South Central 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 inadequate.

At this inspection the rating has changed to 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.

The service was in breach of the legal regulation in relation to good governance. There was a lack of understanding regarding governance and risk management, with roles and responsibilities unclear.

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 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.

Since the last inspection, there had been many changes at SCAS including a change in leadership team and a transformation programme to address challenges related to financial stability, operational performance and service delivery. This programme referred to as fit for the future, included 4 workstreams, governance and well-led, patient safety and experience, performance recovery and culture and wellbeing.

Staff understood the need for change. However, the uncertainty it brought and with the high operational workload it was having a negative effect on staff morale. This was highlighted in the most recent staff survey 2024, where questions related to the organisation were mostly RAG (Red, Amber, Green) rated as amber or red, indicating serious concerns about how operational staff felt about the organisation. However, despite the staff survey results, staff continued to be proud to work for the trust, wear the uniform, and the service they delivered to their patients.

Staff still believed in the mission and vision of the organisation ‘we deliver the right care, first time, every time’ and ‘to be an outstanding team, delivering world leading outcomes through innovation and partnership’. The vision was underpinned by the trust values of caring, innovation, professionalism and teamwork.

The trust was committed to eradicating bullying and harassment from the organisation and the emergency and urgent care service, which had been highlighted as areas of concern previously. There was now an allegations policy which outlined the procedures and guidelines for handling accusations of misconduct or wrongdoing by employees. However, there was a mixed view from operational staff, with some saying they had seen no incidents of bullying and harassment and others saying it was still occurring and not always dealt with effectively or appropriately according to policy by senior managers.

Nationally, sexual safety in ambulance trusts was a serious concern, with recent increases in reported incidents of sexual harassment and misconduct. The trust had launched it’s sexual safety charter and there was increased training in awareness and what was actually meant by sexual safety. Again, there were mixed views from operational staff regarding occurrence and how seriously it was taken by managers.

There was a clinical strategy 2023 – 2028 which prioritised emergency care, including cardiac arrest, heart attacks and stroke patients, as well as urgent care for mental health crises and frail elderly patients. Delivery against the strategy was reviewed through a combination of audits, data analysis and feedback mechanisms.

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 operational service was led by the executive director of operations, and they were supported by three assistant directors of operations, one for the north of the patch, one for the south and one who headed up urgent care. There were 7 areas across the patch, known as nodes, 4 in the north and 3 in the south. Each node was managed by a head of operations (HOO) and supported by the clinical operations manager (COM). Within each node were operational teams, the number dependent on the size of the area it covered. Each operational team was managed by a team leader and supported by the clinical team educator (CTE).

The organisation had recently employed a chief paramedic, and along with the chief nurse and chief medical officer, had responsibility for clinical oversight of the service, including the processes and tools implemented to ensure the integrity and safety of clinical practice. Operational staff saw the appointment of a chief paramedic as a positive change for the service.

Operational teams consistently spoke highly of their team leaders and CTEs describing them as visible, supportive and approachable, and team leaders and CTEs had peer support from each other in their nodes. However, views were more mixed regarding management beyond this level, with some concerns raised about the visibility and supportiveness of higher-level managers.

Service leaders could not articulate how cross-node working occurred and how consistency was being maintained between nodes, and across the service as a whole. While heads of operations (HOOs) and clinical operations managers (COMs) referenced meetings with their counterparts, they did not explain these to be formal forums where operational efficiency, clinical quality, staff well-being, and best practices were systematically shared.

The service had made investment in their leadership training, and we were told about the transformational leadership courses. Transformational leadership is a leadership style focused on inspiring and motivating staff to achieve a shared vision, often through personal growth and innovation. However, when we asked team leaders what training they had received for their role, many reported they had received no formal management training to prepare them for the position.

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

The service leaders acknowledged that, historically, staff did not feel safe raising concerns related to patient safety, quality of care, or workplace issues due to fear of blame or detriment. Addressing this was one of the trust’s key focuses within the people and culture transformation workstream, which aimed to foster a more open, supportive, and transparent organisational culture.

