Royal Sussex County Hospital

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• 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 reviewed 6 quality statements for the key question well led. 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 people 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 requires improvement. At this assessment, the rating has remained requires improvement. This meant the service was not always consistently managed and well-led. Leaders and the culture they created did not always provide high-quality, person-centred care.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 vision and values of the service were clear, person-centred, and included honesty, compassion, equality and safety. Department managers led by example and monitored practice against the trust values. The emergency department adopted the wider vision and values of the trust. Staff had chosen the organisational values alongside patients and the public. They were compassion, communication, inclusion, respect, teamwork, and professionalism.

Department managers ensured that staff in all areas understood and supported their vision for the department. Staff were frustrated about the situation the department found itself in but did not feel the responsibility was held by the department leadership.

Staff fostered a person-centred culture that was open, inclusive, and empowering. Department managers and staff demonstrated a strong understanding of equality, diversity, and human rights, and prioritised safe, high-quality, and compassionate care. Staff consistently showed kindness, dedication, and a strong work ethic in caring for patients. Department managers modelled these values and actively supported their teams. However, wider organisational support for the department was limited. Staff gave positive feedback about their managers, describing them as doing the best they could under challenging circumstances.

Leaders demonstrated a clear understanding of the local demographics and social needs of the Brighton area. They adapted the department to reflect these needs, recognising that 10% of attendances involved patients with mental health needs. In response, they created dedicated spaces within the department to support patients who required extended stays due to mental health concerns.

In the 2024 NHS Staff Survey, the trust saw a slight increase in staff agreeing the trust takes positive action on health and wellbeing. However, this remained below the national average.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Feedback from both staff and department managers found that the trust leadership team were not always visible in the department and at times left the staff and department managers and leaders to solve numerous challenges. Staff found this disheartening and isolating. It left department leaders in an uncomfortable situation because they were not empowered or given the support to continue to run the department safely.

Department managers led with integrity, openness, and honesty and made sure they aligned to the organisational vision when possible. Medical and nursing staff and leaders understood the key risks to the department. They understood the issues, challenges and priorities in their service, and beyond. However, risks were not managed. Department managers and leaders had escalated and recorded risks associated with overcrowding, unsuitable environment, staffing provision, IPC risks and the use of temporary escalation areas but there was a lack of action at an executive level to recognise these risks and their severity.

Department managers had the skills, knowledge, experience, and credibility to lead effectively. However, we were concerned that, the wellbeing of the department leadership team was impacted given the number of significant challenges within the department. In addition, we were concerned that departmental leaders were not having their own development and learning needs met.

Department leaders told us they felt helpless and upset with the way they had been treated by their line managers. They demonstrated how they escalated many of the department issues and the lack of response from their line managers.

Several ‘end of shift’ manager reports showed a situation where department leaders were managing extreme risk without sufficient staff provision. Staff escalations to department managers were acted upon but beyond the triumvirate leadership level, there was not a clear or timely response or understanding to the concerns the department faced. This demonstrated a significant failure of communication and disconnect between the senior leadership team and the department.

Clinical leaders told us they had raised concerns in writing on several occasions about patient safety, high acuity patients being cared for in inappropriate areas of the department and overcrowding but did not receive a response.

Since the assessment, trust leaders have taken initial steps to improve oversight of the department and manage patient flow more effectively. They prioritised ending the use of temporary escalation areas for patient care and introduced escalation processes to monitor these areas when occupancy exceeded a set threshold. Senior leaders instructed department managers to relocate their offices within the department to enable quicker escalation and response.

The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard. Staff told us there was not a culture of speaking up within the department. While department managers initially supported staff who raised concerns, they reported that these concerns rarely led to meaningful action or consequences. Staff experienced high levels of stress and pressure, which contributed to low morale. As a result, well-qualified, committed, and competent staff left the department, citing a lack of improvement despite raising concerns.

Department managers told us that when they escalated issues, their line managers and senior leaders rarely acknowledged or investigated them. Trust leaders did not consistently act on feedback from the Freedom to Speak Up process, and staff remained unclear about how their input was used to prevent recurrence of similar issues. Managers expressed frustration and uncertainty about the outcomes of raising concerns, which made it difficult to maintain open communication with their teams.

Although department managers and leaders welcomed feedback and appreciated staff who spoke up, they reported significant challenges when raising concerns with their own line managers. In August 2023, the trust introduced an external Freedom to Speak Up service, with a planned review in August 2025. However, staff told us they did not know who the Freedom to Speak Up Guardian was and the trust could not provide data on how frequently the service was used or identify any emerging themes or trends. While the service met basic requirements, the trust did not offer suitable support for staff who spoke up.

The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Department managers and leaders demonstrated proactive oversight by running internal status reports alongside daily safety huddles. They escalated capacity concerns to senior leaders using a colour-coded system. However, managers consistently reported that the escalation protocols did not resolve overcrowding, which had become an accepted norm within the emergency department.

Senior leaders did not take sufficient action during periods of overcrowding, and this failure compromised patient safety. Trust leaders did not consistently use accurate or comprehensive information to inform decisions about risk, performance, and patient outcomes. Communication about operational pressures within the department did not reliably reach senior leadership, and the point of failure in this communication pathway remained unclear.

Department managers said that the OPEL system did not reach level 4 due to the hospital always having an intensive care bed available for very unwell patients. Department leaders told us the flow issues were seen by their line managers as the department’s problem to fix. The department situation rarely placed the wider hospital into elevated OPEL Level 4. This was the highest escalation available to the hospital and would alert system partners that could provide greater support and resources.

