Southampton General 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

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.

The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The trust values were clearly stated and understood by staff. The values were: patients first, working together and always improving. Staff demonstrated their understanding of the trust’s vision and values as they went about their work. There was a very strong sense of commitment and responsibility to do their best, get things right for the patients, their families and carers. A member of senior clinical staff told us there was a hard-working team and positive culture. The staff “cared about the patients and cared about their services.” Staff we spoke with were passionate about their work and the difference they could make to children and young people and their families. There was strong sense of teamwork and collaboration amongst all roles.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Although the Children and Young People’s service and Neonates did not have a specific written strategy, distinct from the trust strategy, the senior leaders had a strong vision for where the children’s hospital needed to get to. They were working to balance the importance of having a strong children’s hospital with being part of the trust.

Senior leaders explained how they had recently contributed to the revised strategy. Several listening events had been held with staff in the spring and summer of this year, across the department and they had engaged with the director of strategy. Staff had been given access to a QR code for staff to engage, and a good response was received from this approach, which was shared with the strategy team.

The voices of young people had also been included in contributing their thoughts and ideas. We were told that Neonates had been focusing on the patient voice too, recognising the importance of getting it right for those who could not advocate for themselves. Bringing in the voice of parents and families was seen as key to localised approach, and one which could reflect the national level drive for improvements in this area. Senior leaders told us the revised strategy was nearing completion.

The evidence showed an exceptional standard. The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Child health was led by the divisional director of nursing and professions. They were supported by the care group clinical lead, a care group manager, lead matron and 4 other matrons. Paediatric Intensive Care and Neonates also had a lead matron. There was also a divisional clinical director and divisional director of operations. Staff holding leadership roles with associated responsibilities had been trained and developed to take these on with commitment, enthusiasm and were highly motivated. All matrons had a level of responsibility for quality, governance, complaints, risk, budget, staffing and patient flow. Leaders were aware of the challenges of running services when there were restrictions on finances. They were open and honest with their staff about the situation, but were willing to challenge upwards, as necessary.

Senior leaders within the Children and Young Peoples Service led with enthusiasm and passion, something which was mirrored at all levels. The culture between clinicians and management was described positively to us, with one surgeon saying, “we are very well led, by capable, compassionate and dynamic leaders.” They added that the matron team was much improved from how it was 2 years ago. They described the team as more “energetic, functional and a dynamic team, who, operationally were very good.”

Not all staff we spoke with had met the most senior members of the trust, although they knew who they were. However, they were very aware of the senior leadership team for the children’s service, and who to go to, if they needed anything. We saw and staff told us, the more senior ward managers matrons and above were available and supportive. Staff said managers were approachable and ward managers were relaxed, encouraging teamwork and mutual respect.

A doctor in training told us they enjoyed working at the hospital. They said the environment was supportive, with good inter-specialty team working to ensure everyone finished on-time. Although they had not needed to exception report, they felt they would be supported if needed.

Staff told us they had the chance to move into different roles and to be developed into more senior positions. A staff nurse who spoke with us told us how they had worked their way up through an apprenticeship and the required training from a healthcare assistant role. For staff wishing to develop further there was access to clinical facilitators, with teaching on the ward, as well as access to formal study days.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Feedback from patients and their families was collected and summarised by the Experience of Care Team. The information included ‘what our patients say about us’ and ‘experience of care heroes. The latter included commentary where staff had been nominated by patients for going above and beyond. We reviewed the reports for each ward and saw feedback was mostly 100% very good, with many comments and high praise offered.

Family and Friends feedback was collected and reviewed by the Experience of Care Team. This team was working with the Quality Patient Safety Partners to address some of the points identified. An action plan was expected in 2026. The service also collected feedback from young people on the PEEER Youth Service, which supported young people living with a long-term health condition to thrive in their community and within their health-care journey. The trust shared examples of some of the feedback they had received from both young people and parents. It was clear from the information that having access to a youth worker was a valuable experience for young people.

The freedom to speak up guardian (FtSUG) had not heard any concerns raised from Children and Young People in this financial year, and the last concerns were raised in 2019. The presence of FtSUG was found to be beneficial, as staff could raise awareness through their relationships with managers and staff could speak up quickly, helping to ‘nip in the bud’.

The evidence showed a good standard. 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 trust had an Inclusion and Belonging Strategy for 2023-2026. Part of the strategy indicated the importance of having a clear picture of people who identified as Lesbian, Gay, Bi-sexual, Transgender, Queer, (Questioning), Intersex, Asexual in the workforce, and these groups were represented across all roles. They also wanted to understand their experiences positively or negatively in relation to declaration rates. Measures of progress and success were stated, along with target dates.

