South East Coast Ambulance Service NHS Foundation Trust

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 people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We assessed a total of 7 quality statements from this key question.

At the last inspection we rated this key question requires improvement.

At this inspection the rating has remained as requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found 1 breach of regulation in this key question, in relation to good governance. Providers must ensure that their governance systems were effective for oversight and decision making.

This service scored 61 (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 a clear vision and improving culture supported by strong organisational values, and staff were proud of the care they delivered. Staff generally aligned with this shared direction. However, uncertainty around ongoing structural changes, perceived limited staff involvement in decision-making, and inconsistent experiences of behaviour and cultural issues meant the shared direction and culture was not yet fully embedded across the organisation.

Staff across the organisation demonstrated a clear understanding of, and commitment to, the trust’s vision to transform patient care by delivering prompt, standardised emergency responses and providing seamless, accessible virtual services for non-emergency patients. This vision, alongside the purpose of saving lives and serving communities, was supported by the trust’s strategic aims and core values of kindness, courage and integrity.

Since the last inspection, the trust had undergone significant organisational change, including an executive leadership restructure, the development of a transformation programme, and the introduction of a new trust strategy covering 2024–2029. The trust had also adopted a new divisional operating model, establishing three semi-autonomous divisions—Surrey, Sussex and Kent. This approach was intended to strengthen system alignment and enable services to better meet the needs of local populations and to give greater decision-making to the divisions.

Staff working in the emergency and urgent care service generally welcomed the direction of travel and supported the changes introduced. However, many reported continued uncertainty as divisional structures were not yet fully in place. Staff told us they were unsure how the new arrangements would affect their roles or how services would function operationally once the model was fully implemented.

Results from the 2024 staff survey, which had a response rate of 67%, indicated that only 28% of staff felt involved in decisions that affected their team or department, and 30% felt able to make improvements within their area of work. Staff we spoke with echoed these findings, describing a perceived disconnect between senior leadership and frontline teams. They reported examples of decisions being made without meaningful consultation, initiatives starting but not being followed through or communicated, and instances where staff felt their feedback had been sought but ultimately disregarded.

Engagement activity was undertaken across the service in relation to the operations restructure. Colleagues had been offered multiple structured opportunities to engage in and contribute to discussions, delivered through a range of formats across divisions and staff groups. The service advised that feedback had been captured and used to inform subsequent design and implementation activity.

The trust remained committed to addressing bullying and harassment, issues that had been highlighted in previous inspections. Staff reported that the organisational culture had improved in recent years, supported by education on appropriate behaviours and greater willingness to challenge poor conduct. However, views among operational staff were mixed; while some told us they had not seen any incidents, others reported that bullying and harassment continued to occur at various levels. Staff survey data showed a downward trend in reports of bullying, harassment or abuse from managers, decreasing from 22% in 2022 to 15% in 2023 and 12% in 2024. A similar reduction was seen in reports involving colleagues, decreasing from 22% in 2022 to 19% in 2023 and 16% in 2024.

Sexual safety remained a national concern across ambulance trusts. The trust had signed the NHS Sexual Safety Charter and implemented its own charter, reinforcing a zero-tolerance approach to sexual misconduct. Staff had access to relevant policies, training, and reporting mechanisms. Although experiences and perceptions varied among staff, the 2024 staff survey showed that 8% reported experiencing unwanted behaviour of a sexual nature in the workplace, a slight improvement from 2023. When benchmarked against other ambulance trusts, this represented the best score in the sector.

Overall, staff expressed pride in working for the trust, in wearing the uniform, and in the care they delivered. The 2024 staff survey showed that 50% of staff would recommend the organisation as a place to work, an improvement from 31% in 2022 and 44% in 2023.

Leaders at the operational frontline were viewed positively as supportive, accessible, capable, compassionate, and inclusive. While there was increased visibility and engagement from senior leaders, some staff perceptions felt disconnected from senior leadership at times.

At the time of inspection, the trust was in a period of organisational transformation, moving from previous operating arrangements to a new divisional model. This model was still embedding, with new divisional leadership roles recently appointed and structural arrangements continuing to develop.

The operational service was led by the chief operating officer, and they were supported by the 3 new divisional directors of operations for each of the areas, Surrey, Sussex and Kent. Each of the divisions was split into operating units, with these units headed up by an operations unit manager (OUM), who had day-to-day responsibility for operations in their units. Operating units were further split into hubs or ambulance stations, for example Banstead and Chertsey make ready centres made up one operating unit. OUMs were supported by operations managers (OMs). Within each operating unit were operational frontline teams, the number dependent on the size of the area it covered. Each operational frontline team was managed by an operational team leader (OTL) and were responsible for the day-to-day smooth running of their team, ensuring operational readiness, clinical excellence, and staff well-being, especially in critical incident scenarios.

