South Western Ambulance Service NHS Foundation Trust

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• 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 all 7 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 the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders ensured there was a shared vision and strategy and that staff knew, understood and supported the vision, values, and strategic goals. Most staff we spoke with knew and understood the provider’s vision and values and how they were applied in the work of their team. The organisation implemented the One Team Model in autumn 2025. The One Team Model aligned to the trust’s strategy to support staff, patients and partners in improving patient care through improving South Western Ambulance Service NHS Foundation Trust’s (SWAST) operating model and delivery of its strategy. Staff we spoke with felt the culture of the service and organisation was improving because of the One Team Model. Staff expressed confidence the trust was modernising and stabilising.

Individuals felt supported in their teams and socially connected. The staff we spoke with told us there was an open culture of safety and wellbeing within each team. Staff and managers described a strong ethos and drive to improve and maintain a positive open culture across the service with a focus on support, learning, and innovation.

Staff and leaders ensured that the vision, values and strategy had been developed through a structured planning process in collaboration with people who used the service, staff and external partners. Staff had the opportunity to contribute to discussions about the strategy for their service through team discussions.

However, not all staff felt connected to SWAST. In the 2025 NHS staff engagement survey, 39.2% of staff responded they would recommend SWAST as a provider. Staff attributed this to frustrations in organisational processes. The trust was aware of these issues and had recently published an action plan ‘From Friction to Growth’ to address the issues identified in the NHS Staff Survey 2025. The plan emphasised building a vision and improving engagement and co-design with staff.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered and risks were well-managed.

Leaders at every level were visible and led by example. Senior leadership completed shifts with frontline staff, fostering a culture of inclusion and transparency. In Great Western Air Ambulance Charity (GWAAC), leaders were visible and familiar to team members. This highlighted close working relationships. Senior staff actively engaged in listening exercises and one to one meetings.

High-quality leadership was sustained through safe, effective, and inclusive recruitment and professional development. Leadership development opportunities were available, including opportunities for staff. The trust offered Leadership Sprint Days which included sessions on handling conversations effectively.

Managers understood the challenges staff faced daily in their roles and provided compassionate leadership with a priority on staff wellbeing. They could clearly explain how the teams were working to provide high quality care. As part of the One Team model, reduced manager-to-staff ratios enabled more meaningful engagement, career conversations and tailored support. However, some staff told us there was inconsistency in how people were managed and clinical team managers (CTMs) reported increased workloads which impacted their ability to meaningfully engage with their teams. The Devon region had recently merged from two regions into one with single leadership. Managers told us this area was difficult to manage adequately because of its size. Some CTMs acknowledged they struggled to engage with some members of their staff due to scheduling difficulties.

Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. However, a few frontline staff told us they felt a disconnect between leadership and frontline staff. The 2025 NHS Staff Survey results showed there was a lack of communication between staff and CTMs. The trust was aware of this and had developed an action plan with renewed focus on manager and team relationships.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

When concerns were raised through freedom to speak up systems, action was taken. Staff told us they had raised concerns through the freedom to speak up reporting system regarding pockets of culture which did not meet the trust’s aims at one ambulance station. As a result, there was increased management presence at the station, confidential one to one meetings with each individual, and actions taken to resolve the issues. Managers told us staff have become more willing to bring issues to the managers as they witnessed managers take action.

There was a culture of speaking up when staff actively raised concerns and those who did were supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially and lessons were shared and acted upon. Staff were encouraged by leaders to raise concerns and report incidents through their electronic incident reporting system. Individuals could submit concerns anonymously. The trust was able to follow up on anonymous concerns through a new communication system where they could speak with the anonymous reporter. Most staff we spoke with were aware of this system and spoke positively about it.

Freedom to Speak Up (FTSU) champions and guardians were established across the organisation.

However, not all staff felt comfortable to raise concerns or that any action would be taken as a result. In the 2025 NHS Staff Survey results, 51% of staff agreed they would feel safe to speak up about anything which concerns them in the organisation. Not all staff felt concerns raised would be acted upon. The survey results showed, 36.70% of staff were confident the organisation would address their concerns if they spoke up. The trust had taken action to improve their freedom to speak up processes and transparency in actions to reinforce psychological safety.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders made reasonable adjustments to support staff with protected characteristics to carry out their roles well. Staff told us a manager had supported a member of the team who had dyslexia to access reasonable adjustments at work, including IT support to ensure they could fully carry out their role. SWAST provided an inclusive learning environment for individuals with learning difficulties to access the same opportunities as other staff. The organisation provided specific learning difficulty assessments to all individuals enrolling in the Paramedic Degree Apprenticeship and then provided individual support plans, specialist tutor support, and regular reviews to identify any additional support throughout the process.

The trust fostered an inclusive working environment for neurodiverse individuals. The trust launched a Neurodiversity Policy and Toolkit for all colleagues in 2025.

