to incidents such as reminding staff of adherence to policies and colour coding medicines bags to reduce human error.

The service ensured staff’s welfare and offered psychological support. We saw evidence of Trauma Risk Management (TRiM) referrals following a potentially traumatic incident. Staff and their family could access free counselling support through a self-referral basis or through manager referral.

Staff were invited to team engagement events and were able to directly access the registered manager and other management to ask questions or make suggestions. Information was cascaded to staff via the app on mobile devices.

The service did not complete an annual staff survey. They provided us with a station improvement plan which included the plan to move the crew room upstairs to provide staff a larger space, additional amenities and the standardisation project for both the primary response bag and internal set out of vehicles across the fleet. These plans were a direct result of staff feedback which had been made in collaboration with staff.

The service acknowledged that it had limited patient feedback due to undertaking work on behalf of an NHS ambulance trust. We requested patient feedback and patient survey results for the last 12 months. We were provided with 2 feedback forms relating to event work. The service had recently updated their website to capture more patient feedback. The service did not have any examples of changes made as a result of feedback in the last 12 months.

The service engaged with an external occupational health provider to ensure that new employees were fit to work cand advised on changes in staff health and safety. We saw evidence of support offered to staff by the service to facilitate return to work after a change in health.

The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear. During our previous inspection in July 2023 some staff felt they could not raise concerns. During this inspection, staff we spoke to told us they felt comfortable to raise concerns. The service had also appointed 2 Freedom to speak up (FTSU) guardians. We saw evidence of FTSU posters in all staff areas.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices would be heard. We reviewed information which showed there had been 3 matters raised via the speaking up process in the past year. We saw evidence of action having been taken.

The local senior leadership were aware when whistleblowers had raised serious concerns and took steps to investigate and address the matters raised. Prior to the assessment the CQC had received 5 whistleblower cases relating to poor equipment stock levels, conditions of vehicles and management attitude. However, we did not find any evidence to support these concerns. The NHS ambulance trust also confirmed that they did not have any concerns regarding management or operational processes.

A risk register and management reports contained analysis of concerns over time and associated action plans.
Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Senior staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process. We reviewed 2 complaint responses, and these were responded to in line with policy. There was evidence of review of documentation, speaking with staff and review of CCTV footage to allow for a thorough investigation.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The service had clear responsibilities, roles and systems of accountability, however the service’s governance was not always effective and did not always meet regulatory requirements. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on information about risk, performance and outcomes, and shared this with others when appropriate. However, the service did not always ensure all audits were completed in line with policy. Staff did not always have an annual appraisal.

Leaders and staff were aware of their own roles and responsibilities within the service. Staff knew the scope of clinical practice that they worked within dependent upon role. The service policies were detailed and regularly reviewed, all clearly setting out responsibilities and roles. Staff acknowledged accessing and reading the policies on their electronic devices. All staff were compliant with their training. Collectively, these measures contributed to the effective delivery of care and treatment supporting the safety and wellbeing of both staff and the public.

We observed a daily Tactical Operation Centre (TOC ) meeting with senior leaders. The meeting reviewed staffing and operational needs for the day and week ahead as well as incidents in the past 24 hours. Each action from the meeting was recorded with a named designated owner for each task.

Senior leaders met monthly to discuss performance and operational performance such as incidents, internal audit data and key performance indicators identified by the NHS trust. We were unable to review governance meeting minutes as these were held virtually on Microsoft teams and were recorded. However, we did see evidence of the last 5 clinical governance meeting action trackers. These detailed the action owner, deadline alongside a description and progress made.

The service met with the NHS Ambulance trust on a weekly basis to discuss incidents and investigations as well as a monthly meeting to discuss contractual performance, safeguarding, operational and clinical updates. Feedback from the NHS Ambulance trust was positive and identified leaders were proactive and responsive. For example, they carried out a deep dive into medicines incidents because of increased medicines incident reporting and medication errors by Medicare staff. This resulted in a change of the medicine management process. The trust also undertook a yearly onsite visit; this took place in Autumn 2025. There were no concerns raised at the last visit.

