South East Coast Ambulance Service NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a process for learning from incidents, complaints, and patient feedback. They identified learning at individual, team and organisational levels, ensuring continuous improvement. Discussions from learning took place at various meetings across the trust’s governance structure, ensuring a continuous loop of information from the frontline to the executive board and back down to the frontline. The Emergency Operations Centre (EOC) formed part of this structure, so information flowed to and from the service.

The service investigated incidents that had resulted in harm. They had also started to investigate ‘near misses’ and incidents which had not caused actual harm. This was good practice as "no harm" events (incidents that could have caused harm but did not) are crucial for learning and improvement. The trust used the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS Englandmandated, systematic approach for responding to patient safety incidents. It shifts focus from accountability to learning, emphasizing compassionate engagement with affected families and staff, proportionate responses, and system-based investigations to improve safety. We saw the framework was referenced throughout policies related to incidents. Staff in the service knew about and understood PSIRF.

The service produced a quarterly integrated patient safety report which was presented at the quality and patient safety committee and the executive management board. Together with information from learning from deaths, complaints and patient experience questionnaires, this report provided insights to guide strategic decisions to reduce harm and mitigate risk. We reviewed 3 reports and saw incidents were grouped into themes, and gaps and actions outlined clearly. We heard from managers that patient safety incident investigations (PSIIs) and after-action reviews had improved, and the service had moved away from a ‘blame culture’.

We saw managers used PSIIs to make service improvements. The minutes from the quarterly quality and patient safety committee showed robust discussion and quality improvement plans for each incident theme identified. For example, a theme identified clinical assessments for patients with mental health conditions were not completed in a timely manner. A clinically led trial started in quarter 3 of 2025, enabling dedicated time to support the prioritising of pending dispatch calls. Early data indicated positive outcomes, and the trial was ongoing.

The service held regular meetings with the commissioner. We observed part of a meeting where incidents were discussed. SECAmb representatives showed awareness of current EOC incidents and could outline actions to the commissioners.

The service held a weekly incident review group where they reviewed patient safety information and agreed which incidents required formal investigation. The service shared learning from incidents with EOC staff through newsletters and emails.

The service had an up-to-date and comprehensive Patient Safety Incident Response policy, including information on the Duty of Candour (the NHS Duty of Candour is a legal obligation for healthcare providers to be open, honest, and transparent with patients and families when things go wrong with care). Staff and leaders understood the duty of candour. Throughout the financial year of 2024 to 2025 the Duty of Candour was a focus for improvement. By quarter 4, the trust responded to 9 out of 10 patients within their internal target of 10 days.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service used a national clinical tool called NHS Pathways to assess, triage and direct callers (this system is a series of algorithms, or pathways, that link clinical questions and care advice). Call handlers in the Emergency Operations Centre (EOC) asked callers a series of questions and provided the most appropriate clinical response; for example, dispatching an ambulance, getting a clinician to call back, or signposting to other, more suitable, services. They asked questions according to the system’s algorithms and categorised calls according to urgency. Each category had a target response time to ensure the highest risk patients would be seen as fast as possible. Staff collected key details about patients and their condition and needs and passed this information to colleagues, such as clinicians and dispatchers. In turn, dispatchers shared this information with crews on the road so that appropriate care could be given.

Call handlers accessed a directory of services (DoS) which was part of NHS Pathways. Once patients had gone through the triage, the DoS provided information about where they should go next, for example, an urgent treatment centre or their GP.

EOC clinical staff had access to electronic external healthcare information; for example, they could review patients’ GP information and mental health histories. We saw clinical staff regularly accessed external patient information to determine what level of care and treatment they needed.

Call handlers accessed support from their team leaders when needed. The call centre was divided into several smaller pods. Each pod had 6 call handlers and one team leader. Team leaders provided immediate support during or after calls.

Each EOC had systems to cover increased service pressure within and external to the service. SECAmb shared an agreement and processes with other ambulance trusts for times of high pressure. For example, calls from other trusts could be redirected to SECAmb’s EOCs when other ambulance trusts required support. Reversely, other trusts helped SECAmb’s EOCs if they faced increased pressure on their system.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The Emergency Operations Centre (EOC) service operated within a clear trust-wide safeguarding governance structure, supported by a dedicated local safeguarding team. The team met regularly to review safeguarding incidents, themes, and emerging risks relevant to operational services, including EOC activity. They also invited external speakers to broaden understanding of safeguarding issues, demonstrating a proactive approach to developing staff awareness in response to changing risks.

