Wexham Park 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 assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was outstanding.

Our rating for this key question stayed the same. We rated it as outstanding.

Leaders ran services effectively using best practice systems and supported staff to develop their skills. Staff understood the service’s vision and values, and these were fully embedded in their working practices. Staff were motivated to provide the best care they could for their patients. There was a shared purpose on improving the quality and sustainability of care and people’s experiences. Staff were proud to work at the service, there was strong collaborative team working and staff felt respected, supported and valued. Staff at all levels were clear about their roles and accountabilities. Leaders operated effective governance processes and used innovative approaches to drive and improve the delivery of high-quality person-centred care. The service engaged well with patients, staff and the local community to plan and manage services. Strategies and plans fully aligned with plans for the wider health economy and leaders demonstrated commitment to system-wide collaboration.

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.

All staff wanted to work in a successful department and looked for ways to improve patient experience, safety and outcomes. They saw themselves as one team and as a collective shared a passion for delivering the best care and treatment they could for their patients. There was a visibly, friendly and positive atmosphere in the department where staff went out of their way to support each other, patients and their families. Staff we spoke with expressed pride and commitment working in the department. Many had worked there a long time due to the high job satisfaction, supportive leaders, career growth opportunities, and the positive working environment.

The trust had a shared vision ‘to be a leader in health and wellbeing, delivering exceptional services for our local communities'. The vision was underpinned by the trust values of committing to excellence, working together and facing the future, and strategic ambitions.

The trust, in collaboration with people who use the services, staff, and external partners had developed a new 5-year strategy, Frimley Health 2030, aiming to deliver compassionate, effective, and modern healthcare, enhancing patient experiences, and reshaping how healthcare is delivered. At the time of inspection, it was in its final draft and had not been implemented.

The emergency department shared with us their objectives for 2024-2025. They explained they were currently developing the next set of objectives which would align with the new 5-year strategy, and its strategic ambitions. This included making business plans where the department needed additional financial and operational support to meet the objectives.

Senior leaders collaborated with staff, service-users, the wider hospital and healthcare communities when setting objectives. They spoke knowledgeably about the community they served, the key issues and challenges, and how they needed to evolve to meet the needs of local people. Leaders were actively involved with system partners to develop strategies on how to manage increased pressure on the wider healthcare system which in turn, impacted on the demand for ED services. For example, working with GPs in the local area to make referrals to alternative pathways to avoid ED attendances.

The emergency department (ED) had its own vision statement of, ‘together we will deliver quality emergency care to our patients. Driven by our commitment to excellence, compassion, and safety'. Leaders had ensured there was a shared vision in ED, and that staff in all areas knew, understood and supported the vision, values and strategic goals. All staff working in ED, had faith in the senior leadership team, and knew how their work contributed to the vision and success of the department. They followed the trust values in their day-to-day work.

Staff reported the team worked effectively together, with staff across all areas respecting each other and working together to provide the best possible care and treatment to patients. We observed the friendly and respectful interactions between ED staff of all grades and disciplines.

Leaders had fostered a strong positive departmental culture. There was mutual respect and trust amongst everyone, regardless of role, experience or seniority. Leaders showed recognition and appreciation to staff and encouraged a healthy work-life balance. They ensured there was effective open and transparent communication.

Staff told us how leaders provided opportunities for learning and professional development to enhance skills and career progression. Leaders had developed a no-blame culture where incidents were used as a learning opportunity which concentrated on addressing systemic issues rather than assigning blame to individuals.

Inclusivity was promoted, where everyone felt valued and respected regardless of their background or identity. The workforce had expanded over the last 12 months, including on-boarding international nurses. We were told that there was now a mix of long timers and newer members of staff, and a mixture of cultures, where everyone worked and supported each other to deliver the best care they could to their patients. This was observed whilst in the department.

There were high levels of satisfaction across all staff, despite the challenges they faced. We were told there was a good atmosphere in the team even when the department was under pressure. We were told as a team they shared the stress. We observed this on the inspection, the department was busy with many people in waiting areas and patients being cared for in the corridors, however the department remained calm at all times and staff cheerful.

