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

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

At our last assessment we rated this key question as Good at this assessment the rating has 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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the need of people and their communities.
The Emergency Care and Medicine (ECAM) division did not have a shared vision, strategy and culture which underpinned the trust strategic objectives. The ECAM divisional leaders told us that 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.

We received details of the planned recovery and design project for UEC. This project was set out to improve waiting times, ambulance waiting times, and patient care and safety. There were plans to incorporate a virtual hospital and an improved frailty model. These plans fed into the overall trust strategic objectives but divisional leaders did not tell us of this piece of work.

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.

Not all the staff we spoke to were aware of the trust values of the overall vision and strategy of the department.

The majority of staff we spoke to said that the department was a good environment to work in, they felt supported and treated fairly and equally. There were no concerns raised around bullying, sexual safety or inappropriate behaviours and staff felt safe coming to work. We observed good staff interactions and staff treated each other with kindness and respect.

However, the latest staff survey results indicated that the UEC department scored below the trust average for all 9 elements of the survey. The latest GMC survey highlighted that medical trainees did not feel they were receiving adequate experience on placements.

Staff in children’s ED told us that the culture had improved since being incorporated into the women and children’s division and had seen a change in senior leadership team.

Staff were invited to join quality improvement and clinical audit meetings at “audit drop in café”. This was a meeting held once a month for staff to engage with the quality improvement and clinical audit teams, to discuss projects and improvements for better safety and health outcomes for patients.

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. They did not always embody the culture and values of their workforce and organisation.

At the time of the onsite assessment the senior leadership team for the division of ECAM consisted of a divisional director, head of nursing for medical care, head of nursing for urgent and emergency care and a vacant position for a divisional operations director that had been vacant for 2 years.

Senior 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 senior leadership long-standing relationships within the division and throughout the hospital.

There were still elements identified in the last assessment of the service in 2022 that had still not been fully addressed or improved. The 15 minute triage target of people entering UEC was still not being achieved. Staff were still not fully compliant in all levels of safeguarding for adults and children. Checks were not always being completed on specialist equipment. This indicates that leaders may not always be aware of the risks of the department and are slow to take action.

Leaders described their roles and responsibilities for the services they managed as well as the priorities and issues the service faced. 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 acknowledged that there was still a lot of work to do 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.

Staff were split into teams within the department so they each had a manager/leader at department level that they could go to for any personal concerns, appraisals, annual leave. Leaders who undertook this role told us they had an open door policy and felt confident that staff would talk to them if they needed to.

Staff told us that leaders were visible within the department during day shifts but were not seen on night shifts. Staff in Frailty S:DEC told us that leaders were rarely seen.

Junior medical staff told us that all seniors were approachable and spoke favourably of the supervision and support they received. However, the latest GMC survey highlighted that medical trainees did not feel they were receiving adequate experience on placements.

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.

The trust Freedom to Speak Up (FTSU) service provision historically operated with 3 FTSU guardians to cover the wider service. However, due to sickness absence there had been operational challenges for the last 12 months. 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.

To improve accessibility and staff confidence in speaking up there were a number of reporting and engagement options including, anonymous reporting mechanisms, telephone discussions, face to face meetings and QR codes.

There was a display within the department informing staff of FTSU. Staff told us that they were aware of FTSU but had never used it. Some staff said that although they themselves felt confident to speak up they knew of other staff that were not. This was reflected in the recent staff survey the “we have a voice that counts” section ED department scored below the trust average.

FTSU themes included staffing pressures, staff wellbeing and morale, behavioural and cultural concerns and patient safety and quality concerns. There was a FTSU champion within ED and senior managers told us the last FTSU for the department was around flexible working.

The trust used “you said we did” initiative in response to patient and carer feedback. One of these initiatives was implemented within the ED following patient complaint for not having access to food and drinks in the waiting area. Vending machines were now in place and hot and cold drinks are provided.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had received training in Equality Diversity and Inclusion (EDI) and human rights with an overall compliance for both medical and nursing staff of 91%.

Staff we spoke to told us that they felt they were treated fairly and equitably within the department. However, recent staff survey results did not reflect this narrative.
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. Data showed that representation and declaration rates had improved in parts of the workforce, however, inequalities in experience, opportunity and outcomes remained persistent for both disabled staff and staff from Black and Minority Ethnic (BME) backgrounds.