We saw an up-to-date and comprehensive safeguarding policy, aligned to relevant national legislation including the Children Act 2004 and the Care Act 2014. The trust’s safeguarding training strategy clearly outlined the levels of training required for different roles, including EOC staff. Given that EOC call handlers and clinicians regularly engaged with children, vulnerable adults, and individuals in crisis via telephone triage, appropriate safeguarding training was essential to ensure staff could recognise risk factors without visual cues and escalate concerns appropriately.

Safeguarding training was delivered through a combination of face-to-face sessions and e-learning. Mandatory training data showed over 90% compliance for level 1 and level 2 safeguarding training across both clinical and non-clinical EOC staff, covering adults and children. The most recent annual safeguarding report identified that over 70% of staff had completed level 3 adult and children safeguarding training by March 2025. While this was below the trust’s expected compliance rate of 85% for 2025–2026, leaders confirmed staff were booked onto further sessions throughout the year to improve compliance.

Operationally, safeguarding processes within the EOC were embedded and consistently applied. During call listening, we saw staff recognised safeguarding concerns and acted appropriately. They had immediate access to an electronic safeguarding referral form and completed this before moving on to the next call. The electronic system automatically routed referrals to the internal safeguarding team for review and further action, including escalation to the local authority where required. Staff told us they received feedback from the safeguarding team following referrals, which supported learning and reinforced good practice.

Call handlers had access to supervisors and EOC managers for advice. During a complex call involving unmet social care needs, we observed a call handler appropriately seeking supervisory support. The supervisor advised consultation with a clinician, and the process was seamless and timely. This collaborative approach ensured the caller received appropriate advice and demonstrated effective multidisciplinary working within the EOC environment.

Staff we spoke with were able to describe safeguarding scenarios confidently and demonstrated awareness of protected characteristics under the Equality Act 2010. They knew who the safeguarding lead was and how to escalate concerns.

Safeguarding processes within the EOC were embedded, understood, and supported by accessible leadership and clear escalation pathways.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

When people called 999, call handlers in the Emergency Operations Centre (EOC) assessed them using NHS Pathways to determine what actions to take to provide the most appropriate level of care. This ranged from signposting to another service, arranging a follow-up call by a clinician, to dispatching an ambulance.

Call handlers had access to a variety of data on their screens. For example, they could see how long the current estimated wait for ambulances was, which they could explain to patients during calls. This was useful in managing expectations and reducing the number of callbacks from patients asking where the ambulance was.

The clinical pathway tool provided call handlers with strict scripts. Towards the end of a call, the script instructed call handlers to give advice to patients; for example, what to do if a patient deteriorated. Patients had the choice whether to receive this advice verbally over the telephone or through a text message. We saw most patients chose the text advice as they found it difficult to take everything in during a potentially stressful situation.

Staff responded appropriately when they recognised patient deterioration or increased risk during a call. We listened to a call in which the call handler had to start guiding a caller through cardiopulmonary resuscitation (CPR) as their friend had collapsed and was in cardiac arrest. The call handler did this calmly and until the ambulance arrived on scene. If a patient’s medical condition deteriorated during a call, call handlers would re-triage the patient and increase the call category if required.

Many patients calling 999 required a clinician callback to assess what type of response or advice they needed. SECAmb employed a variety of clinicians in both EOCs, including general clinicians (mostly with a nursing background), mental health professionals, and critical care paramedics. Although SECAmb did not employ midwives directly, they had agreements with 3 acute hospital trusts and accessed midwife support via those. The midwifery clinicians had an on-call system. Every morning midwifery staff put a message on an internal collaboration platform to let call handlers know who was on duty and what number to call.

Staff reviewed special notes and flags on the system during calls with patients. For example, we observed a mental health practitioner during a call with a patient checking previous episodes and warnings of aggressive behaviour. They passed this information to the dispatchers to help send the most appropriate crew. Special notes and flags also included information on advanced care planning

Dispatchers saw crews and vehicles available for dispatch on their screens and could choose the most appropriate team to attend to patients. They could divert crews as required; for example, if a category 1 call (category 1 relates to immediately life-threatening situations) was received, dispatchers could radio a crew closest to the patient in need even if that crew was on their way to another patient. This was to allow the quickest response time to patients in need.

