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 patient 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.

At our last assessment we rated this key question Good. At this assessment the rating has remained 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 had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives.

Leaders had a clear vision and strategy for the service, aligned to the wider provider objectives and strategic direction. This included a focus on delivering high-quality, patient-centred care, expanding core services such as orthopaedics, gynaecology, endoscopy and diagnostics, and improving access to diagnostics and treatment pathways.

The strategy set out plans to optimise capacity, develop connected care pathways, and enhance digital systems to support efficiency, patient experience, and clinical outcomes. Care pathways were designed to provide rapid access to “one‑stop” clinics, where patients could undergo consultation, diagnostic tests (such as imaging and biopsies), and initial treatment planning on the same day or within defined timeframes. For example, within the breast pathway, patients were seen in clinic and received imaging and biopsy on the same day, with results available within a few working days.

The services’ strategy also included longer-term ambitions to expand services, increase clinical complexity, and develop innovative models of care, particularly within day case pathways.

Staff we spoke with were aware of the service’s goals and could describe how their roles contributed to delivering these objectives. Leaders described ongoing work to monitor performance against the strategy through regular review processes, including executive and performance meetings.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration.

Staff felt motivated about the future and planned changes for the service. Leaders recognised that staff had initially been apprehensive about becoming part of a larger organisation; however, they reported that staff increasingly recognised the benefits of the transition. Staff were described as now being more motivated and able to see the advantages of moving from a charitable model to a larger organisation.

Leaders said staff understood the future direction of the service and were engaged in delivering planned developments, reflecting a shared sense of purpose across teams. They described the period since 2024 as a challenging transition, including organisational change and system implementation, but reported that staff had maintained patient experience during this time. Leaders also described a management approach focused on empowering staff and encouraging their active involvement in service design and improvement, supporting the development of a positive and inclusive culture.

The service had systems in place to recognise team and individual staff achievements, including a monthly award scheme. Leaders told us that staff could be nominated by both colleagues and patients, and these nominations were reviewed as part of the recognition process.

Recognition of staff contributions was communicated through local channels, and leaders told us that staff received acknowledgement for their work as part of this approach.

We scored the service as 3. The evidence showed a good standard. The service had 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 usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

The service had a defined leadership structure. Overall responsibility sat with the Director of Clinical Services. Reporting into this role were the Inpatient Services Manager and the Theatre Manager.

Under the Inpatient Services Manager, there were operational leads for key areas, including the inpatient ward and day surgery unit. The inpatient ward (Alexandra Ward) was led by a ward lead supported by senior staff nurses, staff nurses, a healthcare assistant, and administrative support roles. The day surgery unit was led by a day unit lead, supported by senior staff nurses, staff nurses, healthcare assistants and patient services staff.

The theatre service was managed by the Theatre Manager, supported by a deputy theatre manager and a range of clinical and operational leads, including general surgery, anaesthetic, recovery, orthopaedic and endoscopy leads, alongside administrative and sterile services support staff.

Leaders were visible and accessible to staff. Staff reported that senior leaders were regularly present within clinical areas and could be approached directly. Leaders were available during working hours and through on-call arrangements out of hours. Communication channels included face-to-face contact and electronic messaging systems, which enabled staff to contact leaders and share information as required.

Leaders had a range of experience, skills and abilities to run the service. They understood the priorities and challenges within the service and were able to respond to issues as they arose. Leaders were described as approachable by both staff and patients, and staff told us they were supported to develop their skills and take on more senior roles.

Leaders reviewed incidents and concerns raised and took action as required. They maintained oversight of service delivery through regular presence in clinical areas. Staff and patient feedback was collected and reviewed, and leaders told us this information was used to inform service improvements.

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.

Staff and leaders described an open and transparent culture within the service. Staff told us they were able to raise concerns and share ideas and felt able to do so without fear of detriment. When concerns were raised, leaders responded and undertook investigations as required, with staff reporting that these were handled sensitively and confidentially. Serious concerns, including those raised through whistleblowing, were escalated to senior leadership and provider level in line with established processes.

Systems were in place to monitor and review concerns. Risk registers and management reports recorded issues raised, alongside analysis of themes and trends over time and associated action plans. This supported oversight of risk and ongoing monitoring of improvement actions.

Patients, families and carers were provided with information on how to raise concerns or complaints. Staff were encouraged to address concerns at the point of care where possible to support timely resolution. Where concerns required formal investigation, this was supported by established policies and procedures.

