Archived: King Edward VII's Hospital

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

The relatively new leadership team were effectively managing a period of significant change, supported by business planning and a strong focus on staff support. There was evidence of an inclusive culture of continuous learning and improvement. Leaders worked together to deliver safe, person-centred, and sustainable care. While new staff brought fresh perspectives, all employees were navigating a high level of change, presenting both challenges and opportunities.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good. We found that the service remained well-led, with clear leadership and a continued focus on improvement, but some aspects no longer reflected the highest level of performance.

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.

Leaders demonstrated a shared vision, strategy, and culture, which was communicated through listening events, staff briefings, and surveys. Staff were encouraged to contribute their views and showed understanding of how their roles aligned with the organisation’s goals.

The hospital had undergone a significant transformation through an ongoing change programme. Leaders were reshaping many aspects of service delivery. As a result, some staff reported uncertainty and anxiety. This was also reflected in staff survey feedback.

The introduction of new leadership added a further layer of adjustment, contributing to a sense of instability. However, this change was widely seen as a positive step toward a more resilient and forward-looking future. Leaders acknowledged the emotional and operational challenges and actively listened to staff and service users through structured feedback mechanisms, acting in response.

Risk management and strategic delivery were supported by a business continuity plan, which identified key risks, actions, and owners. Progress was monitored through key performance indicators, dashboards, and consideration of local factors in planning.

Leaders demonstrated a commitment to equality and diversity requirements through a clearly stated Philosophy of Care. Staff provided people with respect for all religious and cultural beliefs. Staff championed inclusion and individual choice, and ensured that care was delivered with dignity, empathy, and compassion in a supportive and personalised environment.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support, and embodied the culture and values of their workforce and organisation. Leaders demonstrated the skills, knowledge, experience, and credibility to lead effectively, acting with integrity, openness, and honesty.

Leaders had the experience and capability to deliver the organisational vision and manage risks. This was evidenced, for example, in strategic decision-making and the use of risk registers. While some staff expressed concerns about the responsiveness of the senior leadership team, this was being addressed through early stage listening events and ward visits. Feedback from these sessions was used to inform changes, demonstrating a commitment to improvement.

Leaders encouraged a positive culture where people felt they could speak up and their voice would be heard.

Leaders had established mechanisms to support speaking up, including 2 Freedom to Speak Up Guardians. While some staff, particularly those who had worked at the provider for a long period of time, felt anxious about raising concerns during this period of change, others reported feeling able to speak up.

Listening events and ward visits had been introduced to encourage open conversations with leaders and staff, though these were still in the early stages. There was evidence that feedback was being acted upon.

Leaders valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders and staff demonstrated an understanding of equality, diversity, and inclusion. Staff received relevant training, and care was delivered in a culturally sensitive and inclusive manner, reflecting the diversity of both the workforce and the patient population.

Staff had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The governance team included an associate director of governance, a complaints manager, a quality lead, and a patient safety lead.

Leaders met regularly at a range of quality and safety meetings to look at governance. Compliance, safety and quality topics on agendas included clinical audit compliance. We looked at data for April to December 2024 where audit results fell short of their key performance indicators. For example, pharmacy audit results were 86% compliant where the target was 95%. All audits that did not hit the required target had a robust associated action plan that was monitored through the Patient Safety Committee.

Leaders implemented a comprehensive business continuity plan, outlining key risks such as power failure and staff shortages, with clearly defined actions and designated owners to ensure accountability and resilience. Staff attended a daily meeting where any issues were highlighted.

Staff understood their duty to collaborate and work in partnership to work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

Staff worked closely with external partners, including local hospitals and social services to ensure continuity and coordination of care, particularly for patients with complex needs. This collaborative approach supported smooth transitions and helped maintain consistent, person-centred care across different settings.

Internally, staff held regular multidisciplinary meetings and daily cross-departmental huddles to share updates, learning, and feedback. These meetings included representatives from various areas, promoting transparency and collective problem-solving. Listening events were also held to encourage open dialogue and remove hierarchical barriers, further strengthening team cohesion and shared responsibility.

Learning from incidents and complaints was actively shared among staff, and improvements were made as a result. This culture of openness and collaboration extended beyond the organisation, reflecting a commitment to continuous improvement and seamless care delivery through effective partnerships.

Staff focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

Leaders showed a commitment to staff development through a wide range of formal learning opportunities. These included accredited qualifications that supported both individual growth and team performance. The provider worked closely with local universities to support staff in further education.

Staff were supported to complete master’s degrees and continuing professional and career development. For example, health care assistants trained to progress to a mammographer. All training was regularly reviewed and improved based on staff feedback to ensure it remained accessible, relevant, and effective.

Leaders supported innovation and improvement by actively engaging with the Independent Healthcare Providers Network (IHPN). Staff attended key events such as patient safety conferences, and local community practice sessions, with shared learning fed back into governance.

The Infection Prevention and Control (IPC) team led several improvement campaigns, including the ‘Glove Off’ initiative to boost hand hygiene and reduce waste. IPC staff led a campaign on inoculation injuries supported by sharps safety training. The hospital also took part in World Hand Hygiene Day each year, reinforcing its commitment to safety and best practice.

Staff drove innovation through new safety initiatives. A medical device passport was launched to record staff competencies for the safe use of medical equipment. The medication safety officer led efforts to raise awareness around antimicrobial use and supported its reduction, further strengthening the hospital’s commitment to safe and effective care.

Leaders committed to maintaining high standards through recognised accreditations. The Cancer team actively working towards Macmillan Adoption.

The hospital was awarded VTE Exemplar status in 2023 and continued to uphold those standards.