Call handlers always tried to speak with patients directly. For example, if a friend or relative called 999 for help, call handlers started triage immediately to establish whether an immediate response was needed. If they had time, they asked to speak with the patient. This helped establish what help was needed; for example, call handlers could hear things like patients’ breathing, speech, and confusion.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The Emergency Operations Centre (EOC) was completely secure. Staff had access control cards to enter the EOC. Computers were password protected and staff ensured they locked their computers when they left their station. Staff kept electronic patient records, which enabled other staff to have immediate access to important information. For example, a supervisor helping a call handler had access to electronic patient records immediately. Both clinical and non-clinical staff received General Data Protection Regulation (GDPR) training. Figures showed the EOC service was compliant with this training. We witnessed several situations when staff referred to GDPR during calls. For example, a member of staff from a nearby hospital called and asked for the names of paramedics who had attended a scene as they wished to make a complaint. The call handler explained they were not able to provide this information due to GDPR regulations. GDPR is important as it gives individuals more control over their personal data, strengthens privacy rights, and holds organisations accountable for protecting data.

Each EOC site had uninterrupted power supply (UPS) generators and business continuity facilities in the event of power or IT failure. A fully equipped call and dispatch suite usually used for training became a call centre if required. This included paper-based priority boards set up and kept for any occasion when IT systems might be interrupted. Managers explained systems were regularly evaluated. If electronic systems became interrupted, all calls currently in the EOC system were automatically sent to a central printer and printed out on paper. This meant patient safety was maintained as no call was lost.

Staff ensured they kept their desks tidy. They ensured no cables got in the way of their workspace. All staff had multiple computer screens, allowing them to work through the triage tool whilst accessing other relevant information on other screens.

The service adhered to The Health and Safety at Work Act 1974 and The Health and Safety (Display Screen Equipment) Regulations. They ensured staff completed Display Screening Equipment (DSE) assessments regularly. This assessment covered computers and workstation assessments to ensure staff had suitable set ups to prevent strain and injury. We reviewed 10 sets of assessments which had been completed fully. The service ensured they put reasonable adjustments in place where necessary and had processes to monitor this. For example, cochlear implants could directly link to the computer for staff who could not use headsets. The EOCs were also set up for wheelchair users.

The provider ensured the EOCs had height adjustable desks for each member of staff. This meant staff could sit or stand and adjust their desks accordingly. Staff had ergonomic chairs to support their posture and provide maximum comfort during long periods. This was important as shifts could be 12 hours. We saw many staff worked standing up.

Each EOC provided a suitably decorated and furnished ‘quiet room’ available to staff at any time and used as part of the trust’s Trauma Risk Management (TRiM) programme and mental health first aiders. TRiM is a trauma-focused peer support systemdesigned to help people who have experienced a traumatic, or potentially traumatic, event

The service complied with testing electric appliances (every 2 years) and fire extinguishers (once a year), in line with their policy. They used external contractors to carry out these tests, and we saw data which showed testing was up to date for both EOCs.

The trust prepared for times when equipment failed, and staff knew what to do. Regular planned outages took place every 3 months to test emergency systems worked properly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Actual staffing levels within the Emergency Operations Centre (EOC) did not consistently align with planned establishment figures. We reviewed workforce data from September to November 2025 and found significant shortfalls in some key clinical roles.

Planned staffing for EOC clinicians was 98 whole time equivalent (WTE) posts. However, actual staffing was 53.2 WTE in September 2025, reducing further to 50 WTE by November 2025. This represented only 54.3% and 51.4% of the planned establishment respectively. These sustained shortfalls meant the service had the potential to operate at approximately half of its intended clinical workforce capacity during the period reviewed.However, the service worked to mitigate the risk by providing an average 33 WTEs each week by using operational and agency clinicians working in the clinical assessment service.

For EOC mental health practitioners, the planned establishment was 12 WTE. Staffing improved over the same period from 9 WTE (77% of planned levels) to 11 WTE (96% of planned levels), indicating progress towards full establishment in this role.

EOC urgent care practitioners had the most significant gap between planned and actual staffing. The service planned for 6 WTE but consistently had only 1.8 WTE in post across all 3 months, equating to 31% of the required workforce. This represented a substantial and sustained deficit in urgent care clinical capacity.

Resource dispatch coordinators also fell below planned numbers during September and October 2025, operating at 55% below establishment. This position improved by November 2025, when 10.6 WTE were in post against a planned 12 WTE. Leaders told us that recruitment in this area had been temporarily paused while a pilot role was trialled. Recruitment had since recommenced.

The service supported gaps in staffing by using operational staff in a virtual care role and by employing agency staff.

Staff told us the lack of staff increased the pressure they felt in trying to provide a timely service to patients.

The service ensured the actual staffing of EOC call handlers consistently aligned with planned staffing. We reviewed the data which showed a small gap of between 1% to 2% below planned staffing. This did not impact the service and there were always enough call handlers to take calls from the public and other professionals.

While there were signs of improvement in some areas, particularly within mental health practitioner roles, there remained significant and sustained staffing gaps within core EOC clinical functions during the period reviewed.

