South Western 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.

We assessed all 8 quality statements from this key question.

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

At this inspection, 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.

Safety was a top priority that involved everyone. There was a culture of safety and learning based on openness, transparency and learning from events that had caused harm or created the risk of harm. There were good mechanisms to monitor and review patient safety events, conduct learning, and put it into practice. Staff knew what patient safety events to report and how to report them.

There were structured processes to ensure learning was identified and acted upon. The patient safety oversight group triaged events and escalated events to the trust’s executive decision-making panel (EDMP). The EDMP reviewed patient safety events in line with the NHS Patient Safety Incidents Response Framework (PSIRF) and decided the type of learning response. PSIRF is the NHS’ approach to how providers investigate and learn from patient safety incidents to support improvements.

Staff were able to suggest and lead improvement projects. To help with staff skills and knowledge, staff members had created a bulletin board at a station with electrocardiograms (ECGs) from patient incidents to show examples of common and uncommon diagnoses.

Risks were not overlooked or ignored. People and staff were encouraged and supported to raise concerns. They felt confident they would be treated with understanding and not be blamed or treated negatively if they raised concerns. The leaders worked in a supportive manner to address any issues. When conducting investigations from patient safety events, managers used a reflective ‘record of recollection’ approach to understand the context of each event.

Lessons were learned from safety incidents or complaints, resulting in changes to improve care or safety for others. For example, following incidents regarding some staff reporting their fingers being caught in ambulance sliding doors, stickers were added to the vehicles at latch touch points that said ‘Mind your fingers’ and an announcement was put in the monthly staff bulletin. The service recognised increased reporting during periods of higher operational demand, such as winter, and used this information to better plan services. Also, one of the air ambulance services the trust commissioned conducted daily case reviews as part of the morning safety brief to learn from the previous 24 hours’ cases. The team flagged any areas for improvement and shared immediately within the briefing. The team also identified any traumatic incidents to the manager who conducted welfare checks on affected staff.

The service conducted system-wide learning and monitored themes which emerged from patient safety events. The trust monitored Patient Safety Incident Investigations (PSIIs) in relation to health system pressures such as emergency department flow affecting ambulance response times. PSIIs are structured reviews into healthcare incidents or near-miss incidents. Through this thematic review of system pressures, South Western Ambulance Service NHS Foundation Trust (SWAST) had identified actions to improve response times.

Incidents and complaints were investigated and reported. The trust completed investigations within the NHS national guidance of 6 months of the incident happening. The average length of time for 2025/2026 PSIIs to be completed was 86 working days. However, this was more than the trust’s internal target of completion of 60 days. The length of time for PSIIs to be completed had decreased since December 2023 because of the meeting and approval structure.

There was good oversight of patient safety events through regular review and audit. Clinical team managers (CTMs) audited patient care records each month to identify learning and improvements. The CTM audit was comprehensive and supported improvement of staff’s clinical skills. Within the last 3 months, 5,449 records were reviewed by CTMs and members of the clinical team and 3.9% of the records reviewed were identified as needing some improvement. Actions were identified from the audits for each individual to improve. These identified actions were monitored by CTMs and the Electronic Patient Record Compliance and Risk Group.

Staff understood duty of candour. They were open and transparent with patients and their families. Staff understood the importance of giving patients and families a full explanation if and when things went wrong.

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.

Safety and continuity of care were a priority throughout people’s care journey. Staff completed structured safety briefings at the start of each shift, which supported the identification and sharing of risks. The emergency operations centre provided crews with essential patient information before attendance which ensured staff were prepared to meet patients’ needs safely.

Systems for dispatch and resource allocation were effective. Staff told us they were redirected to higher category calls when required. There were clear processes to access clinical and operational support. Staff could seek advice from senior clinicians, specialist paramedics and the critical care desk, with alternative support available through the care hub. The service worked well with internal teams, volunteers and external partners to provide coordinated care.

Care pathways were well developed and supported continuity of care. Staff used alternative pathways, such as GP services, same day emergency care and minor injury units, to avoid unnecessary conveyance to emergency departments. Staff had access to up-to-date pathway information and clinical advice, which supported decision-making.

