The Queen Elizabeth 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 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 good. We found a breach of good governance in relation to assessing, monitoring and improving the quality and safety of the services provided. At this assessment the rating changed to 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.

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 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture. They did not always understand the challenges and the needs of staff, people and their communities.

The Emergency Care and medicine (ECAM) division did not have a shared vision, strategy and culture which underpinned by the trust strategic objectives. The ECAM divisional leaders told us their top priority was patient safety and quality of care linked to national standards. However, there was no clear strategy to support how the division would achieve this.

Staff did not always know and understood the trust’s vision and values and how they were applied in the work of their team.

The trust strategy set out long-term ambitions for the period 2024 to 2030. These were structed around 10 strategic objectives grouped in 3 themes of Quality, engagement and healthy lives. These aligned to the trust’s core values of kindness, wellness and fairness. Progress was tracked through quarterly reporting by divisional management groups.

Staff told us they did not always feel supported by leaders and reported a culture that was not always supportive. For example, incidents were not used as an opportunity to learn and teams reported they were understaffed and stretched despite raising this to divisional leaders repeatedly.

Staff groups reported fragmented teamwork within medical specialities which impacted on care for patients and their well-being. This was further impacted on by teams’ inconsistent processes and pathways such as board round and referrals.

The last NHS staff survey showed that staff within the division showed that over 50% of all staff did not feel supported, listened to or encouraged by their manager. Within all 9 descriptors within ‘your managers’ section of the survey there was a decline is satisfaction from 2023. An action plan was in place to address themes from the staff survey.

There was evidence of patient involvement within the division in the last 12 months to drive improvement in line with the trust strategy such as developing a sensory appropriate area for neuro-diverse patients on Stanhoe ward.

Staff were positive and cheerful when they interacted with one another as well as patients and relatives. We observed respectful relationships amongst staff during our onsite assessment both on the wards and throughout the hospital such as holding doors open and asking if they needed support following a period of sickness absence.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support.

At the time of the onsite assessment the divisional triumvirate consisted of a divisional director, head of nursing for medical care, head of nursing for urgent and emergency care and a vacant divisional operations director for 24 months.

Leaders had the skills, knowledge and experience to perform their roles. The 2 heads of nursing had worked at the trust for over 20 years; both starting their nursing careers at the trust and had held matron positions before progressing to their current positions. This was supported by qualifications in leadership and innovation to support their leadership positions. The divisional director had been in post since 2023 and had worked at the trust for the last 10 years. This meant that the triumvirate had long term tenure and long-standing relationships within the division and throughout the hospital.

Leaders described their roles and responsibilities for the services they managed and current issues the service faced, such as workforce and capacity. They were open and honest about areas where they did not have full governance oversight such as harm reviews for patients awaiting appointments. Divisional leaders stated they were ‘behind the curve’ when it came to addressing health inequalities and they were working with the director of transformation to reduce disparity. They acknowledged that the division needed to take action to ensure delivery of the strategic objectives to provide the best care and experience and to increase equality in the health outcomes, alongside a happy workforce.

Ward managers told us they felt comfortable approaching the triumvirate if required and were able to give examples of how they had taken action to support them when needed.

Staff at ward level could escalate concerns when required. Some staff members told us that they would escalate to divisional leaders where their line manager was inexperienced or unavailable. Staff told us leaders were visible.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

Managers and staff did not have access to the feedback from patients and carers which was reflective of the patient population as completion of the friends and family test was poor. Due to a delay in reviewing incidents, complaints and patient safety incidents there was a risk of missed opportunity to learn and make timely changes in response to feedback.

People felt they could speak up but they did not always feel that their voice would be heard. For example, staff escalated concerns regarding staffing levels but they continued to occur, and staff did not see any action taken to address the concerns raised. Staff, therefore, did not feel confident that their concerns were always listened to.

Some staff groups told us they did not always feel able to raise concerns to senior leaders due to fear of retribution and they were actively discouraged to raise concerns as there was a need to maintain professional working relationships. Staff gave examples of times where they were unable to seek support but went to colleagues they knew in order to seek support or assistance. Not all staff we spoke to were aware of the freedom to speak up (FTSU) service.

The trust FTSU service provision operated with 3 FTSU guardians to cover the wider service. However, they had experienced operational challenges for the last 12 months due to sickness absence and other staffing factors. Since March 2026, the service had a full-time FTSU guardian and 1 bank guardian providing approximately 1.5 days of cover to support service continuity during annual leave and sickness absence. Where guardians were unavailable, staff could access support through FTSU Champions, Mental Health First Aiders and wider wellbeing and support networks within the Trust.

In the last 12 months there had been 35 FTSU cases with themes such as behavioural and cultural concerns, staffing pressures and workforce capacity and communication and continuity challenges. We saw evidence of action taken in response to themes.