The organisation had employed a chief paramedic in July 2024, and along with the chief nurse and chief medical officer, had responsibility for setting clinical standards, ensuring the capability of the clinical workforce, and evaluating the quality of clinical care.

The trust had implemented a structured, organisation‑wide engagement framework, intended to increase senior leadership visibility and staff involvement during the period of organisational transition. This included executive-led visits, divisional engagement forums, and mechanisms to support frontline staff’s involvement in strategic discussions and to help connect with staff. Engagement activity was documented to evidence staff engagement. However, despite the engagement activity, staff experience of senior leadership visibility and inclusion was inconsistent. While some staff reported positive engagement with senior leaders, others said they were not aware of these opportunities or did not feel involved. Some staff remained unclear how the new divisional structures would deliver consistency, operational efficiency, clinical quality, staff wellbeing, and the systematic sharing of best practice. To help address these uncertainties, the new divisional directors had had begun hosting monthly virtual sessions to share information with staff.

Operational frontline teams consistently spoke highly of their operational team leaders, OMs and OUMs, describing them as present, supportive, inclusive and accessible. However, views were more mixed regarding management beyond this level, with significantly more negative views. Some staff reported limited visibility of senior managers, inconsistent support, and a lack of meaningful involvement in decisions that affected their work, which contributed to feelings of being disconnected with higher-level leadership.

Some operational team leaders (OTLs) told us they received no formal management training in preparation for the position, and that they developed their skills through operational exposure. However, the trust told us a range of leadership and management development courses were available to OTLs, including a mandatory 'fundamentals of management training' course. We were not provided with a breakdown of how many OTLs had attended these courses to date. OTL training had been added to the risk register as some areas were not receiving the required training. The service also reported that it had initiated a pilot new managers induction programme, with the first cohort of 8 participants commencing in September 2025. In addition, a pilot programme focused on leading effective appraisal conversations was planned.

The service had established Freedom to Speak Up arrangements with increased staff confidence to raise concerns. However, not all staff felt assured that action would be taken indicating further improvement was needed to strengthen trust and outcomes.

The service recognised the importance of fostering a speaking up culture where staff felt able to raise concerns without fear of blame or detriment. Leaders continued to develop this culture to support patient safety, quality of care and staff well-being, including psychological safety. Staff had access to a range of formal speaking up routes, including HR, union representatives, incident reporting, the whistleblowing hotline and the Freedom to Speak Up Guardian. Informal routes were also available, such as a dedicated whiteboard in crew rooms to encourage open discussion.

The service had established effective Freedom to Speak Up (FTSU) arrangements, with a Freedom to Speak Up Guardian and two deputy guardians in post. Information on how to contact the guardian was accessible via the staff intranet. The trust also maintained a network of FTSU champions across the organisation, including within the emergency and urgent care service. These champions helped raise awareness of the importance of speaking up, acted as points of contact for staff and provided initial support to colleagues wishing to raise concerns. The champion role was voluntary and carried out alongside their substantive duties.

Staff told us they would raise issues with their line managers, especially the operational team leaders, as they would be confident they would be listened to, which demonstrated a trust in local leadership. The service had introduced learning and listening reviews, which staff reported helped ensure concerns were taken seriously and used as opportunities for improvement. Staff members were aware of the FTSUG service and knew how to raise a concern through that route if they needed to.

Between April 2024 and March 2025 there had been 136 contacts to the FTSUG from the emergency and urgent care service, which related to 46% of all contacts to the service. These focused mainly on relationships/behaviours (25%), system processes (19%), and leadership concerns (18%) within the service. The trends reflected broader organisational factors rather than isolated issues within individual operating units. The freedom to speak up team were liaising with the newly appointed divisional directors of operations to explore emerging themes and key issues, and address barriers to speaking up.

The 2024 staff survey showed continued improvement in the speaking up culture, with 58% of staff feeling safe to raise concerns, up from 53% in 2023 and 45% in 2022. Confidence that the organisation would act on concerns also increased, with 41% of staff believing their issues would be addressed, compared with 35% in 2023 and 27% in 2022. While this showed a positive upward trend, leaders recognised there was further work to do to strengthen staff confidence. These results were in line with other ambulance organisations when benchmarked.