The trusts Workforce Race Equality Standard (WRES) annual report for 2025 stated the main findings when measured against 9 indicators contained within the WRES dashboard. Whilst not specific to the children and young people’s service we saw the key points were clearly stated and included for example, a continued rise in Black and Minority Ethnic (BME) staff to represent 31.3% of the workforce. It was noted the appointment of BME applicants was slightly above white candidates. Although there remained some differences in accessing non-mandatory training and development opportunities, the gap was narrowing between BME and White staff. The perception of career progression opportunities was greatest for white staff and less so for BME. They also found BME staff were nearly twice as likely to report discrimination by managers or colleagues, with a small increase this year. We saw the WRES action plan was in progress, with most target dates set for April 2026.

There were standard working patterns within nursing; however, we were told reasonable consideration was given to needs, such as working mainly night shifts, with occasional days to keep abreast of things which generally only went on during those hours.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance, and outcomes, and share this securely with others when appropriate.

There were clear leadership structures within Children and Young People’s services, which sat in Division C. Roles and responsibilities were clear and there were systems and process to ensure accountability and good governance to manage and monitor the service.

Staff told us there was a Care Group Governance Meeting, which took place monthly. This fed into the Divisional Governance Group and in turn, the Quality Board. There was a process of escalation from wards and theatres. Additionally, some clinical areas held their own governance group, feeding into the Children and Young People’s Governance Group, which was chaired by the chief nurse.

Governance meetings included for example, activity data, number of incident reports, themes, trends, and monitoring against risks on the risk register. The risk register for Child Health and Neonates had 19 risks listed, these were reviewed either monthly or every 2-months, depending on the seriousness of the risk. This was in line with the Risk Management Strategy and Policy. We saw several examples of risks having been reviewed and progress on the required actions having been fully considered, as well as next review dates stated.

In the Child Health Risk meeting, each clinical area was represented and had an open floor to discuss concerns in their area. All of this was collected and a report for each care group was produced, which fed into the divisional governance meeting and upwards. We reviewed several risk meeting discussion notes and found these to be clear and contained learning points.

Examples of reports generated at the division, care group, and ward levels, included various measures, such as escalations based on National Early Warning Score 2 (NEWS2) and National Paediatric Early Warning Score (NPEWS). The number of Call 4 Concern made, number of cardiac arrest calls, Critical Care Outreach Team activations and reasons for referral, and unplanned admissions to the intensive care unit (ICU) were also so reported.

Within children’s services, doctors in training told us there was a once-a-month mini resident doctors forum, with an open agenda. This was fed back to the consultants who dealt with any issues. Doctors in training told us they were in general supported to raise incidents. Learning from the incidents; however, was a bit variable. One doctor told us they had raised incident and understood it had been discussed at a 'higher level’, but they had not received any direct feedback.

The Virtual Enhanced Care Group (VECG) provided a detailed report annually to the Mental Health Board (MHB) (an Executive level Board) and a monthly overview. Any required escalations were made to the Quality Committee every quarter. Information was also shared with the Integrated Care Board (ICB) for NHSE, if children or young people were involved. We saw Mental Health Board meetings were held at regular intervals. Agenda items included for example, Children’s ED Mental Health Data Report, the trust CAMHS Liaison Governance Reports and the ligature audit.

Some staff with lead roles on wards and in departments had a responsibility for audit, for example, infection prevention and control, moving and handling and locking of drug cupboard keys. Feedback from audits was shared with staff and if required, as part of the ‘Big4’ focused messages. Big4 messages were shared across the whole division and included information from reported incidents.

Wards had named leads for a range of areas, including risks. Information collected at ward or department level was fed into the local risk registers and upwards. Examples of local risks included the waiting list for cardiac surgery and mental health provision for children and young people. Teams were provided with risk-related bullet points from monthly risk meetings, which the named staff member attended.

Divisional leads told us there were other structures where risk and assurances were fully considered. Multi-professional reviews took place. For example, the Child Deterioration and Death (CDAD) meeting included mortality information. There was a structured, multidisciplinary, and well-embedded approach to learning from deaths and clinical deterioration, with clear governance, escalation pathways, and mechanisms for sharing and applying learning at both local and trust-wide levels.

A summary from the governance and risk lead was shared to divisional leads after each CDAD. This provided a safety net in case divisional leads were not aware of something. Learning from CDAD was shared through the Children’s Hospital governance structures and fed into wider Trust Learning from Deaths processes, ensuring organisational oversight and sharing of learning.

From our discussion with doctors, we were told any child who had died or deteriorated and been admitted to Paediatric Intensive Care Unit (PICU) was discussed; however, they said there was no clear sharing of learning, but action points were clear at the end of the meeting.

The trust was having to make careful consideration of how money was spent and invested in the services. As far as reasonably practical, such decisions took account of the service needs and patient care. However, some staff were worried about the impact on reduced staffing levels, not just on wards but in other important services.