The ED was led by a chief of service, head of nursing and the associate director. This leadership style is referred to as a triumvirate.

The triumvirate were supported by a deputy chief of service, and matrons who were responsible for the day-to-day nursing aspects of the adult and paediatric EDs, plus leads in governance, audit and morbidity and mortality.

We found the leadership team to be cohesive, visible across the department and well respected by peers and colleagues. They had a shared purpose and motivated the staff to deliver and succeed. The matrons were highly respected by the nursing team, they possessed strong leadership, clinical expertise, and the ability to foster a positive, safe, and effective environment for both patients and staff, while also contributing to service improvement and strategic decision-making.

Nursing and medical priorities were aligned and professional standards were upheld and promoted by the leadership team. Clinical effectiveness, safety, patient experience, quality, performance and financial sustainability were all considered equally.

The ED leadership team understood and could describe the challenges to quality and sustainability within the department and had pro-active, on-going plans in place to address them. They were aware of the challenges to meet ED targets and had plans to improve service delivery. They were working to maintain patient safety at times of high demand.

There was a clear, strong, clinical leadership presence in ED, and we were told by staff it was easy to access and locate the consultant in charge of the shift. Their visibility was maintained throughout the inspection. Consultants demonstrated clinical ownership of the patients in the department, and we saw the consultant in charge discussing patients with medical staff during the inspection.

Each shift had a nurse in charge who was supernumerary and not rostered to deliver direct patient care. This meant they could provide leadership and support the staff on duty. The paediatric ED had its own nurse in charge. During the inspection we found these nurses to be knowledgeable, approachable and passionate about the team and the patients they cared for.

Staff spoke highly of the ED leadership team, consultants and senior nursing staff, saying they found them supportive and approachable. During the inspection we observed many interactions between staff and their managers, and it was evident there were excellent working relationships amongst staff of all disciplines.

The leadership team were mindful about succession planning and supported staff to develop their leadership and operational skills.

Poor patient flow was a major challenge for the department which was leading to overcrowding, extended wait times and potential adverse patient outcomes. Leaders could talk extensively about measures they had, and continued, to implement to mitigate these challenges whilst maintaining the well-being of staff. However, it was less clear of their influence and involvement in driving systemic change within the wider hospital and with decision-makers, to address the problem effectively.

There had been changes to the trust's executive management team in 2024, including a new chief executive, chief of nursing and midwifery and chief operating officer. Senior ED staff spoke highly of the team and felt they were beginning to understand the challenges and demands faced by the emergency department. However, this was not always echoed by other ED staff, with some feeling that the executive team were not visible enough in the department and did not truly understand the impact crowding and corridor care was having on staff and the patients they cared for. Listening events were being arranged with ED staff, where the executive team would be present, to hear the departments voice directly and for them to voice their concerns to make the department fit for the future.

Leaders in ED had created a safe environment where staff felt comfortable raising concerns about patient safety, quality of care or workplace issues. They knew by openly listening and addressing staff’s concerns, staff would feel listened to, and it promoted a culture of openness and transparency in the department.

Staff told us there was a culture of speaking up, they felt safe and supported in doing so, and without fear of detriment. Staff gave us examples where they had raised concerns with their managers. We were told these were treated sensitively and seriously, and managers worked with the member of staff to resolve the concern. Staff we spoke with were happy with the outcome and felt comfortable to raise concerns again.

The service had established Freedom to Speak up arrangements, with a freedom to speak up guardian (FTSUG) in post at the trust. Information about the guardian and how to contact them was available on both the internet and the staff’s intranet. Telephone numbers and email addresses were included in the information along with a national helpline for whistleblowing. Staff were aware of the FTSUG service and knew how to raise a concern, however, they told us they would more likely raise issues with their line manager or senior staff in ED as they were confident they would be listened to and the issue resolved. Staff did not know if there were any freedom to speak up ambassadors, staff members who work alongside the FTSUG to act as a point of contact and could signpost to the Guardian when appropriate, in the emergency department.