The service demonstrated an improving trajectory, with increasing numbers of staff reporting that they felt safe to speak up. However, this was not yet fully embedded, as just over half of staff felt safe to raise concerns and fewer than half believed action would be taken. In addition, recurring themes relating to relationships, leadership, and system processes indicated that some cultural and organisational challenges remained.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust was committed to creating a workforce where equality, diversity and inclusion (EDI) was embedded. The trust had an equality, diversity and inclusion (EDI) action plan with 4 areas off focus, staff networks to empowering staff voice and enabling employees to shape future services, inclusive recruitment to ensure a representative, accessible workforce rooted in local communities, staff development to personalised career support, retention and structured development for all staff and data insights to ensure there was data-driven workforce planning, culture change and accountability.

The service workforce broadly aligned with the demographics of the SECAmb footprint in relation to gender. However, the service was underrepresented by those whose ethnicity was not white. The service had acknowledged this and was going to use the EDI action plan to address.

The trust had established staff forums to provide safe and inclusive spaces where employees could share experiences, raise concerns, and contribute to equality, diversity, and inclusion (EDI) initiatives. These forums also served to raise awareness of EDI priorities, advise on related policies, and ensure diverse perspectives were considered in decision-making. The trust’s staff networks included disabilities, neurodiversity and carers; cultural diversity and faith; pride; gender equality; and armed forces and veterans. Each network had both an executive and non-executive sponsor, giving them direct access to the Trust Board. Network chairs were allocated 15 hours per month to carry out their responsibilities, and each network received a dedicated budget to support activities and events. Staff in the Emergency and Urgent Care Service actively contributed to these forums and networks, reporting that they provided a valuable platform to have their voices heard.

All new or significantly revised policies and procedures produced by the service were required to undergo an equality analysis to ensure compliance with the trust’s obligations under the equality act.

The service had seen an increase in younger female staff, with 57% of the urgency and emergency service being female. The gender equality network was reviewing the representation of women in senior leadership, noting a gap at Band 7 and above. In response, an aspiring women leaders network was established in July 2025 to provide coaching and mentoring, host networking evenings to build professional relationships, and offer informal conferences. These initiatives aimed to support and encourage the growth and development of frontline and first-line women leaders.

The newer-style hubs included a range of facilities to support inclusion, such as dedicated spaces for breastfeeding mothers to express milk, prayer rooms, and quiet rooms for reflection. However, some of the older stations found it more difficult to provide these amenities. At one site, for example, blinds had been fitted to an office window so that mothers could use the room to express milk, but they were required to request that managers vacate the space before it could be used.

The 2024 Workforce Race Equality Standard (WRES) results showed that 23% of white staff and 19% of staff from all other ethnic groups had experienced harassment, bullying or abuse from other staff in the past 12 months. This reflected a continuing downward trend for both groups. Among white staff, the figures have decreased from 26% in 2023 and 32% in 2022, while reports from minority ethnic staff had fallen from 25% in 2023 and 39% in 2022. These results demonstrated a strong and sustained reduction in staff-on-staff harassment, with the most significant improvements seen among minority ethnic staff. However, the service recognised that the levels remain sufficiently high to require ongoing attention and continued cultural improvement.

Nearly half of white staff (47%) and just over two-fifths of staff from all other ethnic groups (41%) believed the organisation provided equal opportunities for career progression or promotion. This reflects an improving trend over time, with positive perceptions among white staff increasing from 43% in 2023 and 37% in 2022, and among staff from other ethnic groups rising from 40% in 2023 and 30% in 2022. While the data indicate a sustained positive shift, particularly for minority ethnic staff, overall confidence remained low, and some inequality continued to be experienced.

The 2024 Workforce Disability Equality Standard (WDES) results show that 21% of staff with a long-term condition or illness reported experiencing harassment, bullying or abuse from a manager or colleague in the past 12 months, compared with 11% of staff without a long-term condition. This reflects an improving trend for both groups. Among staff with a long-term condition, reports of harassment have decreased from 23% in 2023 and 29% in 2022, while for staff without a long-term condition the figures have reduced from 14% in 2023 and 18% in 2022.

The service had a revised governance framework in place following a divisional restructure. The process of implementation had not yet achieved full consistency or reliability across all operational areas. In addition, variations in governance processes, gaps in assurance, and weaknesses in data and information integrity reduced confidence in oversight and decision-making.

The trust had a governance framework, a system of rules, procedures and responsibilities that guided the organisation’s operations, to ensure accountability and continuous improvement across clinical, corporate, staff and financial performance, and the service contributed to this.

