- SERVICE PROVIDER
South Central Ambulance Service NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 19 December 2025 assessment
Contents
Ratings - Emergency and urgent care
Our view of the service
Date of assessment: 07 May – 08 May 2025
We carried out this assessment to assess if improvements had been made since the last inspection in April 2022 when the emergency and urgent care service was rated as inadequate. We assessed 32 quality statements across the safe, effective, caring, responsive and well-led key questions. We found the quality of care had improved however there were still areas where improvement was needed.
At the last inspection there were trust-wide breaches of regulation in relation to:-
Safe care and treatment, safeguarding, governance, staffing and duty of candour.
In addition, at the emergency urgent care service level there were actions the service should consider improving before they became a breach in regulation. These included the storage of medicines, shortfalls in infection, prevention and control, skill mix of ambulance crews, the completion of adverse incidents, clinical support and supervision of newly qualified staff.
At this assessment, trust-wide improvements were found, and the emergency and urgent care service was no longer in breach of safeguarding and duty of candour.
However, the emergency and urgent care service was still in breach of 3 regulations in relation to safe care and treatment, governance and staffing.
At this assessment, we found that the emergency and urgent care service was still needing to embed a positive learning safety culture based on openness and honesty, where events were investigated, and learning was shared to promote good practice and continuous improvement. Staff still did not always receive effective support, supervision and development. Clinical oversight within the service was not consistently assured.There were continued concerns regarding the storage and oversight of medicine management. This posed a risk to patient safety and compromised the quality of care. Due to high demand and operational pressures, patients did not always have access to care and treatment when they needed it. Measures to ensure equity in experience and outcome were yet to be delivered and there were gaps in end-of-life oversight in the service. We found there was still a disconnect between frontline staff and senior leaders and staff did not always feel respected, supported and valued. There was an improving culture but in some parts of the service, morale continued to be low. There was a lack of understanding regarding the structures or processes to ensure effective clinical governance, supervision, and accountability across the service. Roles and responsibilities were not always clear, and governance processes were not always understood including risk management.
However, there were now established safe systems of care in which safety was monitored and assured. Staff assessed risks to patients, acted on them and kept good care records. Staff had effective and embedded understanding in how to protect patients from abuse. The environment was safe and well maintained, equipment, facilities and technology supported the delivery of safe care. The service had improved standards of infection prevention and control and there were enough qualified, skilled and experienced people who worked together effectively, to provide safe care. We found the service planned and delivered people’s care and treatment in line with legislation and current evidence-based good practice and standards. The service worked effectively across teams and services to support people. Electronic systems were used successfully to share patients’ assessment of needs when they moved between different services. People’s care and treatment were routinely monitored to continuously improve it. Outcomes were mainly positive and consistent and mostly met both clinical expectations and the expectations of people themselves. We found the service treated people with kindness, empathy and compassion. Their privacy and dignity were respected. People’s needs were listened to and staff responded to minimise any discomfort, concern or distress. The service cared about and promoted the wellbeing of staff. We found the service made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs. The service provided appropriate, accurate and up-to-date information in formats tailored to individual needs. The service had systems and processes in place to make sure everyone could access the care, support and treatment they needed when they needed it. Staff were proud to work at the service. The service collaborated and worked in partnership with the wider health and social care services to support care provision, service development and joined-up care in their local area, and for the wider healthcare community.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People who used the service told us they were treated with kindness, empathy and compassion. They spoke positively about staff and said they were listened to and communicated with in ways which suited their needs. Patients commented on staff being calm and supportive, and how they explained what was happening and what was going to happen in a way they could understand. People were put at ease by staff at a time when they were feeling vulnerable and scared.