Between April and December 2024, there were 4 contacts made to the FTSUG from the ED department. These related to behaviour and relationships, systems and processes and staff safety.

Patients knew how to make a complaint or raise concerns. The service clearly displayed information about how to raise a complaint throughout the department.

Call 4 Concern, a patient safety initiative where a special team at the hospital could be contacted when it was felt patients were not receiving adequate clinical attention and there were concerns, was available to patients, relatives and staff. Details of this service were displayed throughout the department.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The emergency department (ED) had a clinical governance system in place through which the department were accountable for continuously improving the quality of their service, assuring patient safety and managing key risks.

There was a dedicated governance lead who was supported by the ED leadership team. Clinical governance meetings were held monthly and were open to all staff who worked in ED and included a member of the public, so the patient voice could be heard. The meetings had a set agenda which followed the Care Quality Commission (CQC) key questions of safe, effective, caring, responsive and well-led. The meeting included key elements such as patient safety, patient experience, risks and clinical audits. An action plan was produced after every meeting and progress reviewed at the following meeting.

Information from these meetings, including changes in practice or additional learning would be disseminated down to staff in various ways. For example,handovers, meetings and via emails. Staff at all levels were clear about their roles and they understood what they were accountable for, and to whom.

Information was escalated up to the trust board via the monthly divisional governance meeting. The ED team was represented by the governance lead and the ED leadership team at this meeting.

There were clear and effective processes for identifying, recording, managing and mitigating risks. The department operated a local risk register which was reviewed at the clinical governance meeting. New risks were added to the register and risks already on the register were monitored and managed. If the risk was determined to be a high, it would be escalated to the hospital risk register. We reviewed the risk register and could see risks highlighted to us were captured on the risk register, for example capacity and flow and increased violence and aggression seen towards staff in the department.

The service was able to recognise, rate and monitor risk. This meant the service could identify issues that could cause harm to patients or staff and threaten the achievement of their services.

The department had clear service performance measures, which were recorded and monitored by the service and wider hospital. Data collection was detailed and included data on a range of performance measures and quality indicators, which included audit results and patient feedback. Areas of good and poor performance were highlighted and used to challenge and drive forward improvements. Monthly reports were produced and discussed at the relevant governance meetings.

Where relevant, performance was tracked over time to highlight unexpected variations in performance which warranted investigation. This meant staff could identify at a glance, areas of increased performance or areas that required investigation and improvement.

There was a systematic programme of internal and external audit to monitor quality, and operational processes in the department. This helped leaders understand and analyse performance issues and put measures in place to address them.

The department used various IT systems to collect, analyse and share information within the department and the wider trust.

Staff were required to complete information governance as part of their mandatory training. Staff were up to date with this training with records showing 92% compliance for the ED.

There were effective arrangements to ensure data or notifications were submitted to external bodies as required. The service collated and submitted data to a range of national audits. This allowed the comparison of data against national averages and standards to help facilitate continuous improvement.

The department could monitor its performance on a live basis through an electronic patient dashboard. For example, monitoring the four-hour targets, patient waits in the department, and the patient decision to admit status. The dashboard was constantly monitored by staff in the department who could see the department’s live activity and operational performance. The information was also shared at the trust’s site meetings which occurred throughout the day to monitor and coordinate patient flow through the hospital.

The hospital had a full capacity protocol which was used when the number of patients occupying the department was beyond the capacity for which it was designed and resourced to manage. This protocol was used alongside the escalation triggers when there was a surge in activity and when there was insufficient staffing to manage normal activity.

The emergency department had positive and collaborative relationships with external partners to support care provision, service development and joined-up care.

The service was represented at the local integrated care board meetings regarding emergency medicine and together, with other stakeholders, built a shared understanding of challenges within the health and care system and looked at ways to meet the health needs of the local population, improve patient outcomes, relieve pressure on the services and ensure equitable access to emergency healthcare.

The service worked with local community services, such as the urgent care centre and primary care providers to help reduce the strain on the emergency service, the local community trust who provided mental health support to patients arriving at the department in mental health crisis, and the local ambulance service to improve patient handover.

