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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

Service leaders and governance processes assured high-quality, person-centred care. We checked that leaders supported learning and innovation and collaborated with partners to deliver care that was safe, person-centred and sustainable.

We saw that leaders promoted a positive culture which enabled staff to develop and provide the best care for patients. Leaders were capable and worked to ensure the long-term sustainability of the organisation. They valued and empowered all staff and encouraged colleagues to speak up if they had concerns. Leaders worked with other services and local communities to build relationships and improve people’s 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.

Leaders and staff told us they were proud of the hospital’s values, which focused on being compassionate, exceptional, ethical and charitable. Staff described these values as underpinning day‑to‑day practice and shaping behaviours across the service.

Despite the recent acquisition by a Metabolic Services Limited as part of Bupa, leaders told us the hospital’s strategy would continue to reflect the needs of the local services it provides. Leaders stated that the Bupa values were consistent with those already in place at the hospital, including a focus on patient care. Staff demonstrated an understanding of the provider’s vision and values and how these applied in their roles. Policies and procedures supported alignment with the organisation’s strategy.

Leaders told us the hospital was in the early stages of aligning with the Bupa governance frameworks. They said the service planned to review and further develop its strategy in line with the wider group to ensure it remains consistent with organisational priorities while continuing to reflect local service needs.

Due to the recent acquisition by Bupa, leaders had intentionally delayed a hospital-wide staff survey during the previous year while the transition was underway. However, they told us they had sought staff views on the acquisition, and feedback had been positive. Leaders also described engagement activities led by Bupa to address staff questions and provide reassurance that the hospital would be supported through the transition. For example, leaders told us Bupa policies were being introduced gradually to allow staff time to adapt without feeling overwhelmed.

When we spoke with Outpatient Department (OPD) staff, they were positive about the opportunities arising from becoming part of Bupa. Staff told us they received appropriate training for their roles and were supported to develop their skills and take on additional responsibility, which allowed them to work effectively and confidently with patients, which improved patient care. They told us they felt confident to make suggestions and provide constructive feedback to colleagues and leaders, and that this would be listened to. We observed staff working effectively as a team to support seamless patient pathways.

Staff spoke positively about service developments, including the introduction of further ‘one‑stop’ clinics as part of the Bupa development. Leaders also described potential opportunities for staff to collaborate across other Bupa group Diagnostics and Secondary Care London (DASCL) sites, supporting shared learning and wider career development.

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,

Leaders at the location were visible, approachable and supportive. The leadership team carried out regular departmental visits, and the hospital ensured a manager was always available to support staff during Outpatient Department (OPD) hours. Staff told us leadership was open, honest and approachable, and that the hospital culture respected the individual needs and preferences of both staff and patients.

The OPD was led by a Head of Department, supported by pre‑assessment services and two OPD leads. These managers held daily OPD meetings to share information, updates and learning. They also used these meetings to recognise staff achievements and encourage teamwork.

Leaders told us they were focused on the future development of the workforce. They were involved in talent‑mapping activities to identify potential future leaders and create pathways into management roles. Leaders also described their commitment to working with Bupa group to expand career development opportunities and collaborative working across the group. This aimed to develop staff but would also open opportunities to increase patient choice in both the range of services available and their location within the whole Bupa group.

Staff told us their line managers were open and supportive, and that they were encouraged to develop skills for their own career development. Hospital leaders recognised staff contribution and long service through a range of initiatives, including bespoke length of service badges, messages shared at all‑staff forums, a staff‑nominated reward voucher scheme, staff newsletters, a “starboard” for peer recognition, and staff social events.

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.

Outpatient Department (OPD) staff told us they felt confident to raise concerns with their OPD manager, other OPD senior leaders or the wider leadership if needed. One staff member described OPD managers as supportive, open and inclusive.

Staff were aware of the hospital’s Freedom to Speak Up (FTSU) arrangements and knew how to contact the FTSU Guardian if they wished to use this route instead of approaching their line manager. Staff told us they had not needed to use this service. They demonstrated an understanding of FTSU principles through their knowledge of policies and mandatory training and were able to describe where to access further guidance.

Senior leaders told us the hospital had retained its existing FTSU framework following the acquisition by Bupa. They explained there were plans to transition to a model more closely aligned with Bupa FTSU champions.

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 policies for the promotion of equality and diversity, with equality standards within its recruitment policy, to ensure staff were treated fairly and there was inclusivity. Data showed that all Outpatient department (OPD) staff had completed the Equality, Diversity training. Some staff had been able to alter their working hours, working flexibility to fit in with their family and other commitments.

Staff told us there was a culture of fairness and inclusion within the OPD and the wider hospital. They described positive, cohesive working relationships and said they felt part of a hospital community. This was supported through team‑based and hospital‑wide activities, including participation in local charity events, staff social events and inter‑departmental award schemes.