Medicare performance data was analysed and discussed monthly, and where improvements were needed, action plans were developed to identify and improve the service. For example, there was an increase in vehicle breakdown and defects reported. The service carried out a deep dive and made changes to ensure the replacement of brake pads was within 6 months to avoid unnecessary delays.

The service was also undertaking an International Organisation for Standardisation accreditation to provide themselves with assurance around their quality management, safety, and efficiency. The internal ISO integrated management review action tracker showed that 5 tasks were overdue. We were told that progress was being made against this and would be reviewed at the next audit visit.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure.

Leaders were not submitting statutory notifications following notifiable incidents. We reviewed incidents, safeguarding referrals and number of deaths of patients whilst receiving regulated activity by Medicare crew. We found that the service had not notified the CQC of the 48 deaths since April 2024, although it is acknowledged that these were reported to the NHS ambulance trust who would in turn notify the CQC through their reporting of the same incident. The service sent these retrospectively following our assessment in line with their conditions of registration.

Audit processes and the outcomes were used to ensure quality of services was maximised. However, audit data reviewed showed that some audits were not always completed in line with policy, such as staff IPC audits, hand hygiene and uniform audits.

There were some shortfalls in oversight from senior leaders identified during the assessment in relation to accurate record keeping and governance. For example, deep cleaning paper records did not align with digital records and the frequency of these cleans was not always in line with policy. Staff did not always follow the linen policy, by using hospital linen. However, leaders did not take any action to address the non-compliance.

During our last assessment we found that staff did not always have an annual appraisal. During this assessment there was a completion rate of 81% of all staff, with the lowest percentage for Paramedic staff. Senior leaders provided an update on action taken to address the repeated breach. Following the assessment, further appraisals had been carried out and dates were confirmed for those that were outstanding bringing compliance to 90%.

Leaders made sure that accurate information was discussed and shared with key staff. For example, monthly performance information was sent to all staff via the app on their mobile devices. Some staff did tell us that it could be difficult to find time to read all the information shared due to shifts being busy and working patterns.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution. We saw evidence of action taken to mitigate risk such as storing vehicles in another building. We also saw evidence of identifying risks to be added to the risk register discussed within monthly governance meetings.
The service had a business continuity plan detailing processes that would be put into place should an event have an adverse effect on the service provided. For example, serious weather conditions, loss of technology and communication systems.

There was digital leadership oversight of governance such as audit, training and professional registration. Systems were built in to prevent staff who were non-complaint working. This ensured that the service had a centralised, real time and visual dashboard for monitoring key performance across clinical and operation domains.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patient. Staff share information and learning with partners and collaborate for improvement.

We observed staff collaborating in good partnership working with primary care healthcare professionals and staff within the Accident & Emergency department to achieve the best possible outcomes for the patients that they were treating sharing information to help with ongoing care and treatment.

The service regularly engaged with the NHS ambulance service that commissioned their services. We reviewed the last regulated provider governance inspection visit report for the Head office location in Chelmsford carried out in July 2025. We found that the service had completed actions identified following the visit by their NHS ambulance provider. For example, the CQC rating was not displayed, during our onsite visit we saw this displayed.

Leaders engaged with external agencies to support staff such as occupational health provider, employee assist for mental health support as well as unions to ensure fair representation for disciplinary processes.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged to contribute to changes made to the service.

Staff were committed to continually learn and improve service. We saw evidence of refresher training and clinical supervision carried out in response to incidents.

The service had a station improvement plan which was focused on both clinical and operational needs of the service. For example, there was a strong focus on addressing medicine related errors which resulted in a change in medicines management processes. The service had also employed a group clinical director that worked closely with the education director to ensure that training for staff was adequate to meet the needs of the roles they were carrying out.

The service, where possible interlinked their policies to align with their NHS ambulance provider to ensure processes were aligned when delivering frontline services.

We saw evidence of the development of a clinical debrief document to formally capture actions and learning outcomes following a serious incident.