South Central 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 that leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from harm. However, staff did not always receive annual appraisals and quality varied across managers, and software systems were old.

We assessed 7 out of 8 quality statements.

At our last assessment, we rated this key question requires improvement. At this assessment, the rating has increased to good.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service was previously in breach of the legal regulation in relation to the governance of reporting, reviewing and learning from incidents. Improvements were found at this assessment, and the service was no longer in breach of this regulation.

Incidents were now reported and investigated in line with theNHS Patient Safety Incident Reporting Framework. We saw the framework was referenced throughout policies related to incidents.

Training was delivered through a mixture of e-learning and face to face sessions. Mandatory training modules varied depending on job role. Staff and managers received a notification when training was due to ensure modules did not expire. We viewed mandatory training dashboards and noted the average completion rate across all modules and staff groups was 97%. All modules met the 95% benchmark for completion apart from 2, where 89% of clinicians had completed the training. However, 100% of all other staff groups were up to date.

All incidents were included as part of the Monitoring and Quality Dashboard Report which was reviewed monthly. Concerns from this report were raised with the Trust Patient Safety and Experience Group, then escalated to the Quality and Safety Committee and then to the Board.

Sharing of learning across the organisation had improved. Managers shared the findings from incidents with staff via fact sheets available on the intranet. Incident reports from all departments were included to ensure cross-service learning.

Managers updated the process for cancelling calls following an incident where a family member cancelled an ambulance, only to require an urgent transfer later that day. Following this incident, all call handlers were required to speak directly with patients to assess whether it was appropriate for a call to be cancelled.

The service was previously in breach of the legal regulation in relation to Duty of Candour (the duty to be open and transparent with people receiving care). Improvements were found at this assessment and the service was no longer in breach of this regulation. Staff now understood their responsibilities regarding Duty of Candour. Staff received training in Duty of Candour as part of the incident framework training, reviewer training and engagement courses. Actions and responsibilities regarding Duty of Candour was included throughout policies related to complaints, incidents and learning.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services. However, theComputer Aided Dispatchrequired replacement.

Staff used NHS pathways to categorise all calls, whether they came in via 999 or 111 calls. Once categorised, the calls appeared on the dispatch screen in order that the team could allocate resources. Pathways were universal across all systems. This ensured that both EOC and ambulance crews had access to the same information and medical records.

The service’s systems ensured consistency of care across providers. The maternity clinicians were able to directly book patients into post-natal or labour wards at local NHS trusts via the system. The booking immediately appeared on the hospital’s booking system. We listened to a call from a patient who stated they had spoken with their GP that morning, but their symptoms had worsened since then. Staff were able to access the GP’s updated notes which supported a more effective triage process.

Patient records were completed and stored on an online system. The triage system used prompt questions and answers to navigate an algorithm, which then determined which pathway the patient followed. Records also used a ‘pop up’ information board that included significant events in the patient’s medical history, for example, a red ‘pop up’ indicated the patient had had a significant previous health condition, for example a stroke.

However, managers at all levels advised us the CAD System was old, slow and in need of replacing. The service used an ongoing replacement plan, with regular review and updates by the board. At the time of assessment, the contract for the system was out for procurement. CAD performance and impact on patient delays was monitored by senior leadership and documented via a risk register. However, the shortest time frame for replacement was by the end of 2026. The service had a back-up system in place in case of electrical failure or if the CAD system itself failed.

The service worked with people and healthcare partners to improve people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff understood their role and responsibilities in protecting patients from abuse and could describe triggers from a call that would alert them to raise a safeguarding concern. Staff could identify their safeguarding leads and knew how to refer safeguarding concerns to outside agencies.

Staff demonstrated how they completed safeguarding questions as part of the triage process. Patient profiles included a safeguarding special note section with different colour coded flags highlighting the type of risk associated with that patient. For example, purple notified staff of mental health concerns and yellow highlighted there was a history of domestic violence.

Staff received training specific to their role on how to recognise and report abuse. Staff working in the control room were trained to level 2 and clinicians and staff in specialist teams received level 3 training. We saw training records that showed 95% of staff had completed safeguarding training for both adults and children, which met the 90% benchmark. The service was previously in breach of the legal regulation in relation to safeguarding, as staff were not trained to the appropriate level and there was no specific EOC safeguarding training. This has since been implemented; improvements were found during this assessment, and the service was no longer in breach of this regulation.

The service was also previously in breach as safeguarding oversight was not monitored by the board. At this assessment, we saw improvements as the board now had oversight and the service was no longer in breach of this regulation.

