Whipps Cross University 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. We checked that leaders proactively supported staff to deliver care that was safe, person-centred and sustainable.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care

The service was in breach of regulation for governance of the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a strategy and vision which was in development but not yet finalised. Staff and leaders demonstrated a positive, compassionate, listening culture in many areas but further work was needed to strengthen this across the service.

At the time of our inspection an updated strategy and priorities for the division had not yet been finalised. A plan had been drafted to achieve the priorities for the service and deliver good quality sustainable care. Leaders told us some of their priorities included performance and improvement and innovation and building on work to improve the culture in the service. Leaders told us they were proud to have replaced a lot of equipment throughout the service. A business case had been submitted to introduce a 7-day working workforce model, and they recognised the need to increase the staffing establishment. We saw that actions had been identified as part of the development of the strategy and vision for imaging and diagnostics which supported the hospital’s clinical objectives and the trust group objectives.

Although there had been improvements overall in the culture across the service, further work to improve the culture and working relationships was needed in some areas. Particularly ultrasound, and networked services of echocardiography and the breast clinic where leadership and oversight were not provided by the site. However, there was a focus on the safety and well-being of staff with events, awards and support programs open to staff. Wellbeing champions were appointed across staff groups and supported by the trust’s wellbeing team. Staff had access to psychological support services, mental health first aiders, and flexible working arrangements. Additional wellbeing initiatives included knitting and exercise classes. Monthly staff briefings were used to share CPD updates and celebrate achievements such as “Image of the Month” and “Abnormality of the Month.” The majority of staff we spoke with, told us they felt the culture was improving and moving in the right direction.

Most staff felt supported, respected and valued which was reflected in the 2024 staff survey results, which showed an increase in staff agreeing that they their work was valued by the organisation. It was clear from speaking to staff their work was important to them, and they felt passionate about their contribution to the care and treatment they provide for people.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support but there was scope to strengthen the visibility of leaders, so they were aware of the challenges faced by their teams.

There was a clear management structure with defined lines of responsibility and accountability. The management structure ensured there was senior support and specialist advice for staff when they needed it. Local leadership in most areas was provided by modality leads who engaged well with teams. Managers we spoke to could generally explain what the risks in the areas they were leading were and what action was being taken to address them. However, the service risk register did not entirely reflect all risks in the service and concerns we found during our inspection, such as broken emergency call bells in ultrasound and the lack of MRI safety notices.

Leaders were generally visible and available to their staff and teams. Staff we spoke with told us they mostly felt supported by the leadership team and felt they would take action to address their concerns.

In networked services of nuclear medicine, echocardiography and the breast clinic where leadership and oversight were provided by another hospital location in the trust, leaders were not always clear on the issues they were facing and were not always alert to areas of poor culture having a detrimental impact on staff. Staff in the breast clinic told us there was regularly a lack of visible leadership in the unit which was contributing to delays in recruitment. Staff told us leave was not being managed with the needs of the service in mind. However, the week following our inspection, leaders informed us of plans to formally ensure that a general manager or network manager was physically present onsite at least every two weeks. Following the inspection, the trust informed us that an improvement plan was put in place to address operational challenges and the inspection and staff feedback.

Leaders supported staff in their development and established developmental roles focussed on succession planning: for example, the clinical lead radiologist role, supporting staff into general manager posts, and the increase in the radiographer leadership establishment. Leadership workshops were introduced for line managers across modalities, including radiographers, sonographers, and administrative staff. These sessions were supported by the organisational development team and included management development frameworks.

The service fostered a culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback. We saw QR codes displayed requesting patient feedback, however it was not clear how individuals without a smartphone could provide their feedback.

The leadership team endeavoured to foster a positive culture where people felt they could speak up and their voice would be heard. Most staff told us they felt confident to speak up if needed without fear of retribution. Most staff we spoke with said they would approach their own manager or a trusted colleague, if they needed to raise concerns.

The trust had a Freedom to Speak Up Guardian with whom staff could raise concerns about any issues. We saw information and contacts displayed for staff who wished to raise concerns, including contact information for the guardian service and a confidential external hotline. The trust Freedom to Speak Up Guardian confirmed that there had been no cases raised to the guardian from the service in the 12 months prior to the inspection specific to Whipps Cross Hospital. Data regarding concerns raised to the guardian in the last 12 months within networked services (where leadership, oversight and management was governed by a different hospital location in the trust) showed most concerns were regarding management, behaviour/relationships, systems and processes and bullying and harassment.