The governance structure, due to the divisional restructure of the organisation, had been reviewed and revised, with a new structure launching in June 2025. Reviews of the new governance structure were scheduled at fixed time points to assess effectiveness and if any changes were needed. We were told prior to the restructure there had been a disconnect between corporate and operational services, and that the revised structure was intended to address this. Under the new model, each division had a designated quality lead and clinical lead, with responsibility for ensuring effective escalation from operational services to corporate governance, thereby reducing the previous disconnect.

In the new governance framework, there were schedule of meetings that occurred in the divisions, for example weekly divisional management group (DMG) meetings, and a monthly divisional governance group (DGG) meeting. We were told these meetings had terms of reference, a core membership and a standard agenda to ensure consistency across the divisions. However, on review of meeting minutes from all 3 divisions, this standardisation was not evident. Meeting templates and agendas varied between divisions, and it was unclear whether the same information was being discussed and reviewed consistently across the service.

Each division produced a monthly DGG chair’s report derived from meeting minutes. These reports used a standardised template across all three divisions and included sections for actions, decisions and escalations. However, from the minutes reviewed, it was often unclear who was accountable for specific actions, what the expected timescales were, and where issues were being escalated to within the wider governance structure.

The divisional DGG meetings fed into the Quality and Clinical Governance Group, alongside other governance forums such as the Medicines Governance Meeting. Divisional DMG meetings fed into the Senior Management Group, and both routes provided assurance directly to the Trust Board. While this structure was described, review of meeting documentation did not clearly demonstrate how information was systematically cascaded up or down the governance framework. In addition, it was unclear how information from the divisions was made comparable, or how learning and decisions were shared across divisions to support consistent operational practice, patient safety, oversight and accountability.

Operational unit managers (OUMs) and operational managers (OMs) held meetings with their teams across the footprint. Staff welcomed these meetings as a valuable opportunity to communicate with managers, share information, and learn from one another. It was unclear whether these meetings were formally minuted or followed a set agenda, which may affect consistency and the ability to track actions or outcomes.

Governance arrangements were not sufficiently effective to provide timely oversight or assurance of workforce compliance with mandatory training and appraisal requirements. Performance information available at the time of inspection did not provide an accurate or up‑to‑date picture of compliance, due to reliance on manual data uploads, system limitations, and the absence of clear interim monitoring arrangements.

The service had systems and processes in place to identify, assess and manage risks. Staff followed the trust’s risk management policy, which set out clear processes for risk ownership, review and escalation. Risks were recorded on a local risk register, with guidance in place for escalation to the corporate risk register where risks had a wider organisational impact. The operations directorate senior management team (SLT) had oversight of risks, with a standing agenda item at monthly meetings to review the risk register and discuss risks across divisions. This provided an opportunity for shared learning and consideration of risks that may require escalation. Risks identified as requiring escalation were referred to the Risk Assurance Group, a sub-committee of the Board, for further scrutiny and oversight. Under the new divisional structure, risk management responsibilities were intended to sit at divisional level, with oversight provided through review at the operations directorate SLT meeting. Divisional risk dashboards for Surrey, Sussex and Kent were in the process of being developed to support this approach. However, at the time of inspection, these arrangements were not yet embedded. The SLT monthly meeting remained the primary forum for the identification, review and management of risks, indicating that the transition to a fully devolved divisional risk management model was still in progress.

There was limited assurance regarding the governance processes for decision-making within the service. We were told that some operational decisions had been made without appropriate due diligence or adherence to agreed governance processes. For example, the decision to suspend vehicle deep cleaning due to operational pressures in December 2024, and the implementation of autoclear processes for crews at emergency departments. The service acknowledged that no formal risk assessment had been undertaken prior to implementing the change to the vehicle cleaning regime,and quality impact assessment documentation was incomplete. There was limited evidence to demonstrate where the decision was discussed or reviewed within formal governance structures, including the decision to move from a temporary pause in deep cleans to a permanent change in policy. In addition, it was unclear how significant operational decisions were communicated across the organisation. For example, at the time of inspection, the trust’s public-facing website continued to state that 100% of vehicles were deep cleaned every six weeks and stripped of equipment and furniture for cleaning. In practice, the organisation had ceased deep-cleaning vehicles for approximately ten months prior to the inspection. This discrepancy raised concerns about the effectiveness of governance processes, including oversight, assurance and communication.