Staff safeguarding training included; Oliver McGowan training, as well as Female Genital Mutilation training. Oliver McGowan Mandatory Training is a specialised training programme focused on Learning Disability and Autism.

The service had a backup safeguarding paper system should the electronic system fail, which staff demonstrated to us.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe.

Staff used a triage system, maps and special notes to assess and respond appropriately to patient risks. We observed special note flags being used in several calls. One flag noted there was a communal defibrillator near to the patient. Another flag stated the patient had an Advanced Care Plan (ACP) (advanced care planning offers people the opportunity to plan their future care and support, including medical treatment, while they have the capacity to do so). These flags supported staff to triage and care for patients based on their individual risk and circumstances.

Staff responded appropriately to the recognition of deterioration and risk. During one call we listened to, the patient reported their breathing had worsened. Staff acted appropriately by updating the triage tool, which then prompted further questions. The patient was re-triaged and the call category increased.

The midwifery specialism team did not have a clinical lead, however the external partner provider service was in the process of recruiting. However, if there were concerns with a call, staff contacted the maternity triage line, the maternity day unit or the Early Pregnancy Unit for support.

The service ensured facilities supported the delivery of safe care.

Equipment on call centre desks were neatly arranged including all cables and leads. Staff used multiple screens, had their own headsets and sat on 24 hour chairs (Designed to provide maximum comfort for all day use).

Managers regularly reviewed the ergonomics of equipment (the study of people's efficiency in their working environment) to ensure staff were physically comfortable and supported. Where staff members required specific equipment, for example, screen tinting for visual challenges, the desk was labelled to ensure it was reserved for a specific person.

Senior managers reviewed environmental factors as part of a transformation programme known as ‘fit for the future’. This included fitting solar panels at the Otterbourne site, (the structure of the Bicester site meant panels could not be installed) and increasing the amount of recycling available at both sites.

The service ensured there were enough qualified, skilled and experienced staff to keep patients safe. Staff worked well together to provide safe care that met people’s individual needs. However, there was inconsistent quality of appraisals.

At our previous assessment, we recommended the service should ensure all staff received a timely appraisal to assure leaders that competency is maintained. The number of staff who had completed an appraisal within the 12 months prior to inspection was 96%, 1% over target. However, some staff in ‘support’ departments advised us they had not had an appraisal in years. Opinion on the quality of appraisal varied greatly dependent on who their manager was. Some staff advised us appraisal was a useful discussion, whilst others stated managers had pre-populated their report. These staff advised us they did not feel safe to dispute the contents of the appraisal. Operational staff usually completed their appraisal during quieter night shifts and team leaders advised us they did not have allotted time to prepare for appraisals. Therefore, they had to prepare in their own time, or whilst “juggling my job, which is not ideal”.

The service used a staff rota that was divided between the North and South called the ‘on-call board’. This board was displayed above the dispatchers and managers. One manager was allocated to ensure oversight of who may be needed and where. Managers attended the daily teleconference call to discuss that day’s resources and any upcoming gaps in the rota.

Staff ensured that a crew with the appropriate skill mix was dispatched to the patient. The dispatch team had a ‘crewing sheet’ that included details of skill mix. When crews logged onto an ambulance, their details were sent to the dispatch team, who could then assign them a job.

Two years ago, the service had 42 clinicians, this had since increased to 70.4. From November 2024 to March 2025, the total number of actual Whole Time Equivalent (WTE) staff exceeded the planned number. However, in April 2025 actual WTE was less than planned. Managers advised us that recruitment was ongoing.

Managers sent messages to staff work email addresses if last minute cover was required for a shift. In the 6 weeks prior to assessment, actual versus planned staffing levels matched.

The service had a list of bank staff, usually former employees, to support the team. Bank staff were required to complete at least 1 shift every 3 months and to ensure they were up to date with their mandatory training.

All staff, including bank, maintained a ‘Pathway License’, which was proof of competency for the role. This was renewed annually, and staff were required to work a minimum of 40 hours each month to maintain the license.

Staff advised us their shifts were flexible and supported good work/life balance. We spoke with one part-time staff member; they gave managers their availability 3 months in advance, which they advised worked well for them.

Call handlers were supported in career progression. We saw Band 3 staff had received training to become coaches. When they had completed their competencies, they could apply to become a Band 4 quality assurance lead. Staff in Band 4 could branch out into either audit or team leader Band 5 roles.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed staff wiping down their desk areas with antibacterial wipes.

All staff working in operations call centres had their own headsets. Staff were responsible for ensuring headsets were clean, which we observed. Our team were provided headsets during assessment in order that we could listen to calls. The headsets we were provided had covers that were wipeable.

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