The service had a proactive approach to identifying and managing risk. Staff worked with other health and social care providers to ensure continuity of care during and after treatment. However, some staff told us referral processes could be complex and occasionally delayed decision-making.

Arrangements for transferring patients to hospital were clear, and we observed positive working relationships with emergency department staff. Handover times had improved, reducing from 52 minutes 49 seconds in March 2025 to 30 minutes 4 seconds in March 2026. Patients therefore experienced shorter waits to when their care was transferred. However, delays remained at some emergency departments and the trust continued to work with system partners to improve patient flow.

Communication with hospitals was effective. The pre-alert system supported emergency departments to prepare for incoming patients. In some locations, Hospital Ambulance Liaison Officers (HALO) further improved coordination and patient flow.

Response times had improved since the last inspection despite increased demand. However, performance remained below national standards for category 1 and category 2 calls. Therefore, some patients did not always receive a timely response to their care needs.

Information systems supported the delivery of safe care. Staff had access to electronic patient records, including safeguarding information and risk alerts. However, systems were not always interoperable across regions, which created challenges when conveying patients out of area. A crew told us they often experienced challenges in getting patient’s information from the SWAST IT system onto emergency department systems outside of the region. In addition, staff told us completing records could take up to an hour following incidents, which impacted operational efficiency. Leaders were taking action to improve these systems.

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.

There was a strong understanding of safeguarding and how to take action. Staff were trained in safeguarding and knew how to identify adults and children at risk of harm. Staff understood how to raise concerns and completed safeguarding referrals when required. People were supported when they felt unsafe or experienced abuse or neglect.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. Since the previous inspection, SWAST had strengthened its safeguarding governance arrangements. This included introducing safeguarding specialists in each region, improving training and implementing an electronic referral system. Staff told us the new electronic referral system was easy to use and more efficient than the previous process. When needed, staff told us they were able to request additional 15 minutes following an incident to complete the safeguarding referral.

Staff followed safe procedures for safeguarding children. However, the Safeguarding Children Level 3 compliance remained below the trust’s target of 85%. In March 2026, compliance was 73.6%. Staff told us they did not have protected time to complete the e-learning. The service was aware of these shortfalls and had taken action. A learning needs analysis had been completed and safeguarding training was planned in the 2026/2027 mandatory learning programme.

There was a commitment to take immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. SWAST safeguarding specialists worked closely with partner organisations to improve communication, clarify responsibilities and support appropriate referrals. This helped to ensure concerns were managed consistently across the system and only necessary safeguarding referrals were made.

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.

Risk management plans were developed in line with national guidance. Staff assessed risk on arrival and escalated concerns through clinical teams, emergency operations centre, and partner services. This meant staff could respond effectively to changing situations.

Risk assessments about care were person-centred, proportionate, and regularly reviewed with the person, where possible. Staff communicated with patients, so they understood their care and treatment. Staff used visual aids to determine mood and pain with people who had communication challenges. This allowed patients to engage in decisions about their care.

Staff had clear escalation routes for patients whose condition deteriorated. Staff could access clinical advice, specialist paramedics, Community Emergency Medicines Service team (CEMS) and HALO staff to ensure timely onward care. The CEMS team was located in Bristol and provided urgent decision-making support for patients who required rapid assessment but may not need conveyance to hospital. The CEMS clinicians followed standard operating procedures (SOPs) which ensured escalation occurred only when all other options had been explored. Where patients were not conveyed to hospital, staff ensured they were given appropriate safety advice and understood what to do if their condition worsened.

The service sought feedback from patients through surveys and community engagement. QR codes were displayed on ambulances we inspected. However, staff told us that obtaining feedback could be challenging given the circumstances patients found themselves in an ambulance.

Staff demonstrated good understanding of the Mental Capacity Act 2005 and Mental Health Act 1983. We saw capacity assessments were clearly documented. Staff were trained to support patients experiencing mental health crisis and restraint was only ever used as a last resort and in line with legal requirements.

Staff had access to mental health support, including the mental health desk and mental health response vehicles. However, availability of mental health response vehicles was limited. Leaders addressed this risk by increasing access to the mental health desk to 24 hours a day and improving early identification of patients requiring mental health support during the call handling process.