Leaders ensured there were effective ways to engage with staff networks with a focus on hearing the voices of staff with protected equality characteristics. The service had staff networks across a wide range of identities including the LGBTQ+ Network, Neuro-inclusive Network, Race Equality Network, and Menopause Network. We spoke with a LGBTQ+ Network representative who told us the network had regular meetings and managers were responsive to concerns raised from the network. The Women’s Network supported the development of SWAST’s first Female Leaders Leadership Development Programme.

Leaders took active steps to ensure staff and leaders were representative of the population using the service. The trust had made significant improvements in their equality and diversity of staff. In 2023, the trust set out aims for improved diversity by 2026 including increasing ethnic diversity of staff to 4% and increasing female operations officer representation to 40% by 2026. In the EDI Annual Report 2024/2025, the trust was on target to meet these goals with ethnic representation increasing from 0.79% in 2025 to 3.39% in March 2026. The female leadership representation overall had increased from 4.42% in 2023 to 44.42% in March 2025 and from 7.93% to 30.93% for the CTM role. GWAAC had done significant work towards engaging female staff in the clinical team and improving gender equality. Several female staff members we spoke with praised the increase of women in management positions.

However, there was inconsistency in workplace support. Staff told us there was a lack of workplace adjustment support available for women and individuals with long term disabilities. Staff with long term disabilities relied on annual leave and were reluctant to take sick days as there was a risk of HR action. In the NHS 2025 Staff Survey, 58.32% of staff with a long-lasting health condition or illness said SWAST had made reasonable adjustments to enable them to carry out their work. This had decreased from 66.04% in 2022.

Leaders did not take sufficient action to prevent bullying and harassment for ethnic minority staff. Thirty-four and a half percent of ethnic minority staff reported in 2025 they experienced bullying or harassment from patients. Twenty-two percent of ethnic minority staff experienced bullying or harassment from colleagues. This figure was especially high because the ratio of ethnic minority staff made up less than 4% of overall staff at the organisation. The percentage of all staff who responded to the 2025 NHS Staff Survey who indicated they experienced discrimination at work from patients/service users or members of the public had slowly increased from 10.05% in 2021 to 12.57% in 2025.

The trust was aware of these ethnic minority experiences and had tasked the Equality Steering Group to identify actions to improve inclusivity within the One Team Model. Following the 2024/2025 EDI Annual Report, the trust set out a 2025/2026 EDI Annual Plan with identified areas of focus and actions.

Although the service had taken steps to improve the sexual safety culture within the service through the One Team model, a few staff told us of instances where they felt sexually unsafe around colleagues. These concerns were escalated through the internal disciplinary system.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. The service had mechanisms to monitor and manage performance and safety. Governance structures were understood by senior staff with bulletins regularly updating staff on service changes and senior appointments. There were escalation lines, risk processes and audit mechanisms which were supported by regular trust calls and daily huddles.

Governance structures enabled the service to monitor and address clinical and operational concerns through multi-disciplinary meetings. Meetings were structured to align with organisational objectives and actions were followed up.

Staff undertook or participated in local clinical audits and staff acted on the results when needed to improve quality of care delivered.

The trust was aware of risks relating to their operational performance and business continuity and took action to monitor, address and mitigate these risks. Risk was monitored through each team and county with clear oversight of the service’s risks.

Policies we reviewed followed national guidance and supported staff effectively. Standard operating procedures and Patient Group Directions (PGDs) were regularly reviewed across GWAAC and SWAST.

The manager to staff ratio had improved as part of the One Team Model, resulting in better oversight and attention to staff wellbeing. CTMs managed one primary ambulance station and supported a team of CTMs in managing multiple stations. However, management of ambulance stations in rural locations was reliant on the proactivity of each CTM.

The trust monitored performance using electronic reporting systems across and within geographical regions through regular meetings and established communication structures. The trust provided a monthly report to integrated care board (ICB) commissioners on SWAST’s performance.

The trust planned for major incidents and events, including increase in population during the summer months. They had clear processes to monitor and address changes in system pressures.

There was a good understanding of internal and external pressures which could impact business continuity. The trust balanced estate and technology changes with business continuity management.

The trust promoted service resilience and understood the components of good governance supporting staff efficacy. The service had recently published the Employee Life Cycle paper which outlined the work cycle of frontline crews and rated the strength of policies needed for certain parts of the cycle to support staff operations. This showed the service had a good understanding of the needs of frontline staff and the importance of clear governance on workforce wellbeing.

GWAAC had clear governance structures. The Enhanced and Critical Care Group met monthly to discuss medical compliance and incidents. All air ambulances, Hazardous Area Response Team (HART), and the Southwest British Association for Immediate Care scheme (BASICs) team attended. BASICs is a scheme where volunteer doctors, nurses, and paramedics provide immediate care to support the local emergency services. Local ground-based crews were invited to attend for learning. Clinical governance ran effectively.