We observed a culturally diverse staff group within the OPD service and wider hospital, which did not reflect the local demographic and were told about international recruitment, which was supported by the Bupa group, where the hospital had sponsored international workers.

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.

There were clear processes and systems of accountability in place to support the delivery of Outpatient Department (OPD) services. The hospital had clear management structures, with clear lines of responsibility both organisationally and clinically. There were also structured meeting frameworks that enabled senior leadership and local managers to regularly review operational matters. This included daily hospital‑wide huddles, weekly senior leadership meetings, monthly clinical governance and risk meetings, and Clinical Collaboration Committee meetings. OPD and pre‑assessment teams also held daily huddles. Agendas covered planned procedures, staffing levels, patient safety concerns, incident discussions and maintenance updates.

Processes were in place to ensure patient records were stored securely and managed in line with General Data Protection requirements. Most records were being transitioned to electronic format. Staff told us that paper records were scanned into the electronic system at the end of a patient’s treatment and then disposed of appropriately.

This work was taking place alongside the introduction of new IT systems. These IT systems were developed with input from clinicians and supported most hospital activities, including appointment booking and the requesting and reporting of test results. Leaders and staff used these systems to monitor and manage performance effectively.

Staff and managers were clear about their roles, responsibilities and accountability. The service had policies to support effective risk management. Managers identified and escalated risks and put actions in place to reduce their impact. Safety incidents were shared with staff and investigated by senior leaders to support learning and mitigation.

From January 2026, the hospital began implementing Bupa’s framework for managing risks and providing assurance. This supported more standardised incident reporting across the hospital and wider Bupa group, improving consistency, timeliness and benchmarking, without changing the overall level of incidents or risk.

There were location‑specific risk registers that identified risks affecting the whole hospital and those specific to individual departments. We saw a risk recorded in the OPD relating to the management of patient files by consultants within clinical areas. Staff told us this risk was being addressed through the rollout of the new electronic patient record system, alongside departmental monitoring, staff training and ongoing medical records audits. The service had not reported any data breaches, and patient‑identifiable information was not visible in public areas. At the time of the assessment, the electronic system was being used alongside paper records.

Staff reported incidents appropriately and escalated concerns as required. Managers monitored actions arising from incident reports and worked with staff to implement improvements.

We saw evidence of monthly Integrated Governance and Risk Committee meetings, where incidents were reviewed, and learning was shared. Leaders also discussed updates to national guidance and how these should be implemented across the service. Staff had access to appropriate equipment and technology to deliver care safely. Information governance policies and the new IT systems supported the confidentiality of patient records. Staff told us they could access policies and updates through the service's intranet, supported by regular training reminders, staff newsletters and clinical updates. The service also had up‑to‑date business continuity plans for each department, with guidance on managing unplanned service disruption, such as fire, flood or power outage.

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.

As part of the Metabolic Services Limited, owned by Bupa. New Victoria Hospital operated within the Bupa system of Diagnostic and Secondary Care London (DASCL), supporting collaborative working, shared learning, and access to education resources.

The service had contracts with external providers for the decontamination and sterilisation services, and a contract with an NHS pathology partnership for the provision of pathology services. There were formal hospital protocols regarding patient transfers to local NHS hospitals. We were also told there were shared professional relationships with the local acute NHS trust. Many staff had worked or continued to work within this NHS trust, so knew the systems. This knowledge and the relationships established helped ensure swift and efficient information sharing and prompt care for patients if they were transferred.

Pre-assessment staff told us they worked closely with GPs, to help patients experience a seamless process when admitting patients for gender affirming interventions. Information was shared on how the hospital was involved with local community initiatives and charities, such as the Victoria Foundation and the local Macmillan activities. A staff member was listed as a charity raiser on the Victoria Foundation newsletter. The hospital had also held staff social events, where staff were encouraged to take part in charitable activities.

We saw evidence of the hospital’s links with the local integrated care board, with regard to incident reporting frameworks.

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.

Managers encouraged continuous learning and development for staff. Some staff told us they had been encouraged to learn skills that could help them progress into more senior roles, while others undertook skills development in specialisms within their area of practice. A staff member told us they had developed skills in phlebotomy and minor ops, through their work within the Outpatients department (OPD).

Since our last visit the OPD had extended increasing their capacity for OPD services. When we visited, the OPD department housed 14 consulting rooms, 2 treatment rooms, 1 gynaecology suite, 1 audiology room, 1 cardiac diagnostic room & 1 phlebotomy room. Consultants used these rooms for consultations, including minor medical and surgical treatments. These changes improved patient flow and enhanced patient experience and increased capacity across the site. The endoscopy team had received their annual Joint Advisory Group (JAG) accreditation, we were told the hospital was working towards the paediatric JAG accreditation and that the hospital held CHKS accreditation. There were also members of the OPD leadership team with skills and accreditation in coaching and involved in sustainability initiatives around single-use and unused equipment.