Great Western Air Ambulance Charity (GWAAC) had clear processes to monitor and manage risks associated with aircraft batteries. GWAAC delivers air ambulance services within SWAST’s geographic patch. SWAST collaborated closely with Great Western Air Ambulance Charity (GWAAC) and held the associated CQC registration. Responsibility for the clinical and operational deployment of GWAAC resources rested with SWAST, with oversight provided through the Enhanced Critical Care Group.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People were cared for in safe environments that were designed to meet their needs.

However, we found equipment was not always consistently safe and effective. Staff raised there was a connectivity issue between defibrillator equipment in ambulance vehicles and the electronic patient record system. This meant patient data was not always uploaded automatically, creating a risk of incomplete records and delays in clinical documentation. We raised this with the leadership team who were aware and had been working with the supplier and staff to improve the connection. The trust set up a working group to ensure communication about the issue was effective with the long-term aim to procure the equipment.

The introduction of the ambulance vehicle preparation (AVP) system had improved cleaning and stocking consistency at some stations. The AVP team followed cleaning checklists and used an electronic platform to record and monitor vehicle cleanliness. Staff working at stations with a fully implemented AVP model spoke positively about clean and well-stocked vehicles at the start of shifts. All the ambulance vehicles seen or inspected were safe and clean. However, the AVP process had not been implemented to all stations. At stations operating on a hybrid process, staff reported inconsistencies in stock levels and cleaning standards. Crews told us they often restocked and cleaned vehicles at the start of shifts, which impacted their ability to respond to patients.

There were effective arrangements to monitor vehicle performance and assess risk. Frontline crews were able to report vehicle and equipment defects on an electronic platform with clear processes to follow when requesting maintenance or equipment support. All vehicles on the road had up-to-date service records. Tail lift/ramps were inspected during each vehicle servicing as part of the safety inspection report. AVP teams followed comprehensive checklists during servicing to monitor vehicle safety.

However, arrangements for vehicle maintenance and availability were not consistent across all areas. Staff working in rural stations told us vehicles were not always repaired promptly due to the distance from maintenance facilities. Staff told us there was limited vehicle availability at more rural stations which meant staff were sometimes unable to start shifts on time when previous crews returned late. This affected the service’s ability to respond to incidents quickly.

Some ambulance station facilities were not fit for purpose. We witnessed two stations where there was cramped access to stock and cleaning supplies.

Some ambulance station facilities were not well maintained to support safe care. At one station, fire exits were obstructed which presented a risk in the event of an emergency. We raised this to managers on-site. At another station, the sluice was old, rusty, and did not function and at an additional station, the sluice was exposed to the elements and missing a door. These issues could compromise safe waste disposal. These issues were raised to leadership who took immediate action.

The service had a process for monitoring and addressing pests in all clinical and non-clinical spaces. Where pests were detected, an external company visited, took actions to address this and recommended actions to SWAST for long-term prevention. We reviewed reports from 10 stations which had a history of pest issues in the last 6 months and at all 10 stations, the housekeeping issues had been improved so no further follow up was needed. At one station, birds had access to the garage and there were bird droppings on the walls. The service was looking into alternative estates.

All records and personal data were stored electronically and securely. The service was in the process of moving all programmes onto one device to streamline efficiency.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs. Staffing levels were monitored daily and adjusted to respond to changing demand. Teams supported each other to manage unplanned absences and leaders used contingency plans to manage longer-term absence. In February 2026, the frontline operations lead clinician role was 3.8% above funded level and the support clinician role had a 5.0% vacancy rate. There was an improvement plan to support recruitment for the support clinician role. The staffing model reflected population need with higher concentrations of staff in more populated areas.

The trust maintained an approximate one-to-one skill mix of paramedics to emergency care assistants (ECAs) for double-crewed ambulances in almost all geographic regions. In Bristol, North Somerset, and South Gloucestershire (BNSSG) and Gloucestershire areas, there were significantly more paramedics than ECAs. This meant during times of pressure, there could be insufficient operational resource in these regions to meet the 1 paramedic and 1 ECA model for double-crewed ambulances.

Staff received the support they needed to deliver safe care. The service had a formal organisational framework for consistent clinical supervision. The service supported staff development through mandatory training, appraisal and ongoing learning opportunities. Appraisal compliance rates were consistently at or above the trust’s target of 85% for the past 12 months. As part of the appraisal, CTMs conducted ride along with staff to review their clinical skills.