Although restraint was recorded within electronic patient care records and associated systems, there was no effective mechanism to ensure that this information was consistently visible or routinely brought together for oversight purposes. The service did not receive automatic notification when restraint had been used, and information was therefore not systematically collated, reviewed, or analysed at a service level. As a result, oversight of restraint practice was limited and largely dependent on retrospective, case-by-case review rather than proactive monitoring. This meant the service could not be assured that restraint was always appropriate, that less restrictive options had been consistently considered or attempted, or that practice was reliably compliant with the Mental Capacity Act 2005. The fragmented nature of recording across multiple systems also constrained the ability to identify trends, support organisational learning, and provide readily accessible evidence in the event of a complaint or legal challenge. Following the inspection, when asked to provide data on the use of clinical soft restraint in the six months prior to inspection, the service was unable to readily produce this information in a consolidated format, indicating limitations in how restraint data was categorised, extracted, and analysed for governance purposes.

The service understood their duty to collaborate and work in partnership, so their services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service had positive and collaborative relationships with external partners, which supported effective care provision, service development and joined-up working. Stakeholder engagement varied across divisions according to local needs and challenges, and the service tailored its partnerships accordingly. For example, teams in Sussex and Kent worked closely with the Coastguard due to their coastal geography, whereas teams in landlocked Surrey did not. While this variation was appropriate to local context, the service recognised that greater consistency and shared learning could further strengthen partnership working across all divisions. The planned divisional care model was expected to support this.

The service was actively represented at Integrated Care Board (ICB) meetings for emergency and urgent care, working with system partners to build a shared understanding of pressures within the wider health and care system. Together, they worked to meet population health needs, improve patient outcomes, reduce system pressures, and ensure equitable access to emergency healthcare.

The service also collaborated closely with local acute hospital trusts to help alleviate pressure on emergency departments. Successful joint work, particularly in Kent, had contributed to significantly improved ambulance handover times, with under-15-minute handovers achieved over the past two years. This meant ambulances were no longer queueing outside hospitals and could return to the community more quickly, supporting overall service responsiveness.

The service was represented at a range of multi-agency meetings aimed at ensuring vulnerable people received the right support from the appropriate emergency services. This included frequent attender meetings and the frailty and adult complex care steering group. The service also maintained strong working relationships with local police and fire services, collaborating regularly to ensure coordinated, efficient responses to incidents and sharing resources and expertise where appropriate.

Looking ahead, the service planned to strengthen its relationship with local communities through a five-year patient and public engagement strategy, which launched in June 2025, to foster stronger community connections and ensure services continued to meet local needs.

The service focussed on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service used quality improvement projects (QIPs) as a structured approach to identify areas for development, implement change, and measure the impact of interventions, supporting continuous learning, improvement and innovation. The Quality Improvement (QI) team worked closely with frontline staff, providing QI training, helping identify local improvement opportunities and supporting teams to implement their ideas. The Trust also had a network of QI Ambassadors who acted as a link between frontline staff and the QI team, promoting awareness, understanding and uptake of QI methodology. There were 22 QI Ambassadors across the Trust, including several within the Emergency and Urgent Care team.

In September 2024, the QI team launched the Innovators’ Den, giving staff an opportunity to present innovative ideas aimed at improving quality, enhancing patient care and identifying cost-effective ways to deliver services. One notable success was the e-bike initiative, which enabled community first responders to reach patients in remote or difficult-to-access locations more quickly than traditional ambulance vehicles, improving response times and patient outcomes.

The service had trained its advanced paramedic practitioners (APPs) to undertake pre-hospital lung ultrasounds, enhancing their ability to differentiate between respiratory pathologies when attending incidents. This improved diagnostic accuracy supported better decision-making about which conditions could be safely managed in the community. It also helped to direct patients to the most appropriate care pathway at the earliest opportunity, improving access and reducing unnecessary conveyance to hospital.

The infection prevention and control (IPC) team had developed an interactive digital tool accessible on staff work phones, providing real-time, evidence-based IPC information whenever needed. The tool enabled clinicians to instantly access up-to-date guidance on personal protective equipment (PPE), decontamination, risk assessments and IPC procedures, with content updated live to ensure accuracy. The app significantly improved staff engagement, with usage increasing by 200% compared with previous methods, and supported safer practice by making essential IPC guidance readily available at the point of care.

There was an active research and development team within the trust, which played an important role in supporting the delivery of safe, effective and evidence-based care. The team evaluated new clinical practices, contributed to national research programmes and ensured staff had access to the most up-to-date evidence. This supported continuous learning and innovation, strengthened partnerships with academic and system partners, and helped the service understand emerging population needs to improve patient outcomes. Staff in the emergency and urgent care team were involved in a number of the ongoing research projects, including work on ambulance clinicians’ decision-making in older adults with head injuries and a pre-hospital randomised trial comparing medication routes in out-of-hospital cardiac arrest.