Patients and carers were involved in decision-making about changes to the service such as the development of the Peddars Way unit, introduction of decaffeinated tea on West Derham ward and a sensory area on Stanhoe ward. However, there was inconsistent ‘you said, we did’ boards to demonstrate to patients and visitors on how they had taken action in response to feedback.

We saw evidence of patients meeting with members of the senior leadership team following formal complaints and apologies were given where the standard of care fell below that expected.

We scored the service as 2. The evidence showed some shortfalls. The service valued diversity in their workforce. However, action taken was not effective in improving equality and equity for people who work for them.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role. For example, a staff member had a long-term health condition and were only rostered to work day shifts.

The division reviewed annual staff survey results, including equality monitoring to review if it was diverse and experience, opportunity and outcomes were equitable for all staff groups. 2025 staff survey results showed inequalities in experience, opportunity and outcomes remained persistent for both disabled staff and staff from Black and Minority Ethnic (BME) backgrounds.

Data provided from 2024 showed that ethnic minority staff reported a higher experience of discrimination from patients as well as their manager or colleagues than white staff within division. Data sets also showed that people’s experience was not improving from previous years. Some staff told us of racist and bullying behaviour they had encountered or witnessed within the last 12 months. A trust wide anti-racism communication was sent out in response to this by senior leaders within the organisation.

The trust had planned to develop a detailed action plan by 1st May 2026, setting out specific organisational actions to address disparities in recruitment outcomes, exposure to harassment, bullying and discrimination, confidence in fairness of progression opportunities and representation within senior leadership roles.

The Trust conducted 49 facilitated conversations to understand barriers to NHS employment faced by people from deprived and ethnically diverse communities. A working group was tasked with implementing 5 recommendations with a focus on developing community employability support and improving the accessibility of recruitment communications for entry-level roles.

There were staff networks such as REACH (Race, Ethnicity and Cultural Heritage), PRIDE, Enabled and Spirituality which contributed to addressing problems for all under-represented and disadvantaged groups and individuals within the organisation.

Staff within the division had access to year-round cultural and health promotion programme such as neuro-diversity and menopause support.

We scored the service as 1. 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.

The service had some governance processes through various speciality meetings and committees which fed information to the board and back to the ward. There were clear lines of responsibility to support the governance of the ECAM division. Meeting minutes showed that there was a structured agenda to review risk and operational performance across the division monthly.

However, items discussed and raised were not always reviewed at subsequent meetings and speciality governance reports were not always being submitted. For example, in the division risk and governance March 2026 minutes referenced pleural drainage local safety guideline was drafted but never approved as attendees did not read the paper. This was to be approved within 7 days of the meeting. Meeting minutes for the division risk and governance April 2026 did not reference if this action had been completed. Staff told us that often speciality meetings were frequently cancelled at the last minute and often rescheduled into clinic times. When meetings did occur, they felt they were not always productive as they focused on communications rather than shared challenges and service improvement.

Monthly local audits were conducted and formed part of the quality assurance tool reviewed by matrons to ensure an understanding of current risks, performance and outcomes on wards. However, audit data we reviewed following our onsite assessment highlighted that the audits were not being used to drive improvement in areas of poor compliance. For example, we saw evidence of poor documentation for mental capacity assessment (MCA), deprivation of liberty safeguards (DoLS) and completion of risk assessments on site. Poor compliance had not been addressed following monthly audits.

Divisional leaders did not have assurance on all aspects of quality and performance. For example, staff told us they often experienced resistance from other medical specialities when referrals were made resulting in delayed care for patients. Interprofessional standards were not audited, therefore, leaders could not be assured that care was not delayed when speciality reviews were requested.

Divisional risk and governance meeting minutes highlighted that incidents, patient safety reviews and complaints were not completed in line with trust targets. This meant that opportunities to learn and prevent the recurrence of similar harm were missed by leaders.

Divisional leaders had not ensured that staff had completed mandatory training in line with trust targets. At the time of the assessment 11 out of 35 topics were below trust target. We were not assured staff had the appropriate training and divisional leaders were taking sufficient action to address this.

The divisional risk register matched concerns raised by staff and those found on assessment such as delays in access to echocardiogram, staffing to support enhanced care and lack of clinical engagement to undertake reviews and respond to clinical guidelines and NICE guidance.

Divisional leaders did not always ensure that local policies were being followed and did not carry out audits to be assured of compliance. For example, we requested last 6-month audit data for compliance against policy for outlying patients to a different specialty, following our onsite assessment. This was not provided. We did not see evidence of discussion with the patient or their families of decision to outlie in line with trust policy in care records we reviewed. We did not see evidence of the completion of the decision-making tool in line with policy.