However, staff did not feel the appraisal structure supported effective staff improvement. Many staff told us they did not feel the appraisals were a productive use of time to improve skills. Although in the NHS 2025 Staff Survey, 79.62% of staff reported they had had an appraisal or development review in the last 12 months, only 14.31% agreed it helped them improve how to do their job. Many CTMs told us it was difficult to schedule in ride along with staff due to the volume of work. Additionally, a senior member of GWAAC staff told us the appraisal form was aimed at road crews and thus it was difficult to use this form to monitor staff performance for Helicopter Emergency Medical Services (HEMS). This meant that staff were not always supported to develop within their role.

Staff received training appropriate and relevant to their role. There was a structured induction programme and staff told us they felt well prepared for their role.

Frontline staff were trained in safe driving under blue lights as part of their induction. We witnessed crews driving under blue lights using audible warnings and lights. There were safety mechanisms to ensure safe driving.

However, staff were not always up to date in their mandatory training. Compliance for Safeguarding Children Level 3 (73.6%), Infection Prevention and Control Level 2 (76.5%) and Information Governance and Data Security (81.9%) were consistently below the trust’s aim of 85% at the time of the inspection and within the 6 months prior. Additionally, the trust provided learning disability and autism training part 1 and had introduced a new part 2 training package which went live prior to our onsite assessment in April 2026. Operations staff were 92.6% compliant on part 1 training and 26.3% compliant on part 2. Their target was to have trained over 85% of staff who required this training by March 2026. Leaders at the trust had taken action to support staff knowledge in learning disability and autism through training days in 2025/2026. This training was important to enable staff to reduce significant health inequalities.

Staff did not always have adequate time to undertake mandatory training. Many staff told us they were not given dedicated time to complete mandatory training and found it difficult to fit the training in their workdays. The trust was aware of this and had set aside 5 days of mandatory learning for staff in the 2026/2027 training year with identified in-person and online time dedicated to safeguarding and learning disability and autism part 2 training.

The organisation was undergoing structural changes to align services and reduce reliance on agency staff. In autumn 2025, the trust onboarded clinicians from the private ambulance providers across the southwest to minimise agency staff usage. Between January 2026 to April 2026, a voluntary redundancy occurred as part of a cost-saving activity. The lead paramedic role had also been removed. While the changes supported long-term sustainability, some staff told us they were unclear about changes to roles and responsibilities during the transition.

Disclosure and Barring Service checks were conducted for all staff members when joining or taking up a new role to ensure they were suitable for their role.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were protected as much as possible from the risk of infection because vehicles and equipment were kept clean and hygienic. The AVP team cleaned and re-stocked the ambulances and followed structured cleaning processes. Vehicles were deep cleaned regularly. As of March 2026, the trust exceeded their target of 90% with 92.8% vehicle deep cleaning compliance. Clinical air ambulance crews were responsible for aircraft cleaning and completed this routinely.

Each station was cleaned weekly and an external company carried out deep cleans. Clinical waste was disposed of correctly and there were dedicated waste bins for each type of waste generated. Sharps were disposed in line with trust guidance and there was a dedicated waste bin for sharps boxes at the ambulance stations. However, we found examples of poor IPC at three ambulance stations. Boxes were stored on the ground in cleaning cupboards and storage cupboards. This was raised to the leadership team. Additionally, there was inconsistent weekly flushing of sinks at ambulance stations which increased the risk of legionella. The trust had improved their legionella monitoring system as a result.

There were mechanisms to identify infection prevention control (IPC) compliance. The service conducted regular comprehensive IPC audits including hand hygiene, environmental, water, and waste audits. Information was recorded on an electronic system with areas identified for follow up.

However, staff did not always adhere to hand hygiene and uniform IPC best practice to reduce the risk of infection transmission. We observed staff did not always practice good hand hygiene when attending patients at their homes.

Information about risk of infection was shared with relevant partners. Where risks increased, staff followed policies to maintain staff and patient safety. Managers worked with the UK Health Security Agency (UKHSA) to ensure actions were implemented.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed systems and processes to administer medicines safely.