The department displayed information around various different networks that staff could engage with this included LGBTQ and allies, Race, Ethnicity And Cultural Heritage (REACH), Spirituality Network and Disability Staff Network.

There was a mental health first aider within the department and staff had access to an Employee Assistance Programme (EAP).

Staff had opportunities to work flexibly to support personal circumstances and caring responsibilities. Leaders within the department gave us examples where reasonable adjustments had been made to help and support staff, they included: Staff with Attention Deficit Hyperactivity Disorder (ADHD) always work within the same area of the department to allow for consistency and routine. Staff with a known health issue work reduced hours and in an area of the department where the workload may be lighter.

We scored the service as 2. The evidence showed some shortfalls. 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.

Capacity constraints within the department and across the wider hospital impacted the patient flow within the emergency department. Risks were discussed at patient safety huddles each day with capacity and flow meetings held frequently throughout the day. Staffing levels were also discussed.

Long waits within the department led to untimely care. Patients were not seen by specialty teams within an hour of referral. Once seen there were long waits to be moved from the department onto a ward. This meant that patients were often waiting within the department for over 12 hours. Performance was discussed at clinical governance meetings. We reviewed the trust morbidity and mortality meeting minutes that indicated that patients had come to harm due to extended length of stay in ED.

Audit data received shows that the department was not always meeting ambulance national handover and offload targets. Staff told us that patients were often taken back out to the ambulance following initial triage within the RAT area. This led to delayed care, treatment and diagnosis. The service did not monitor how often with was happening.

There were some inconsistences in the completion of risk assessment, for example VTE. There were inconsistencies in the timely recording of NEWS2 scores which meant that the department was not monitoring patients for deterioration or improvement in response to treatments. Due to the inconsistencies, we were not assured patients were being escalated to specialty teams like the Critical Care Outreach Team (CCOT) when needed.

We could not be assured that patients were being assessed and treated for Sepsis within national guidelines. NEWS2 audits were completed at a trust level and not at a department level. We were not assured that Senior Leaders had full oversight of patient deterioration to monitor for ways to improve.

Risks were captured on a divisional risk register, which was discussed at governance meetings. Leaders told us this was then filtered down to department level. However, staff we spoke to were not aware of the department’s risks.
Senior leaders acknowledged that the ECAM division hold the most risk due to the number of and the acuity patients coming into the department, but they lacked real time oversight of risk and were not proactive in identifying potential risks.

The Trust had a business continuity policy and strategy. The aim of this strategy was to identify and mitigate risk to the Trust’s business of providing safe care and treatment for the people using its services. Examples of incidents that may have an impact on the trust service provision are fire, explosion, significant staff absence due to severe weather affecting staff getting to and from work.

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.

The senior leaders had regular meetings with the East of England Ambulance Service to discuss performance and how improvements could be made. The ambulance service staff could also call directly to S:DEC or Frailty S:DEC for advice and guidance which enabled them to put into place an alternative pathway of care that was better suited to the patient’s needs, promoting better outcomes for the patient and avoid conveyance to the hospital.

The trust patient experience team supports Healthwatch in the undertaking of different areas of the trust producing feedback summaries of their findings. These findings are shared with divisions to enable them to respond to the feedback and make improvements.

The department engaged in the Getting it Right First Time (GIRFT) Programme with NHSE to improve healthcare quality.

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.

The service has made limited improvements since our last assessments. In 2022 CQC issued enforcement actions following identified breaches. These beaches related to clinically assessing patients within 15 minutes of arrival in the department. The service did not meet this requirement at this assessment.

In 2022 it was identified that the trust should take action to ensure that staff carried out checks on all specialist equipment in line with service guidance. It was also identified that all staff should complete appropriate levels of safeguarding training for both adults and children. Following this assessment we still found equipment that had not been serviced and both nursing and medical staff below the trust compliance for safeguarding training for adults and children. We could not be assured that learning had taken place following previous assessments.

The department was engaging in 7 Quality Improvement Projects (QIPS) that related solely to UEC they included Delirium screening, seizure history documentation and one around electronic prescribing and Medicines Administration (ePMA) which has been adapted from another Trust. The department is also engaging in a further 7 QIPS trust wide.

The department engaged in the Getting it Right First Time (GIRFT) Programme with NHSE to improve healthcare quality, by improving and optimising patient flow, reduce delays in treatments. There were planned improvements for phased refurbishment of the department.