St John Ambulance - South Region

On this page

• 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 rated well led as requires improvement. We assessed 5 quality statements on leadership, including freedom to speak up and governance. Local leaders understood the challenges faced by the service but were not always visible or accessible to staff. Local leaders had the knowledge and skills, however changes to the providers leadership team during the assessment period September 2023 to July 2024 created a period of instability. The service lacked a shared direction and there was a negative culture amongst staff. Due to a change in commissioned services from the NHS, the service was undergoing a consultation process with some employees at the time of our visit. Some services were likely to stop running because of this, although some services were likely to continue. There were clear governance systems, but we found out of date policies, lack on systematic audits, lack of staff appraisals and there were sustainability risks to the service. Staff were not confident to speak up and reported bullying and poor incident reporting to the CQC, although leaders responded to our concerns when we asked for evidence the risks were being mitigated. However, the service worked well with NHS organisations to repatriate adults and children to various hospitals across the patch although staff told us that staffing levels were at times reduced. Also, the service had recruited a new chief executive who was due to start in September 2024 and there was a plan to deliver a strong leadership presence and a new strategy in 2025.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Urgent and emergency care operations leaders worked hard to maximise the effectiveness of people’s treatment and care. However, financial pressures had led to changes to the leadership structure and difficult decisions regarding the reduction of fleet emergency vehicles, reduction in substantive staff and streamlining of regulated activity work for NHS trusts. Not all staff were happy with the changes. The CQC received 42 information of concern cases from staff who were concerned that leaders had compromised safety because they had lost sight of the challenges staff had faced. Although, during interviews with leaders they explained that safety was considered when making changes to staffing and fleet management.

The current strategy had been due to be reviewed this year but a decision was made to extend the review until new leaders were settled in their roles. The impact of this was that staff felt disengaged and concerned about the financial viability of the service. Leaders had implemented some strategies which were under review such as, moving oversight of clinical education to clinical operations to review training products and delivery methods. The People and Culture team developed a 3 year culture plan and aimed to deliver this by 2026.

Staff we spoke to felt that leaders had the skills to manage the service. However, some staff felt that organisational change had undermined safety. The CQC received 42 anonymous concerns in the South region, staff told us they did not feel the organisation was transparent, they felt that their concerns were ignored, the service was not inclusive and that some local managers and trainers were inappropriate and unprofessional. Some staff told us that leaders lack capability to make the necessary improvements to increase NHS contracts and increase income. Also, some staff raised concerns about sexual safety at work. It was clear there was a disconnect between what managers believed and what staff felt. It was unclear if all the concerns were raised by volunteers or substantive staff.

The service was experiencing a period of change, there had been a shift in the leadership team. These changes had been initiated by the need to align services to the financial landscape. Local operations lead oversaw the day to day running of services although not all ambulance hubs had visible leaders. The main Brighton location was registered office for the South region. The current operations manager was leaving and the interim operations manager, who also worked voluntarily for the service, would be increasing their geographic responsibility in their employed role. The CQC heard conflicting information regarding the local leadership team, and the staff survey commissioned by the CQC reflected these concerns because staff told us that managers did not always act on feedback or respond well to incident reporting. Service leaders also recognised the impact of the changes on staff during this period of instability and confirmed that they had not commissioned a staff survey for 2024 and some staff told us they had not had an appraisal in the last year. As a result of an independent survey commissioned by the CQC in 2023, the St John People and Culture team developed a 3-year plan which is aimed to be delivered by 2026.

Leaders told us they had a process to enable staff to speak up. Staff did not feel able to speak up. After our last inspection the CQC commissioned an external staff survey for the whole of St John Ambulance operations. The results were fed back to the provider in September 2023 and records showed that the provider acknowledged the concerns. The survey showed that 196 staff from the South region responded to the survey. The 'Assurance & Quality' team carried out an assessment of ambulance operations, the assessment team spoke to approximately 100 crew members across England. One of the questions asked was do you feel supported by your leaders and do you know how to raise a concern if needed. The final report of this assessment was shared with the Director of Urgent & Emergency Care with a plan to look at the next steps of the assessment although the plan was not shared with the us. Staff in the South region continued to remain unhappy with the shared direction and culture. During the period January to July 2024 we received 41 anonymous qualified disclosures from staff working for the service raising concerns about lack of leadership, poor culture and safety. Because of the concerns raised we took the decision to inspect the service. Concerns ranged from a bullying culture, inappropriate sexual behaviour, poor driver training and monitoring of drivers, lack of equipment, data breaches, limited access to working vehicles and medication errors. Because of the anonymity of the concerns it was not clear which locations staff were raising concerns about. St John Ambulance – South region covers a vast area, which runs from the tip of South West England to Cambridge and Norfolk. Therefore, we were not assured that staff were able to voice their concerns constructively.

