The New Victoria 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

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 patients 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.

This is the first assessment for this service as a stand alone assessment service group. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

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.

The service and the hospital had a shared vision, strategy and culture. The hospital had recently been acquired by Bupa and was therefore undergoing a period of organisational change. Leaders told us they were building on the similarities between the two organisations’ visions and strategies and encouraging staff to recognise these shared values. They said this approach helped staff to understand and engage with the changes.

The imaging department had its own set of objectives, with a stated goal to achieve a high standard of imaging that reflected the hospital’s business plan and best practice. Key objectives reflected a commitment to transparency and fairness, and to promoting equality, equity and human rights. The objectives were issued in February 2026 and were due for review in 2029.

Staff knew and understood the hospital’s vision and values and how they were applied in their work. We saw the hospitals values on posters throughout staff areas in the department.

Leaders and staff told us values were embedded in team communications, training and appraisals. This ensured everyone knew what was expected. We observed a strong focus on these values in the communications and meeting minutes we reviewed.

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.

The hospital and department had clear management and leadership structures, with defined lines of responsibility and accountability. Leaders understood their roles and how these contributed to the safe and effective running of the hospital.

Since the change in ownership, the leadership team had been relatively stable. A new Commercial Director had been appointed and at the time of the inspection, the interim Chief Executive had just been appointed to a substantive position. Leaders were inclusive and understood the context in which the hospital delivered care, treatment and support. They consistently demonstrated the organisation’s values and culture and led the service with integrity, openness and honesty. Leaders had the appropriate skills, knowledge and experience to lead effectively and were credible to staff working within the service. This supported a positive culture where staff felt respected, valued and encouraged to deliver high quality care.

Leaders met regularly through established governance and management meetings to review performance, risks and priorities. Minutes from these meetings showed leaders had good oversight of the service and were knowledgeable about key issues affecting the hospital. Leaders used these forums effectively to make decisions, agree actions and cascade information to staff within the service, ensuring communication was timely and consistent.

Leaders and staff told us they felt well supported to carry out their roles. Staff said leaders were approachable and visible, and that they felt listened to. Staff said concerns were taken seriously and acted on where required. Results from the November 2025 pulse staff survey showed a score of 78 out of 100 in response to the statement, ‘I believe in leadership’s ability to make the transition to Bupa successful’.

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.

The hospital had a Freedom to Speak Up process supported by an up-to-date policy and named Freedom to Speak Up Guardian (FTSUG). The policy provided information on how to raise concerns internally and external to the service. Staff knew who the FTSUG was and how to access support and raise concerns. Information about the guardian and how to contact them was available on posters throughout the department.

Staff and leaders actively promoted staff empowerment to drive improvement. The culture supported staff to speak up without fear of detriment. Leaders encouraged staff to raise concerns and promoted the value of doing so. Staff told us that they felt comfortable to raise any concerns and were confident that their voices would be heard and demonstrable action taken.

Patients and carers were given opportunities to provide feedback on the service they received. Feedback was actively collected and reviewed through the monthly Integrated Governance Committee and was used to inform and support service improvements. We saw that information about the cost of procedures was displayed in the department and discussed with patients at check‑in. This was noted in governance meeting minutes to be introduced in response to patient feedback.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had arrangements in place to promote equality, diversity and inclusion. The Equality and Diversity policy was up to date and set out the hospitals aim to build a fully inclusive organisation and to eliminate discrimination and encourage diversity amongst the workforce.

Staff understood equality and diversity and its importance in supporting a positive workplace culture. Staff had completed training in equality and diversity. They understood the need to give everyone the same rights and opportunities and to value and respect patients’ differences.

Staff said they had access to ongoing professional development. Opportunities for training and career development had been identified as an area for improvement in the most recent staff survey. In response, leaders had taken steps to work closely with Bupa to explore how staff could be supported to access apprenticeship programmes and how training opportunities could be integrated with the Bupa clinical training academy. At the time of the inspection 11 courses were available on the Bupa campus for staff to book onto.

Leaders described how they engaged with staff to monitor culture and identify any potential bias or discrimination. This included regular engagement with teams and the use of staff surveys to gather feedback from different staff groups about their experiences. Leaders told us that since the acquisition, the hospital had access to Bupa inclusion strategies and equality impact assessment processes.

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.

Governance arrangements ensured that essential information, including learning from incidents, complaints and audits, was shared consistently. Standing agendas were in place for team and governance meetings, which included discussions on patient safety, risk management, feedback themes and quality improvement actions. Meeting minutes demonstrated that previous actions were followed up and when necessary unresolved risks were escalated to senior leaders.

Performance and quality were monitored through regular clinical and operational audits. Audit results were presented at governance meetings, and where gaps were identified, improvement plans were developed and re-audited to confirm progress. For example, we saw action taken following an audit of radiology request forms against IR(ME)R requirements (IM006). Actions included recirculating relevant policies and providing feedback to individual staff. A subsequent re‑audit demonstrated improved accuracy in form completion.

An Imaging User Group met quarterly to provide oversight and assurance that the imaging department complied with Bupa New Victoria Hospital policies, the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R), and other statutory and regulatory quality and safety requirements. Minutes from these meetings demonstrated a coordinated and structured approach to governance.

Governance processes supported consistency and learning. Policies and protocols were reviewed regularly and review due dates for documents were monitored through governance meetings. Governance meeting minutes had action points assigned to staff members to review policies and procedures when they were due. All policies we reviewed were in date.

Risk management was proactive and well structured. The risk register was accessible to staff and reviewed regularly by managers and senior leaders. Staff concerns aligned with risks recorded on the register, demonstrating transparency and shared understanding.

There were capital investment plans that included updating the mammography unit, ultrasound equipment and x-ray equipment in the department since the acquisition. Leaders encouraged staff to report concerns, incidents, and breakdowns to support decision making on capital investments.

The department had a business continuity card should the department be impacted by loss of staff, loss of utilities, loss of facilities or loss of external products or suppliers. Managers ensured radiation incidents were fed into risk management structures, and for accidental and unintended exposures, they notified CQC in line with legislation.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The hospital worked collaboratively with the local NHS trust and partnership arrangements supported seamless care transitions.

Leaders understood their duty to collaborate and work in partnership so that diagnostic and screening services worked seamlessly for patients. The service worked constructively with internal departments and external partners to support coordinated care and timely access to imaging. Staff told us they worked closely with the outpatients department to provide support and training related to imaging. They also described established connected care pathways within the hospital, including breast, gynaecology and cardiac pathways.

Leaders said that the acquisition by Bupa provided opportunities for the hospital to work in partnership in a more coordinated way as a part of the Bupa Diagnostics and Secondary Care London campus.

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.

Leaders supported a culture where learning, continuous improvement and innovation were encouraged and embedded across the department. Staff understood how to report safety incidents and said there was a no blame culture, and they were encouraged to report incidents.

There were effective systems in place to ensure leaders had oversight of incidents. Governance meeting minutes showed incidents were reviewed and lessons learned shared with all staff. The department had a structured audit programme. Staff told us they were supported to lead on audits as a professional development opportunity. We saw audit reports were completed by a range of staff.

Staff were encouraged to participate in learning beyond mandatory training, including communication skills and specialist clinical education. Learning opportunities were tailored to service need and staff roles. We saw that leaders had engaged with Bupa to ensure relevant training opportunities in their campus were available to hospital staff.