Resident Medical Officers (RMOs) described positive working relationships with consultants and told us they felt able to raise concerns. There were established processes to support RMOs to escalate issues, and leaders described that these were reviewed and acted upon.

Freedom to Speak Up arrangements (FTSU) were in place. The service had a designated FTSU Guardian, and leaders told us that speak-up processes were promoted through mandatory training and regular forums and was supported by a FTSU policy.

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.

Leaders took steps to promote equality, diversity and inclusion within the workforce. Staff told us they had opportunities to apply for project work, new roles and external development through open and transparent application processes. Leaders described recruitment, development and progression processes designed to support equality of opportunity across staff groups.

The service had arrangements in place to prevent and address bullying and harassment. Staff reported they felt treated fairly and were able to raise concerns about behaviours where required. Leaders described a focus on ensuring an inclusive working environment, including support for staff with protected characteristics and those from marginalised groups. This included flexibility in working arrangements and shift patterns where appropriate. Some staff told us they had received adjustments to their working arrangements, including changes to working patterns, without needing to formally request them.

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 this information was reviewed and used to inform actions to support workforce experience and inclusion.

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.

The service operated governance processes through a range of committees and local activities. For example Integrated Governance, and Risk and Compliance Committees provided oversight of safety, quality, and risk management. These meetings monitored performance, reviewed incidents, and analysed trends to support improvement.

A range of data and information was collected and reviewed through these governance structures, including clinical indicators, incidents, risks, and quality metrics. This information was discussed at committee meetings, used to benchmark performance across the provider’s hospitals, and informed the development and monitoring of action plans where improvements were needed.

There was a medical advisory committee (MAC) led by a chair and supported by the service leadership, who were responsible for approving practising privileges and reviewing clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared via surgery and hospital daily huddles, team meetings, emails, and electronic messaging services.

Risks were identified and recorded on a formal risk register, which was used to monitor risks and track mitigating actions. The hospital risk register showed that risks were regularly reviewed and had actions in place to manage or reduce these risks. For example, a risk relating to unauthorised access to the inpatient ward was documented, with actions recorded to mitigate this risk.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to positive changes. For example, storage within theatres had improved following concerns raised in the environmental audit.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans such as fire, flood, and power failure.

The service had not reported any data breaches, and systems in place were secure. Patient identifiable information was handled appropriately and was not on display in public areas. The provider had introduced a new secure, electronic patient record system, which was being used alongside paper records at the time of our inspection visit.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

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.

Staff and leaders worked collaboratively with external stakeholders and agencies to support patient care and treatment. For example, in relation to gender affirmation procedures, the service worked with NHS services, gender dysphoria clinics, and community providers to support continuity of care across the patient pathway.

This included coordination of referrals, sharing relevant clinical information, and ensuring appropriate pre-operative assessment and post-operative follow-up. The service also engaged with specialist teams, including wellbeing and mental health support services, to provide additional support where required.

The hospital had service level agreements with a range of partners, including local NHS trusts, ambulance services, pathology and critical care networks, to support safe transfers, diagnostics and emergency care.

Leaders and staff engaged with patients, staff, equality groups, and external organisations to plan and manage services. For example, the service involved peer support workers as part of the wellbeing team for patients undergoing gender affirmation procedures. These individuals, with lived experience, provided additional support alongside clinical teams.

Leaders told us this approach was used to gather patient perspectives and inform service development, particularly in ensuring care pathways reflected the needs of people using the service.

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.

Staff and leaders were committed to learning and improving services. There were processes in place to support learning from incidents and the sharing of good practice at both local and wider organisational levels. For example, changes had been introduced following feedback, including the development of a wellbeing team to support patients undergoing gender affirmation procedures.

Staff demonstrated an understanding of quality improvement approaches, and leaders described opportunities for staff to develop skills in this area. Staff were supported to undertake additional training and development. For example, a diabetes lead role had been developed, with the postholder supported to complete further study at university level.

Leaders also supported the development of specialist roles to improve services. This included establishing three clinical nurse specialist roles within the gender affirmation service. Staff told us they had opportunities to share learning and contribute to service development, including participation in external events such as international conferences.

Leaders told us staff were supported to contribute to service improvement and pursue areas of interest relevant to patient care. Where service needs were identified, staff and leaders worked together to develop and implement changes. The service had also introduced an electronic patient record system as part of ongoing service development.