The service did not have a freedom to speak up (FTSU) policy, although staff could access a FTSU framework via the providers intranet pages. Speaking up was also woven into various other policies like the 'Anti-bullying, Harassment and Victimisation policy' and 'Incident Management Policy'. Across the South region there were 5 FTSU advocates but they did not have protected time to respond to concerns. The service had a freedom to speak up (FTSU) guardian who was also the Director of Governance although this was due to change during the assessment process. They explained that FTSU is not designed to be its own thing, but an umbrella term for every type of speaking up. Freedom to Speak up processes were not compulsory for the service although the National Guardians Office expect primary care provider organisations to appoint a freedom to speak up guardian and strategy. The CQC found that the FTSU process was ineffective for several reasons. The service process appeared to foster a blame culture by the language used in incident reports. The provider produced a presentation report called changing the way we look at incidents. The report looked at the freedom to speak up process and how investigations occured. The words blame and fault were used, the use of this negative language does not foster a culture of fairness and openness. Incident reviews are primarily designed to identify and share learning and when individual practice is substandard, staff should be supervised to improve through the performance process. Also, after the inspection we continued to receive anonymous information of concern and as a result of this asked the provider to issue a statement to assure staff they could speak confidentially to CQC. The Director of People and Culture issued a statement which included links to FTSU online form, the links to whistleblowing arrangements where staff could speak to an external organisation in confidence.

Most staff felt the service celebrated diversity and was inclusive. However, many staff did not feel that the service had a fair culture and there were claims of sexually inappropriate behaviour from 4 anonymous staff working in the South region. Leaders told us they were working to make improvements to the service and the 'People and Culture Committee had committed to implementing a 3 year improvement plan to be rolled out by 2026.

The provider developed a 'Workforce Equality, Diversity and Inclusion' policy which was last reviewed in 2022 which outlined the providers values which were humanity, excellence, accountability, responsiveness and teamwork. Leaders had plans to develop a safe open and supportive culture. The policy provided clear information on how to make complaints and speak up. However, leaders had made the decision not to commission a staff survey for 2024 as they felt the service needed to implement its transformation and wait for the new Chief Executive to start work and embed the planned changes. However, this meant staff were not enabled to voice their feelings and this was a missed opportunity to review staff wellbeing during the change process.

Staff used a personal digital assistant (PDA) to report incidents and near misses. All staff we spoke with were aware how to raise an incident and could show us the reporting system. Staff showed they understood what constituted an incident and told us they were encouraged to report incidents. Staff we spoke with understood the need to be open and transparent with patients. Staff told us they always tried to resolve any issues or complaints at the time they were raised. If this was not possible, patients could be referred to local leaders or more senior members of staff. Staff could explain how information about incident and complaint investigations was used to prevent similar situations occurring in the future, with findings and resulting actions being discussed and cascaded to the team though meetings and bulletins. The CQC received 8 anonymous information of concern cases about leaders not being open about incidents and leaders discouraging staff from reporting incidents. Staff we spoke to advised as that there was an issue with the current IT system in collating themes and trends, but the leadership team were aware of this. Incident data showed meaningful investigations had taken place. Leaders told us that the amount of contracted NHS service level agreements had been reduced. This was confirmed by one third party organisation who did not use the service very often since the Covid pandemic. After the inspection minutes shared from the CQC concern and response team showed that not all equipment failures were reported by crews via the incident reporting system. Fault reporting via the assessment management system from Jan 2024 to date showed that 11 faults associated with Stryker load trolleys. However, a review of St John Ambulance (SJA) incidents showed only one to have been reported as an incident. The others were reported via the fault reporting system.

The Director of Governance did not work in the South region but was responsible for governance across the service and reported to the board. There was no designated local governance lead, although the Ambulance Operations Manager was expected to manage governance as part of their role and reported to the Director of Urgent and Emergency care operations who had a clinical background and proven track record at managing services. The service had a bid team who submitted bids for local NHS contracts based on the number of staff and other resources. The Director of Urgent and Emergency care operations was involved in regular calls with stakeholders to ensure the provider was meeting the needs of the NHS service and Ambulance Operations Managers were responsible for producing monthly reports for the NHS services which included vital information like staffing, vehicle arrangements, incident reviews and patient journey information. The service had a number of service level agreements or memorandum of understandings with some NHS Urgent and Emergency ambulance services. Although, workload had varied since the Covid pandemic. Leaders had a meeting structure for audit and risk, a people committee, a clinical governance committee and a quality and safety committee. Although, the service was in the process of recruiting a new Director of Quality and Safety. The service did not always clearly capture incident themes, this is because the digital system required improvements which meant some data was still captured manually making it more time consuming to assess. The service completed monthly operation reports for their repatriation services. There were 3 main risks to the service, the overall costs of buildings, a recognition of the 30% reduction in paid staff, and financial sustainability. Sustainability was reviewed via operations reports which were published bi annually for the NHS contracted work. Sustainability concerns were voiced in the most recent reports.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.