Consultants reported that multiple layers of management created barriers to direct communication with decision-makers, which reduced the urgency with which senior leaders addressed departmental issues. They described how information was often filtered through several tiers, leading to miscommunication and a lack of confidence that accurate information reached the executive team.

Senior clinical staff highlighted a disconnect between clinical and operational decision-making. They told us they were not engaged or involved in decisions that directly affected their roles, which contributed to a sense of disempowerment and reduced confidence in leadership processes.

Trust leaders engaged with wider improvement programmes, including Getting It Right First Time (GIRFT), and sought external advice through NHS England (NHSE) visits. However, staff told us that leaders did not implement the recommendations from these initiatives, which was a source of frustration to the department.

Systems and processes did not effectively manage current or future risks. Managers and leaders recognised the top risks on the departmental risk register, temporary escalation areas, mental health provision, and infection prevention and control (IPC). During the assessment managers clearly articulated their goals for managing these risks but were unable to achieve them due to ongoing challenges with patient flow and discharge processes across the hospital. Critical incident and OPEL frameworks were not consistently escalated in a timely manner, which contributed to poor patient flow. As a result, the emergency department remained an unsuitable environment for caring for admitted patients, limiting staff’s ability to optimise care and mitigate risks.

Despite these challenges, department managers and staff maintained clear roles, responsibilities, and systems of accountability. Suitable arrangements were in place to ensure the availability, integrity, and confidentiality of data and records. Staff used information to monitor and improve care quality within the emergency department. However, the use of multiple IT systems across different specialties created difficulties in patient processing, leading to delays and further impacting flow.

The trust had business continuity plans for emergencies and natural disasters. While a draft evacuation plan was in place, the mass casualty plan remained under development. Staff raised concerns about fire safety and evacuation procedures, noting that previous practice scenarios had been unsuccessful. The hospital had conducted major incident simulations with key staff to improve preparedness.

Leaders had access to a good range of accurate and timely data to understand performance and quality. The Acute Floor Improvement Group met monthly with a fixed agenda covering service reports, divisional board feedback, and improvement planning. Meetings were well attended, and minutes were shared with the wider team to support learning. Actions were tracked and reviewed at each meeting.

Departmental governance meetings fed into the wider emergency care and medicine triumvirate governance structure. These meetings followed a standardised agenda and reported to the Clinical Outcomes & Effectiveness Group and the Quality Governance Steering Group. Leaders regularly reviewed the departmental risk register, which included concerns around corridor care, staff wellbeing, mental health care, medicines management, and funding. We reviewed the risk register and risks were appropriately rated and aligned with the concerns identified during our assessment.

The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Senior leaders outside the department did not consistently share information or collaborate with system partners when the department faced operational pressures. Staff told us that senior managers failed to escalate issues to the wider system during periods of overcrowding. For example, ambulance services were not always informed when the department experienced challenges with patient flow and acuity.

Staff reported that senior managers beyond the department and triumvirate concealed problems rather than addressing them. They described feeling pressured and bullied not to disclose difficulties, and department managers confirmed they were not always protected from bullying and harassment.

Trust-wide inaction on flow challenges limited the effectiveness of improvement schemes within the department. Despite this, department leaders and staff remained open and transparent. They actively collaborated with external stakeholders and agencies to support patient care.

Staff worked effectively with the local ambulance service, demonstrating flexibility and responsiveness when notified of incoming trauma cases. They valued the information provided by ambulance crews and used it to facilitate detailed handovers, enabling safe and timely care.

Department managers and staff understood their duty to collaborate with patients and partner organisations to ensure services worked well for people. For example, managers held multidisciplinary meetings with the local mental health trust’s liaison team. The trust’s Chief Nurse also met regularly with the mental health trust through the Mental Health Quality and Strategy Group, discussing length of stay, mental health pathways, and environmental concerns. Minutes of these meetings were reviewed and demonstrated collaborative working towards the best care for the patient.

Although the department environment was unsuitable for patients with mental health needs, staff and agency mental health nurses worked together to deliver the best care possible through partnership working. We observed multidisciplinary teams in the department, including pharmacy links, the integrated discharge team, admission prevention team, mental health liaison services, social care teams, the urgent community response team, and the virtual ward team.

For example, advanced community nurses successfully discharged patients who could be treated with oral antibiotics and monitored by community teams, avoiding unnecessary delays in the department.

In response to the issues found on this assessment the leadership team worked collaboratively with their system partners to improve safety of the patients attending the department. An action plan was developed and the leadership team met weekly with the CQC to report on progress made until June 2025.

The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Despite the challenges outlined in this report, department leaders actively promoted a culture of continuous learning, innovation, and improvement both within the department and across the wider system. They encouraged creative approaches to delivering equitable access, experience, outcomes, and quality of life for patients.

In 2024/2025, the department ran 31 quality improvement projects at both national and local levels. These projects focused on key areas including frailty admissions, end of life care, pain management, accessible information, and updates to policies and clinical guidelines.

The service demonstrated awareness of national reviews and implemented learning from reports on patient deaths. Staff actioned this learning primarily through weekly morbidity and mortality conferences.

Medical and nursing staff benefited from structured learning and supervision, which received positive feedback. Medical simulation days were praised for their effectiveness in supporting clinical development.

Appraisals were completed regularly, and completion rates met trust targets, reflecting a commitment to staff development and performance management.