South Western Ambulance Service NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment 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.

However, the service was in breach of legal regulations for the management of equipment and the environment which was not consistently safe.

This service scored 66 (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.

Staff understood what incidents to report and how to report them. Managers encouraged staff to raise concerns when things went wrong. Incidents were discussed with managers and learning and improvement actions reduced the risk of recurrence. One example was an incident involving a carry chair being placed upside down in an ambulance. This led to a fleet-wide review and changes to prevent recurrence. 

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

There were no incidents reported in the 12 months before our assessment. Staff described a culture of openness, transparency and learning, and understood their responsibilities under the duty of candour.

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.

The booking process captured information needed to provide good quality care. Journeys were most often booked by the local hospital or adult social care services. Staff managed patient transport service journeys around emergency calls and the challenges of the remote locations.

Journeys that involved transfers between ambulances and the boat were planned around tide times to manage the risks involved. Staff told us “safety comes first”. They worked with the local health and social care services when arranging journeys around this to ensure patients made their appointments on time.

Staff were knowledgeable about the criteria for patient transport service and felt confident to manage inappropriate referrals to the service when a booking did not meet the requirements. They gave an example of a time they had been booked to take a patient to the dentist and back and had raised this to the caller as an inappropriate use of the service.

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.

The service had up-to-date policies and procedures which defined staff responsibilities and detailed how to report safeguarding concerns for adults, children and young people.

Staff understood the safeguarding process and knew how to identify safeguarding concerns. Staff received role specific safeguarding training, with level 3 compliance for children and adults at 100%. Staff had access to safeguarding support 24 hours a day for advice.

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 and their families so they understood their care and treatment. This included finding effective ways to communicate with patients who had communication difficulties.

The hospital highlighted patient risks when necessary and the booking process captured information on patient needs. Staff also knew who to contact for clinical support or to escalate concerns. Staff worked with the hospital and other care providers to manage patient journeys around tide times to make sure transfers were safe.

There was an up-to-date restraint procedure for staff to follow, and restraint was only ever used as a last resort. There were no incidents where restraint had been used in the 12 months before our assessment.

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.

Staff carried out daily checks to ensure vehicles were safe. Vehicles had up to date insurance, tax and MOT certificates, and were routinely inspected for safety. The vehicles we inspected were clean and in good condition. There was a process to check vehicles had suitable equipment in sufficient quantities to support patient care.

The service had a process to check equipment was safe to use. Electrical equipment was safety checked. All equipment we checked was within the electrical safety date. There was a process to ensure defective equipment was removed from use.

However, the management of equipment was not consistently safe. We found one Entonox cylinder out of date, and another was rusted so staff could not read the label to confirm whether it was safe for use. We found oxygen cylinders in both the ambulance and on the boat were not secured. This was a risk to staff and service users, as they could move or fall during transit and cause injury. These were removed by staff at the time of our inspection and other cylinders were available which were securely stored. One fire extinguisher was due for service in 2025 and there was no record of this being done.

The premises and storage arrangements were not suitable. Storage areas were cramped, with high shelving. Staff used a kick stool to reach equipment which increased the risk of falls and manual handling injuries to staff.

We scored the service as 2. The evidence showed some shortfalls. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, staff did not have all of the training required for their roles. They worked together well to provide safe care that met people’s individual needs.

The service employed enough staff to meet the needs of service users. The remote locations meant there were sometimes challenges with getting staff to the island and staff worked flexibly to accommodate this. Staff told us there were sometimes difficulties when multiple calls came in at the same time and that emergency calls would be prioritised over patient transport journeys.

Recruitment files were checked and found to contain proof of identification, Disclosure and Barring Service checks, references and employment history. Staff received an induction covering the initial training requirements for the role, as well as a local induction specific to the challenges of the remote location. Staff completed a driving assessment as part of their induction, and annual checks of driving licences were completed.

Staff were up to date with mandatory training which was comprehensive and met the needs of the patients and staff. Data showed overall compliance was 96%.

Staff who had contact with patients in person or on the phone were required to complete 2-tiered learning disabilities and autism training. All staff had completed tier 1. However, no staff had completed level 2. The trust had plans to improve training in learning disabilities and autism by introducing a new tier 2 training package which went live prior to our onsite assessment in April 2026. Their target was to have trained over 85% of staff who required this training by March 2027. This training is important to enable staff to reduce significant health inequalities.

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.

Staff protected patients from the risk of infection by maintaining the environment and equipment to ensure they remained visibly clean and tidy. Staff cleaned the vehicles weekly, as well as after a person had been transported. The vehicles were deep-cleaned at least every 12 weeks. Testing was completed to check the effectiveness of cleaning. Staff received training in preventing the spread of infections. If vehicles needed deep cleaning between jobs, staff told us they would travel back to base or use hospital equipment.

The service assessed and managed the risk of infection. The booking team collected details around patients’ infectious status when transferring into the service and staff monitored infection risk when transferring patients to enable them to take precautions. The service supplied personal protective equipment (PPE) for staff to carry out their duties safely.

The service completed monthly audits to provide assurance patients were provided with safe care in line with infection prevention and control standards. The service had undertaken a review of infection prevention and control practices on the Isles of Scilly in September 2025. The result showed compliance was 79% and an action plan had been implemented to improve this. However, there were still some issues. For example, bird droppings were present on walls and ceilings in the garage which was an infection prevention and control risk.

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 safe practice in medicines management, including the use of controlled drugs which were stored in a locked cupboard in the garage.

Although staff did not routinely administer medicines during patient transport, they were authorised and trained to administer oxygen if required. Staff maintained records of medicines administered and remaining stock in line with national guidance.