Leaders and managers did not always have access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. When we requested NEWS2 audit data for medical wards, senior leaders confirmed the division did not monitor NEWS2 completion or escalation, limiting oversight of whether deteriorating patients were being identified and escalated appropriately and in line with policy. There was a reliance on trust wide audit data to gain assurance observations and documentation was in line with policy.

Staff told us they did not always have access to the specialist equipment and information technology needed to do their work. For example, specialist services did not have digital databases. This led to a limited oversight of their patients and a lack of live database which meant that real-time data extraction was not possible to support pathway improvement and decision making. Some specialist areas were using paper records and 5 different programmes to manage one patient. They told us data requests took long due to administrative staff being short staffed and having to work across multiple systems.

During our last assessment in January 2022, we found patient records were not stored safely. At this assessment, on 28 and 29 April 2026, we found patient records were stored securely to keep patient information safe.

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.

Specialist teams engaged with external stakeholders such as commissioners. For example, lung cancer nurse and radiology manager attended a Norfolk and Waveney integrated care system lung cancer screening meeting. The division attended these meetings with system partners to discuss and share ideas for pathway improvement and ensure that local plans were supporting the national screening programme. The programme data had shown that early diagnosis of lung cancer through the screening programme for stage 1 and 2 was 75%, compared to an early diagnosis rate of 28.9% before the programme began.

The Division work closely with partners including the Integrated Care Board (ICB) on a range of services and to optimise flow. For example, Stroke Rehabilitation and CAG (Clinical Advisory Group) Meeting, Admissions Pathway Improvement CAG Meeting and Joint North & South Integrated Stroke Delivery Network (ISDN) Board Meeting which highlighted challenges for services across the network and enabled wider sharing of learning and national priorities.

The division attended internal and external speciality clinical network meetings. These allowed for greater internal oversight of pathways, issued knowledge of peer and national updates. Staff told us these also assisted them in securing external funding for training and advancing their practice.

Patients and staff could meet with members of the division’s senior leadership team and commissioners to give feedback. For example, patients were able to share their experience at board meetings.

We scored the service as 2. 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.

At out our last assessment in January 2022, we found breaches in medicines management, weekly resuscitation equipment checks and mandatory training and safeguarding amongst medical staff. During this assessment there was an improvement seen in the weekly resuscitation equipment checks but staff remained non complaint in safeguarding mandatory training, medicines were not stored safely, and we found that there was a lack of robust governance to identify and monitor risk and performance. Leaders did not address improvements required following the last assessment.

The ECAM division did not focus on continuous learning locally to ensure safe and effective practice as well as outcome for people. Reported incidents were not reviewed in a timely manner to embed good practice to reduce future risks. Overdue incidents rose from 212 in March 2026 to 231 in April 2026 for the division.

The division did not review performance against trust policy or guidance. For example, the division did not carry out harm reviews for patients waiting a new appointment or follow up. This meant the division were not identifying patients that were coming to harm and using data to drive improvement within the service.

The division did not always actively contribute to safe and effective practice. There were delays in reviewing national guidance and reviewing agreed safety procedures seen within the division’s risk and governance meeting minutes.

Audits were performed but this was not being used to drive improvement. The division used the tendable audit tool but the action plan function had not been implemented to provide meaningful data in line with national and local standards. Divisional leaders told us this would be implemented following the assessment.

Local induction was not formally or consistently completed across all medical ward areas. A structured local induction is essential for patient safety, staff wellbeing and operational efficiency. These local systems were not embedded to support staff in the delivery of equality of experience, outcome and quality of life for people. Leaders told us a working group would be tasked with writing an induction policy to ensure consistency going forward.

The ECAM division had 6 registered quality improvement projects (QIP) with the Quality improvement team. There were also other projects registered with the patients safety improvement team. QIP’s included completion of fluid balance charts in patients with intravenous diuretics and ‘Go decaf’ on West Newton and West Dereham wards. This had shown a reduction in reported falls resulting in harm and a cost saving on continence equipment.

Staff had opportunities to participate in research. At the time of our assessment there were 18 research studies being undertaken within the division.

The quality improvement team were trying to support increased engagement of improvement ideas (local data/themes) into active quality improvement projects by hosting monthly, Trust wide QI Café drop-in sessions. These provided an open forum for staff to discuss potential improvement ideas and help foster a culture focused on safety, improved outcomes, better experience, and efficiency, for patients and staff.

The division had demonstrated collaborative working which had lead to innovation and improved outcome such as the lung cancer screening programme.

Staff were encouraged to complete continuing professional development. They were able to access development through internal and external courses. We spoke to staff that had completed apprenticeships and progressed to become ward managers