Staff generally had access to the equipment and information technology needed to do their work, although it was recognised having electronic patient records would be beneficial. Information governance systems included confidentiality of patient records and staff were trained in this area.

Senior leaders and department managers had access to information to support them with their management role. Performance data was collected, monitored and reviewed in the various formal governance meetings. Where improvement was needed, actions were taken. Information was in an accessible format, and was timely, accurate and identified areas for improvement. We saw for example, that the service took part in the trust-wide Clinical Accreditation Scheme (CAS). This process of monitoring included measuring standards in the ward areas and ensuring clinical expectations were being met, as well as quality improvements were sustained. Regular multidisciplinary reviews ensured the service was aware of how well staff were doing regarding the assessment of patient pathways, documentation completion, the environment, patient experience, as well as identifying and addressing any risks.

The CAS process directly supports safe systems, pathways, and transitions by ensuring that care delivery is consistently reviewed, risks within pathways are identified and escalated, and improvements are implemented and monitored through formal governance structures. It also provides a mechanism for sharing learning and best practice across clinical areas, supporting continuity and safety during transitions of care.

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.

We saw many examples of how the service worked together with internal and external partners to support and improve the healthcare experience of patients. This included for example, involving front-line staff, estates, finance, architects and charitable organisations. Several activities had been shared with the wider audience at a conference in 2025, where innovation and learning had been highlighted. For example, we saw information related to a dietitian-led ‘Pitstop and Wellness Day’ related to diabetes in young people and the completion of their health checks. This had been delivered in a primary care network. Other examples included the neuro rehabilitation service, which provided acute intensive rehabilitation for patients up to 18 years following an acute brain or spinal cord injury. The pathway covered acute admission through to transition home and follow up with local community teams. A youth support worker had been introduced to the service in September 2024, with a role in linking with young people who had a spinal cord injury or brain injury. They met with the young person to discuss next steps before a multidisciplinary meeting was held and prior to discharge. The epilepsy service had recognised the need to hear the voices of its young patients through the role of ‘Youth Epilepsy Warriors.’ A video called ‘Epilepsy and Me’ was created by several young people, supported by staff, as a means of improving the understanding of epilepsy among their peers and teachers in educational settings.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch. The trust and its services were part of the Hampshire and Isle of Wight Integrated Care System. There were stakeholder engagement activities at trust level and specifically for Children and Young People, they were a member of the Children’s Hospital Alliance. This was a national network of specialist NHS trusts working together to improve the quality, access and experience of hospital care for children and families.

As a tertiary service, there were established relationships with other hospitals in a wide area outside of the immediate county. This meant the Children and Young People’s service could take patients from further afield, often those with complex needs.

Staff across various roles said they could access leaders and raise concerns or suggest ideas. Senior role holders, including medical and surgical consultants were accessible and easy to talk to.

The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff had opportunities to participate in research. There were 6 paediatric trainees (not counting locally employed doctors) who were clinical research fellows and training paediatricians to deliver research. There were 2 advanced nurse practitioners undertaking research internships and 6 associate principal investigator schemes for resident doctors and senior nurses. Many specialist consultants presented papers externally.

The trust informed us there were 121 current paediatric trials open to recruitment. Since 1 January 2025, the trust had recruited 2314 participants to paediatric specialist studies and a further 1443 under 18’s to non-specialist studies (those that will be recruiting adults and children). We were provided with information about some of the most recent outputs of several research programmes. These included for example, FORCE study (immobilisation of torus/buckle fractures in children), which resulted in guidelines being changed, so these types of bone fractures are no longer immobilised. The patient experience and their management was improved because of this.

The trust held a Quality Improvement (QI) and Research meeting monthly, where they reviewed recent evidence to inform clinical practice and review areas in need of innovation or QI. We were informed about recent QI work, which had included the consultant-led Eating Disorders Service, where length of stay reduced from 48 to 12 days. An out-of-hours online worklist had led to the bleep system being replaced and as a result bleeps were reduced by 50%, improved staff productivity and morale. The CDAD weekly review- provided a rapid review of child deaths and PICU escalations.

Some of the improvements work was summarised in Child Health Care Group Improvement Meetings and included for example, the walk-in walk out pathway in rheumatology, with joint injection patients now discharged directly from recovery. Work as also taking place on the paediatric cardiac surgery waiting list management.

Staff working in the children’s services had contributed to the annual Paediatric Innovation, Education & Research Network conference. We saw several examples of work presented, including the ‘Resolution of comorbidities in children with obesity after 12 months in a tertiary weight management clinic’, the development of a community integration clinic to review neurological rehabilitation patients and information on the impact of dedicated spinal cord injury support to children and young people. Information about a 10-year cardiorespiratory screening programme of children diagnosed with Prader-Willi Syndrome on Growth Hormone was also presented and included the results and the change in the pathway for these children.