The service had close working relationships with the local police force who would bring vulnerable adults and children to the emergency department or who provided support to medical and nursing staff when dealing with violent and abusive patients.

The service worked closely with the voluntary sector, for example advocacy groups and carers groups who provided valuable support to patients and their families when attending the emergency department. For example, a local advocacy group for 10 – 25 year olds supported young people who had attended the emergency department because of self-harm, a suicide attempt or emotional crisis.

The service was represented at many meetings to ensure vulnerable people received the appropriate support from the right emergency services, this included the frequent attenders meetings, the right care right person (RCRP) tactical delivery group, and the mental health vulnerable patients steering group.

The service worked with patient representatives and patient forums to help shape and improve the care and treatment people received when in the department, this included patients of different age ranges and equality groups.

There was a fully embedded and systematic approach to improvement, The service used quality improvement projects (QIP), a structured approach to identify areas for improvement, implementing change, and measured the impact of interventions, to support continuous learning, improvement and innovation work. Staff were trained on QIP methodology and the department actively encouraged staff to find ways to improve quality of care and outcomes for patients.

Leaders told us how the emergency department (ED) was data rich and they were always looking for ways to extract meaningful insight from it to help improve the service and people's experience and outcomes.

We were told about many initiatives aimed at improving performance and patient experience in both the adult and paediatric ED. For example, how to improve patient safety whilst using corridor care in the department, reference clip boards in the resuscitation area to assist staff in common emergencies and how play can be used to lesson pain through play in the paediatric ED.

The service had introduced keeping permanently defrosted fresh frozen plasma in the department. This meant the department could facilitate early administration of a balanced transfusion in trauma patients, this had been shown to promote better coagulation and reduced mortality.

The service had introduced the ambulance feedback request scheme to improve patient care throughout each step of their emergency visit. This was a scheme which met information governance requirements, and where ambulance personnel could formally request feedback on the outcome of a patient they had delivered pre-hospital care to. The scheme had been developed due to the demand of informal requests for feedback, and as a tool for learning. It had been evaluated using QI and had shown positive impacts, including pre-alert learning for both ambulance and ED staff, and on staff's mental health by addressing uncertainty and providing closure to ambulance crews. The team had future plans for the scheme, such as co-working with the ambulance service to see what learning could be shared to enhance pre-hospital care to improve patient outcomes.

When new initiatives were put in place the service would always monitor, evaluate and report to ensure the changes made had added wealth and improvements for staff and people using services.

The department took part in the Royal College of Emergency medicine (RCEM) quality improvement programmes (QIP). With the last three RCEM QIPs being care of elderly, mental health and time critical medication.

The department hosted annual special code red training days involving ED clinical staff along with other emergency responders from the local community, for example the police and ambulance trust staff. The day would involve lectures, covering topics such as traumatic cardiac arrest, practice sessions and simulation exercises with clinical psychologists and human factor experts also taking part. The day was designed to encourage working together in emergency situations to give better outcomes for patients.

There was an active research program within ED. There was a consultant research lead, and a research nurse in the department. The service was an active member of the local research networks and a co-founder of the Thames Valley Emergency Research Network (TaVERN). The service had been involved in National Institute for Health and Care Research (NIHR) projects. Including the diagnosis of acute aortic syndrome in ED with the department's consultant research lead being the co-investigator on the project. The department also recruited and been involved in the FOrearm fracture Recovery in Children Evaluation Study (FORCE). This study investigated the most effective treatment for buckle fractures in children. These fractures, most common in children, involved a compression fracture of the wrist where the bone bulges instead of breaking completely. The study found treating buckle fractures with a simple bandage and no follow-up resulted in similar outcomes compared to using a hard splint and routine follow-up. This had led to a change in practice for the treatment of buckle fractures. This meant less clinical time required, and less invasive methods used for the patient, whilst being equally effective in outcome.

Investing in research was seen by the ED management team as a way to influence and improve care in the future and therefore encouraged medical staff participation.