In the 2024 NHS Staff Survey, 67.1% of staff in the department who responded said they would feel safe speaking up about unsafe clinical practice compared to 53.3% who agreed with this statement in 2023.

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 valued diversity in their workforce. Staff understood equality and diversity and its importance in building a strong workplace culture. Staff felt they were treated equitably which was reflected in the latest staff survey. The service promoted equality and diversity in daily work and provided opportunities for career development.

Project Search was a programme to prepare and guide young people with learning disabilities, autism and/or sensory impairment into paid employment. Staff spoke positively about the contribution of project search to the on the workforce. We observed that graduates of project search made meaningful contributions to the team and patient care. Staff we spoke to who had been part of project search told us they enjoyed their work and that the team works well together.

Leaders took steps to ensure that staff and leaders were representative of the population of people using the service. The divisional triumvirate provided shadowing opportunities to colleagues from diverse backgrounds and roles within the division, fostering an inclusive culture.

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

Governance meetings were held monthly. However, they did not provide effective assurance of key areas such as staffing. These metrics should have reported staffing vacancies, safety of rotas, skill mix, turnover, sickness, and all aspects of training, development and review but this data was not provided.

Risk registers did not highlight an accountable staff member responsible for managing each risk. However, there was a discussion at governance meetings about the risk register, including about emerging risks. Risk registers were clear and up to date and there was generally alignment between the recorded risks and what staff told us the risks were. The risk register showed key risks and control measures that were in place to mitigate risk.

There was a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. The audits were reviewed at the relevant committee meetings and reported to the overarching governance committees. Although staff told us lapses in complying with pause and check was identified as a theme in incidents, we saw that poor compliance in pause and check audits was not discussed at governance meetings. However, we saw evidence this was discussed at the radiation protection committee.

Staff at all levels were clear about their roles and they understood what they were accountable for, and to whom. Staff we spoke with had a good awareness of governance processes and knew how and where to escalate their concerns. They told us teams met regularly to discuss incidents, audit results and provide updates. Staff had access to a range of policies, procedures and guidance which were available on the provider’s intranet, quality management system and on an internal electronic drive. Leaders told us documents had been moved onto the quality management system; however, staff we spoke to told us not all documents could be found there.

Information gathered about patients or others was generally held in secure systems which met data protection legislation requirements. Access to computerised patient records was password protected with a secure login. However, we found approximately 50 patient paper records, some dating back to 2012, left unsupervised in an office within the breast clinic. This posed a risk to patient confidentiality and data security. We pointed this out to staff and were told they could be left there as the room was locked. When we later checked, we found this office was still unlocked.

There was a range of committees with specialist responsibilities. For example, the radiation protection committee reported incidents and actions to the overarching radiology review management group meeting. Minutes from meetings were detailed and clear.

Managers ensured radiation incidents were fed into risk management structures, and for accidental and unintended exposures, they notified CQC in line with legislation. Staff we spoke to during our inspection could share learning from recent incidents and thematic reviews which had taken place and had been reported to CQC.

Arrangements with partners and third-party providers were governed and managed effectively to promote safe and coordinated, person-centred care.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

There were effective systems in place to ensure leaders had oversight of incidents in the service, through trust radiation incident review. The meeting minutes we reviewed showed evidence of incidents being reviewed and lessons learned shared across all sites within the trust. Actions identified from these meetings were recorded on an action log, assigned action owners and updated regularly. This fed into the trust and hospital Radiation Protection Committee. We reviewed meeting minutes for the site and trust Radiation Protection Committee which were detailed and clear and reviewed sufficient information to demonstrate effective oversight of the risks related to imaging.

Leaders and staff strived for continuous learning, improvement and innovation. Staff were involved in quality improvement projects to improve patient flow and utilisation. The service was active in trying to improve and respond to individual patient care needs. They tried to be innovative in their approach to driving improvement. During our inspection staff told us they were trialling the use of dedicated porters in CT to improve patient flow. Staff also told us about the use of artificial intelligence technology to aid in reporting X-ray images, although this was a work in progress. We also saw that there was an improvement project in progress to reduce MRI report turnaround time, however changes had not yet been identified to support the improvement plan.

Staff told us there were various learning opportunities available. There were processes to ensure that learning happened when things went wrong. As part of learning from previous incidents simulation training had been developed to support staff in recognising errors.

Leaders told us the CT team had been shortlisted for a trust ‘WeImprove’ award in recognition of their project for improving flow and scan turnaround times in A&E CT.