Medicines safety was seen as a high priority at all the stations visited. Staff told us they knew who the Chief Pharmacist was and how to contact members of the pharmacy team if needed for advice or support about medicines. There was good awareness of joint team working. Staff had access to relevant medicine policies, procedures and guidelines. One station, Weston, had developed their own medicines assurance programme to maintain compliance. We were shown how staff could access medicines information using the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) app. Overall, staff followed systems and procedures which ensured a consistent trust wide approach for safe medicine management. Where staff had not followed procedure, this was identified and investigated to find out why and any necessary learning and action was taken.

The Trust had up-to-date Patient Group Directions (PGD’s). These are written instructions for the administration of certain authorised medicines by registered health professionals to a group of patients. We were shown how staff accessed PGDs on the JRCALC app. In order to be authorised to use the PGDs, staff had to complete a quiz which ensured they read the PGD and kept their clinical knowledge up to date. Medicines were administered to patients by staff with the legal authority and knowledge to do so.

Medicines were locked and secure and were stored safely in line with recommended practice.

Medicines overall were stored and managed neatly, safely and securely with access only to authorised staff. Access codes to medicine storage areas were changed regularly to ensure security of medicines. We reviewed temperature logs and the temperatures of most of the medicine rooms and refrigerators (where used) were monitored and recorded daily to ensure they were stored within a safe range. However, a few outlier stations did not always record medicine room temperatures daily which we were told was sometimes due to staffing resources. Some stations would benefit from their medicine rooms being upgraded to increase security and capacity for medicine storage.

Controlled drugs (CDs, are medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Stock checks were undertaken and recorded by two authorised staff at least once a day in line with national CD safe and secure medicines handling. There were processes for the safe destruction of CDs. Trust wide audits were undertaken to ensure safe storage, recording and destruction of CDs. Any identified discrepancies, issues or themes were investigated and reported with advice and action agreed to ensure CDs were stored and recorded following trust’s policy and procedure.

There were processes for the supply of medicines to ambulance stations and air ambulance services, although there were two separate processes at the time of the visit. However, work was in progress to ensure a single process would be cascaded to every station.

Most stations used an ambulance ‘crew re-packing’ system where crew re-stocked medicine bags at the end of their shift from a stock supply of medicines. We were shown the comprehensive checking process to ensure medicines were safe to use and were within date before being packed into medicine bags. This process was time consuming with paperwork to complete. The bags were then tagged as ready to use. However, it was recognised as this was completed at the end of a shift there was an increased risk of medicine packing errors. A new ‘pharmacy re-packing’ service was in operation at a few stations. The medicine bags were prepared by the pharmacy team at a central base (tagged and sealed) and sent out to stations ready to use. All used medicine bags were returned to the pharmacy base for replenishing. Staff reported this system worked very well with reduced errors at these stations. It had also increased staff morale as they no longer needed to re-stock medicine bags when they were tired. The new ‘pharmacy re-packing’ service was due to be rolled out to all stations in the summer of 2026.

Staff learned from safety alerts and incidents to improve practice.

Staff told us they received medical notices which included any medicine alerts on the JRCALC app. We were told medicine management training was compulsory and the learning and development team were helpful. There were training days to keep staff up to date. Reminders on safe medicine administration were given to staff about making sure they ‘have the right patient, reason, medication, dose, route and documentation’.

There was a positive culture of reporting medicine incidents. From January 2026 to March 2026, 119 controlled drugs incidents were reported. We were shown how the process of reporting an incident was undertaken and how it was managed. The medicine safety officer reviewed all medicine incidents and identified any emerging trends. Actions and learning from medicine incidents were then shared with staff.

We observed medicines being given to patients safely. We saw staff review patient records and check any allergies before providing medicines. We observed staff explain what the medicine was and gained permission before administering.

Medical gases were not always managed and stored securely in line with the comprehensive trust policy. There was clear segregation between full and empty cylinders. Medical gas warning signage was visible to ensure people were aware of safety around medical gases. However, at one station, we identified 3 medical gas cylinders which were not stored securely. We found at every station visited there were medical gas cylinders which were not contracted by the trust. We were told this was an ongoing issue when the cylinders got mixed up during incidents and it was sometimes difficult to get the cylinders returned to their original contractor.