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 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.

At our assessment of September 2018, we rated this key question requires improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

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 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.

Learning from incidents had improved since the last assessment. Staff knew what incidents to report and how to report them. Incident investigations were thorough and used as learning opportunities. Actions to reduce risk were shared with staff and monitored for effectiveness. Investigation processes invited patients to be involved and share their experience to fully understand where improvements could be made.

When errors occurred, patients were informed and received an apology in addition to actions identified as an outcome of investigations.

Between April 2025 and December 2025, 9 safety actions were identified resulting from incidents reported. We saw changes were made because of investigations. This included actions on ensuring calls were not mistakenly or inappropriately disconnected and patients with breathing difficulties were identified. Safety messages were shared with staff, and learning was highlighted in newsletters and daily huddles.

Staff received a debrief and were supported after a patient safety incident.

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.

Staff recorded patient call details and followed national and local policies to maintain patient safety. Nationally recognised triage systems prioritised patients who had the greatest clinical need. Callers remained on the line with patients until help was provided, or the patient’s condition improved. Call handlers escalated patient risks immediately to clinicians for further input if needed. Dispatchers worked closely with health services across the regions to provide appropriate care for patients. This included air ambulance charities, hospital services, police, mental health care and community services.

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.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff shared information with crews attending scenes for their ongoing assessment of safeguarding issues. Safeguarding processes had been reviewed and arrangements for reporting incidents had been more streamlined. Staff attended annual training and could access support from managers and a safeguarding specialist team.

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.

Staff communicated with patients so that they understood next steps, including finding effective ways for patients with communication difficulties.

Staff identified patients who had made advance decisions to refuse treatment and shared this information with ambulance crews. Clinicians followed established processes to monitor patient safety while they were waiting for an ambulance. Information was recorded and assessed further to ensure patients received the right response. Special notes were visible against a patient’s address which provided information in assessing patient risk.

Patients who called with mental health conditions were provided with information in a calm and respectful manner and we heard how this helped patients in reducing anxiety.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The two emergency operations centres were suitable for their intended purpose and were able to accommodate additional staff in times of incident management. Staff knew how to continue their role if there was a breakdown in communication systems. Systems supported staff to indicate when they were unavailable to take calls. The Bristol operations centre had recently been refurbished, and the environment was calm and inclusive for the different teams it housed. The Exeter base was larger, with separate areas between call takers and dispatcher staff. Plans were progressing for a refurbishment of the space to make it easier for teams to work together.

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.

Retention of staff had been a challenge in these roles. Average sickness rates over the previous 12 months were just below the trust target of 8% in April 2026. There had been monthly fluctuations and managers reviewed reasons for sickness. A staffing restructure was in progress and due to commence on 1 June 2026. This was following a recent review and consultation with call handling and dispatching staff. It was designed to create greater support for staff in these roles and provide greater career options. Recruitment processes were also being reviewed to identify candidates’ suitability when applying for these roles.

Clinician numbers had increased to 152 whole time equivalents. Staff used their clinical skills to review patients’ conditions and identify the most suitable pathway for their needs.

Staff had received and were up to date with appropriate mandatory training which included responding to people suffering a mental health crisis. However, some call handling staff expressed a preference for more training in this field.

Staff had completed training in learning disabilities and autism to tier 1 and managers had created a plan for providing all staff with this training to tier 2.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff wore uniforms suitable for their roles. All areas of the two emergency operations centres appeared clean and had facilities for hand washing, keeping food fresh and heating food up at break times. Call handling staff used a nationally recognised script when assessing a patient’s condition which did not immediately identify infection risks. However, staff recorded any issues they identified on the call and shared with ambulance crews attending. For example, if there was a risk of injury or infection from a person at the property.

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. They involved people in planning, including when changes happen.

Staff followed good practice in medicines management and did it in line with national guidance. Where appropriate staff advised patients to take medicines to relieve symptoms and to help prevent their condition worsening. For example, to take aspirin if a suspected heart attack or inhaler for people with known breathing difficulties.