However, staff felt there was a disconnect between organisational pressures and the human element of work. Frontline staff found the pressure to respond to incidents at the start of shift inflexible and did not allow time for CTMs to conduct return to work conversations after sickness interviews to formally approve an individual’s return.

Electronic systems did not always communicate to support managerial decision-making. Some CTMs told us the systems did not speak to each other and so it was difficult for managers to monitor themes such as staffing trends, to support staff. To address this, CTMs had developed local solutions.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Staff and leaders were transparent and collaborated with all relevant external stakeholders and agencies. Strong partnership working contributed to effective service delivery. Shared governance arrangements supported joint decision-making.

Staff and leaders worked in partnership with key organisations to support care provision and service development. SWAST developed Care Coordination Hubs and Single Points of Access (SpoA) with partners providing a central point for staff to seek advice and provide a direct referral into community and specialist services. We witnessed a crew attend a patient who needed bloodwork. The crew coordinated with the SpoA who arranged for the bloodwork to be conducted at the patient’s GP. This has allowed patients to access care closer to home.

SWAST and the Bristol Heart Institute partnered to establish a direct pathway for patients suffering a witnessed cardiac arrest under a certain criteria where their heart could be re-started. The patients were brought to Bristol Heart Institute within 1 hour to undergo a procedure to open a blocked coronary artery. This pathway increased survival with positive neurological outcome.

Senior leadership met regularly with acute trust leadership to ensure the organisations agreed with the timely handover process 45 minutes (THP45) principles to improve ambulance handovers. Frontline staff had good relationships with emergency department staff. The pre-alert system provided adequate information so the emergency departments could prepare prior to the patient’s arrival. The Hospital Ambulance Liaison Officer (HALO) role facilitated clear communication and prioritisation of handovers between SWAST crew and the emergency department. SWAST worked closely with each emergency department when the latter was unable to adhere to the 45-minute handover and followed clear, mutually agreed lines of escalation.

There were multi-agency arrangements to support emergency responses. SWAST worked with external partners including mental health trusts, Police services, Fire services, Coastguard and Royal National Lifeboat Institution (RNLI) to support operations. Staff were eager to cultivate these relationships, particularly with the mental health trust and the police force.

Staff and leaders engaged with people, communities and partners to collect feedback and share learning. SWAST collected feedback from the communities it served through town halls and the Community Feedback Forum to inform the care model.

SWAST was transparent with all stakeholders about their performance and worked together to identify improvements. The trust met monthly with each of the 7 Integrated Care Boards (ICB) in their geographic region to discuss performance and areas for improvement. The trust attended the Ambulance Partnership Board monthly and had regular meetings with the Lead Commissioner for each ICB. SWAST had an identified local operational and clinical lead allocated to work with each ICB in the region.

We scored the service as 3. The evidence showed a good standard. The service focused 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.

There was a clear focus on continuous improvement and innovation across the service. The service had implemented several areas of innovation across medicines management, direct patient care, and quality of care. The trust introduced Urgent Care Medications bags on the Isles of Scilly with medicines any registered healthcare professional can administer with the support of a prescriber from an urgent care background.

Leaders ensured that best practices and learning was communicated to partners. As part of the One Team model, SWAST developed a plan to cascade best practices to areas of the trust and across the southwest health systems to improve system engagement and maintain integrated working.

The service had strong external relationships that supported improvement and innovation. SWAST worked with other ambulance trusts across the country to drive improvements. SWAST captured patient feedback to understand the patient experience of ambulance handover delays as part of an improvement initiative with the National Ambulance Service Patient Experience Group.

The trust had a Research, Audit and Improvement Department which promoted clinical research and continuous improvement in operational performance. SWAST researchers met with the Community Feedback Forum quarterly to inform research projects. As part of SWAST’s focus on understanding and improving staff wellbeing, SWAST had co-published research with the University of Oxford and University of Melbourne into why emergency medical service employees do not seek help for mental support.

Leaders encouraged staff to participate in clinical trial research that drove innovation in the workplace. We spoke with staff who were involved in two trials: ‘Pronto’ pilot and ‘CRASH 4’ trial. The ‘Pronto’ pilot sought to determine whether a stroke was caused by a clot or haemorrhage through a finger prick blood test. The ‘CRASH 4’ trial was a study that assessed the effectiveness of an early injection of tranexamic acid to older adults with mild traumatic brain injury to reduce or delay bleeding, disability and cognitive decline. For each trial, the staff member had undergone training and sought consent from each patient before enrolling them.

However, some staff we spoke with felt they did not have the opportunity or mechanisms to develop and share best practice and innovations across the wider organisation, only with their local teams.