Some staff told us they found work difficult and stressful due to lack of staffing. We heard staff felt managers did not organise sickness or annual leave cover arrangements well. Some staff said they had been stopped from doing overtime work, which they felt could help during periods of staff shortages. We asked the service leaders to explain cover arrangements and the overtime restrictions mentioned by staff were confirmed. The provider only used overtime as a short-term measure for unexpected sickness; this was to maintain staff wellbeing and reduce costs.

Staff sickness increased from June to November 2025 and went from 5.3% to 8.4% in this period. The highest vacancy rate was 8.2% in October 2025 but reduced to 6% by November 2025. Staff turnover was consistently around 35%. These figures were in line with the national averages, which indicate EOC figures tend to be high driven by burnout, pressure and high demand.

Service leaders were aware of staffing issues and worked in various ways to try and ensure safe and effective cover arrangements for call handlers were in place. For example, the service had started a training programme for senior emergency medical advisors to equip them with the relevant skills to step up in their role and work as team leader when needed. These were non-clinical staff who helped during the initial stages of 999 calls. We saw an example of this during our inspection. The 2 EOCs supported each other in terms of staffing; for example, if one EOC had low staffing the other EOC stepped in and supported call taking and clinical support.

Staff completed mandatory training via a mixture of face-to-face and e-learning sessions. The service managed training centrally and monitored this through an online learning management system. Staff received training based on their role, scope of practice, and professional registration. Managers tracked staff training via a dashboard, which alerted both the individual and their manager when training was due. The service’s trust’s target for mandatory training was 85%. We reviewed training figures across all staff groups, and the service was compliant with this target, apart from 2 training modules. The 2 courses which did not meet the target included Infection Prevention and Control (IPC) level 1 for clinical staff members and resuscitation level 2. The service had identified an issue with their internal training material for the resuscitation course and was currently in the process of revising this to ensure it captured the necessary material. Leaders told us staff would receive this training in quarter 1 of the financial year 2026 to 2027.

The service was previously in breach of the legal regulations relating to mandatory training. Improvements at this assessment meant the service was no longer in breach of this regulation.

Staff received regular appraisals, supporting professional development and reflective practice. Appraisals provided staff with the opportunity to review their performance, identify learning needs, and agree objectives for future development. We reviewed 6 appraisals and saw staff completed them in a clear and structured manner. Appraisals included current performance and future development goals. The provider had an up-to-date appraisal policy, referencing relevant national frameworks.

The service ensured clinicians accessed clinical supervision. Clinical supervision is essential forensuring safe, effective, and ethical patient care while supporting the professional development and emotional well-being of practitioners. Staff undertook at least 4 supervision sessions a year, along with ad-hoc supervisions as and when required. Practice development leads, critical care clinical operations managers and clinical education practitioners had responsibility for supporting supervision. They ensured staff recorded supervision and acted on any outcomes. The provider had an up-to-date clinical supervision policy and procedure, referencing relevant national clinical regulators. The policy clearly outlined how the service planned to track supervision and how to measure its effectiveness. For example, they ensured supervision was part of the staff satisfaction survey and analysed staff wellbeing data.

We also heard about reverse mentoring. Reverse mentoringflips traditional mentoring by having junior staff, often fromethnic minorityorLGBTQ+backgrounds, mentor senior leaders to share their lived experiences, challenging biases, and improvingdiversity and inclusion. We heard how leaders made changes on the staff information boards to support neurodivergent staff members following reverse mentoring.

On joining SECAmb, staff received an induction tailored to their role. This included both corporate and local induction. The service’s human resources team checked professional qualifications and conducted pre-employment checks to ensure staff’s registration was active and unrestricted. We reviewed several staff records and saw all relevant checks were in place.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection.

Staff kept the Emergency Operations Centre (EOC) environment visibly clean and tidy, free of clutter. The provider had a contract with a commercial cleaning company which clearly set out cleaning requirements. The trust’s estates department monitored this contract. The department carried out regular monthly environmental audits, together with local leadership team staff, to ensure cleaning met the provider’s standards. We reviewed audits and did not identify any issues.

The provider had an up-to-date IPC policy, outlining roles and responsibilities and referencing several legal frameworks.

Staff had their own headsets. Each desk had disposable antibacterial wipes for staff to wipe down their workstations to minimise the spread of infections.

Staff recorded and accessed patients’ healthcare associated infections information on the clinical triage tool. If patients had known illnesses, such as hepatitis or COVID-19, this was flagged on the system. When healthcare professionals called 999 about a patient, staff asked about infectious disease risks. This was important information to pass to ambulance crews so they could plan for patient care appropriately. The service had an IPC team who staff contacted for advice if needed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.