The trust had grown the freedom to speak up team since the last inspection. There was now a lead freedom to speak up guardian (FTSUG) and two further FTSUGs in the organisation. In addition, the trust had a network of FTSU champions across the organisation, who raised awareness about the importance of speaking up, were points of contact for staff, and provided initial support to colleagues who wanted to raise concerns. The FTSU champion role was voluntary, and appointees carried out this work alongside their substantive posts. Each operational node in the emergency and urgent care service had a FTSU champion for local staff to contact. Staff knew who their FTSU guardians and champions were.

However, we found mixed feelings amongst operational staff. Some staff told us they felt it was safe to speak up, while others believed it was not safe to do so due to past negative experiences. Other staff members felt comfortable speaking up to their team leaders but not at a higher level and felt action would be taken via this route.

Information from the staff survey 2024 showed that 50% of operational staff felt safe to speak up with anything that concerned them in the organisation, however, 68% of staff felt the organisation would not address concerns raised.

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 had established staff forums to create a safe and inclusive space for employees to share experiences, discuss concerns and to contribute to the equality, diversity and inclusion (EDI) initiatives within the organisation. These forums also provided a platform for raising awareness about EDI priorities and progress, offering advice on related policies, and ensuring that diverse perspectives were considered in decision-making. Staff networks included disability awareness, representation and equality; race equality and inclusion network, and multi faith. All networks had an executive sponsor which meant they had direct access to the board. Staff in the emergency and urgent care service contributed to staff forums and belonged to staff networks and found them a good way to get their voice heard.

The trust’s workforce was a 50/50 male, female mix which included many women at a senior level at both trust and service level.

The 2024 staff survey showed that 70% of operational staff felt colleagues were polite and treated each other with respect, and 87% of operational staff had not experienced discrimination from other staff. These findings suggested a generally positive working environment, though they also highlighted that nearly a third of staff may not consistently experience respectful interactions, and a minority still reported instances of discrimination.

It was acknowledged that the current service workforce lacked ethnic diversity and did not reflect the demographic makeup of the community it served, with Black and Asian groups notably underrepresented. We were informed of ongoing initiatives aimed at identifying and addressing the barriers that may discourage individuals from these communities from pursuing careers within the ambulance service. These barriers included cultural or familial expectations, as well as perceptions about the demands and challenges associated with the role.

The service was 24 hours a day, 7 days a week service which meant operational staff were expected to work unsocial shifts and flexible working opportunities were limited. The service were piloting initiatives such as self-rostering and rota changes in an effort to improve work-life balance. However, flexible working remained a significant concern amongst staff, with only 26% of operational staff reported being satisfied with the opportunities for flexible working patterns in the 2024 staff survey.

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.

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.

Senior operational staff told us they attended many meetings, and the same information could be repeated in several of them. However, they were unable to clearly explain the governance structure or processes in place to ensure effective clinical governance.

There was also notable confusion regarding the use and structure of risk registers. At some operational nodes, senior staff reported the existence of local risk registers, while at others, we were informed that only a single corporate risk register was maintained. We requested copies of the risk registers and were provided with the corporate risk register. Upon review, we noted that key risks raised during our visit such as handover delays and delayed response times were appropriately captured. We also observed that these risks were being discussed at clinical governance meetings. However, it remained unclear whether there were consistent, clear, and effective processes across the service for identifying, recording, managing, and mitigating risks. The lack of clarity among staff and inconsistencies suggested a lack of understanding amongst staff.

System and processes to ensure clinical oversight showed gaps. For example, there were no formal processes in place to ensure information disseminated down to staff, including changes in clinical practice was read, put into practice and embedded.

The service had clear service performance measures, which were recorded and monitored by the service and wider trust. Data collection was detailed and included data on a range of performance measures and quality indicators, which included audit results and patient feedback. Areas of good and poor performance were highlighted and used to challenge and drive forward improvements. Monthly reports were produced and discussed at the relevant governance meetings.

Where relevant, performance was tracked over time to identify unexpected variations that warranted further investigation. This approach enabled staff to quickly pinpoint areas of improved performance as well as those requiring attention and improvement.

However, we observed that discussions in meetings were heavily weighted towards operational performance metrics, with comparatively less emphasis on clinical quality measures. This imbalance could limit the organisation’s ability to fully assess and respond to clinical risks or opportunities for improving patient care, treatment and outcomes.

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 to support care provision, service development and joined-up care.

The service was represented at the local integrated care board meetings regarding emergency and urgent care medicine and together, with other stakeholders, built a shared understanding of challenges within the health and care system and looked at ways to meet the health needs of the local population, improve patient outcomes, relieve pressure on the services and ensure equitable access to emergency healthcare.

The head of operations (HOO) role was mainly externally facing. They and the clinical head of operations (COM) and hospital ambulance liaison officers (HALO) had been instrumental in building relationships with the acute trusts in their area, especially with the emergency departments (ED), to launch the release to respond initiative and other ED avoidance pathways.

The service had close working relationships with the local police force and fire service, who they would frequently collaborate with to ensure a coordinated and efficient response to incidents, often sharing resources and expertise, and initiatives like the Joint Emergency Services Interoperability Programme (JESIP) which improved how emergency services worked together during major incidents.

The service worked with the local community, for example in schools, local events, and care homes, to increase public awareness and understanding of the ambulance service, ensuring timely and appropriate emergency care, maximizing the chances of a positive outcome, and preventing strain on emergency services. By fostering stronger connections with the community and improving public knowledge, the service hoped it would contribute to more effective and efficient use of emergency resources.

Staff attended local safety advisory group meetings, which along with other agencies, provided guidance and advice to event organisers on safety aspects of their events.

The service was represented at many meetings to ensure vulnerable people received the appropriate support from the right emergency services. This included the frequent attenders meetings, the right care right person (RCRP) tactical delivery group, and the mental health vulnerable patients steering group.

The service worked with patient representatives and patient forums to help shape and improve the care and treatment people received from the ambulance service. This included patients of different age ranges and equality groups.

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 (QIP), a structured approach to identify areas for improvement, implementing change, and measured the impact of interventions, to support continuous learning, improvement and innovation work. The trust had trained 42 members of staff in QI methodology. We were given examples where QIP was being used to improve performance and patient experience in the emergency and urgent care service. For example, the double crewed ambulance load list and pouches QI Project. This project focused on the comprehensive restocking of double-crewed ambulances to ensure that only essential and required items were loaded. The primary objectives were to reduce cognitive load on ambulance crews in emergency situations, to eliminate overstocking and reduce unnecessary duplication of supplies, and reduce the weight of ambulances and consumables wastage for cost saving and sustainability.

The SCAS Bright Ideas scheme was a programme designed to encourage and facilitate staff suggestions for service improvements. It provided a structured process for staff to submit, develop, and potentially implement their ideas, ultimately enhancing the service provided to patients and staff.

The North Harbour resource centre was being used as a proof of concept (POC) hub. There was a POC working group overseeing this work. This was where new ideas of working could be trialled and evaluated to validate whether a concept could be successfully implemented and met requirements, before committing significant resources to full-scale development. There were 4 workstreams which were testing concepts such as alternative roster options, staffing structures, hub mechanics and communication channels.

There was an active research team within the trust whose research activity levels were amongst the best throughout the UK ambulance services and had a national reputation for delivering high quality research data. The service worked with the medical director to deliver these programmes. They had been the second highest recruiting site for the PARAMEDIC3 trial, which was looking at the most effective way to treat someone when their heart suddenly stopped working outside of hospital by giving drugs through a vein or into the bone. Answering this question would help to improve future treatment of people who had a cardiac arrest. The trust was the highest recruiter for the CRASH-4 trial which was aiming to provide reliable evidence about the effects of early intramuscular tranexamic acid on intracranial haemorrhage, disability, death and dementia in older adults with symptomatic head injury. Currently, SCAS with help from the service were recruiting and taking part in 9 research trials. Investing in research was seen as a way to influence and improve care in the future and therefore invested resource into the programme.