Queen Alexandra 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

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led.

The service was in breach of legal regulation in relation to good governance (contemporaneous records and identifying and assessing risks).

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

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The Trusts Values were incorporated into all aspects of an employee journey from recruitment to annual appraisals. We reviewed induction materials such as presentations and checklists which showed how these values and culture was embedded. Annual staff appraisals were undertaken alongside the values to ensure employees understood expectations and if their behaviours demonstrated this.

Staff could explain how they were working to deliver high quality care. We spoke with staff who told us how they worked to support patients in the department to ensure they were safe and cared for. Throughout our inspection we saw staff working hard to deliver care and provide the best possible outcome achievable.

Within UEC, the internal professional standards were used to outline standards and behaviours that underpinned staff expectations. We reviewed these and saw they clearly articulated the Trust’s core principles aligned with values such as compassion, teamwork, and continuous improvement. However, while collaboration is mentioned, there was limited evidence of frontline staff contributing to strategic discussions. There was also limited evidence to support how the wider hospital supported meaningful work to improve patient flow and care from the emergency department.

We scored the service as 2. The evidence showed some shortfalls. Leaders understood the context in which the service delivered care, treatment and support. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. However, they did not always take timely actions in response to risks which had a meaningful impact on staff and patients.

Leaders recognised the risks in the department and documented strategies and plans to address these. Risks were captured on a local and trust level risk register and were rated in terms of likelihood and consequence. The trust had risk management processes which meant that risks were escalated appropriately from the emergency department up to board level when required.

Staff and leaders at all levels demonstrated a good understanding of the risks within the emergency department and the action being taken to mitigate or remove risks. We discussed the top risks for the service with the leadership team. We heard how the top 3 risks were, Decision to Admit (DTA) and bed allocations not aligning with the continuous flow policy, risk of harm to Mental Health (MH) patients while they waited for assessment, and staffing.

The biggest risk identified was corridor care in escalation areas. There were 7 separate risks documented which related to the use of escalation areas and lack of patient flow. Despite mitigations, these remained of the highest risks on the departmental risk register.

Concerns regarding the environment for Mental health patients had been added to the risk register in 2022. Although this was prior to the department moving to a new building, a review of mediations had taken place since, yet it still remained one of the highest rated risks. This demonstrated that concerns with environments presented an ongoing risk which had not been resolved for over 3 years. Overall, 5 of the 23 active risks documented, related to the provision of services for mental health patients and that quality and safety of care could be compromised for those patients with mental health concerns.

In addition to this, we saw that 22 active departmental risks, only 5 had mitigations in place which had reduced ongoing risk. In addition to this, 5 risks had increased in RAG rating since they had been added. This indicated that although leaders had good oversight of the service they had not always taken appropriate or meaningful actions to manage risk and performance.

Local and Senior Leaders were visible in the service and approachable for staff. Staff felt that the executive team were present in the department and gave the example of the medical director who has shadowed a shift as well as the director of nursing. However, staff felt that senior leaders should be more present to engage directly with patients. We also saw this raised in staff wellbeing feedback.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate leadership structure with medical, nursing, and operational leads. There were clear reporting structures and key roles were supported by deputies or associate roles to support succession planning. Staff mostly told us they felt supported and guided by their immediate leadership team. Local leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. There were multiple daily safety huddles and bed management meetings which enabled sharing of information and escalation of patient risks and capacity and resource issues. Risks were discussed at safety huddles, board rounds and bed management meetings and leaders were proactively managing and escalating any concerns.

We also heard from staff that they felt there were limitations in translating this leadership presence and engagement into action and this was limiting their effectiveness to deliver the care they strived to achieve. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. However further work was required to develop and maintain substantive and consistent improvement in patient flow and improve staff morale.

We scored the service as 3. 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.

Leaders fostered a positive culture where people felt that they could speak up and that their voice would be heard and were able to describe how staff reported concerns and how these were investigated, then feedback given to staff, via various forums. The department had a well-established and evolving Freedom to Speak Up culture. Staff were encouraged and supported to raise concerns, and the transition to a 24/7 independent provider demonstrated a strong commitment to psychological safety, transparency, and continuous improvement. There were multiple channels for raising concerns including surveys and listening events.

We scored the service as 3. 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.

Policies and processes were in place to ensure the service was inclusive and fair in the way it operated. Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work. The trust had an Equality, Diversity and Inclusion Strategy in place this ‘pledged to address inequalities for our people, patients and communities with real purpose and action.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The service promoted equality and diversity in daily work and provided opportunities for all staff to develop. There was a trust level Leadership programme called ‘Beyond Boundaries’ which worked to develop staff from ethnic minorities into leadership roles.

The trust held events like the Diwali Celebration and International Food Festival, these were open to all staff and promote cultural understanding and inclusion. These events also fostered team cohesion and awareness. Within UEC there had also been an ED Cultural Celebration event.

There were equality and diversity champions within the service such as ‘DisAbility’ Staff Network, Race Equality Network and the Lesbian, Gay, Bisexual, Transgender + Staff and Allies Network. These networks worked alongside leaders to shape organisational strategies, policies and processes. It was hoped this would improve staff experience on a wide range of issues. There were wellbeing initiatives including forums, newsletters, and wellbeing lead updates.

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.

The emergency department sat within the urgent care directorate. Staff told us feel that they did not always feel they were listened too. Staff also felt that staff facilities need to improve along with better lanes of communication provided.

Staff told us the senior trust leaders were present and listened to the concerns of clinicians on the frontline. However, they struggled to provide effective and solutions. Leaders told us they understood but did not always have resources and space to manage the priorities and issues the service faced. Capacity constraints within the service and across other parts of the hospital impacted on patient flow in the emergency department. We heard from staff that they felt frustrated that escalation areas were being used and that they could not see changes from these concerns being raised.

The hospital operated in accordance with the Operational pressures escalation levels (OPEL). This was used in conjunction with the continuous flow policy to support rapid discharge and movement throughout the hospital. However, records showed the full capacity & continuous flow protocol was in place for 174 days out of the 186 days prior to inspection. Therefore, it was not clear if this policy was effective in efforts to improve flow and maintain safe care.

The number of ambulance handover delays over 60 minutes at the trust had improved considerably since September 2024 where it peaked at 40.5% which equated to 3,614.96 hours lost. This had reduced by to 23.43 hours in February 2025. Although staff recognised that changes to ambulance delays were needed, they felt that this moved the risk directly to them and that this was not well understood by other departments within the trust. Staff felt the clinicians throughout the rest of the hospital did not engage in mitigating the risk posed by overcrowding in emergency department by facilitating flow throughout the hospital and preventing emergency department attendances. It was not felt among staff the senior leaders had taken issues to address this and hold other areas of the service to account.

In response to changes within the trust the department had recently moved away from a divisional structure, meaning that the urgent care team now reported directly to their senior leadership team. Leaders described this as allowing a more direct line of sight and contact.

Most staff had access to the equipment and information technology needed to do their work. We saw that staff had ample access to computer systems both in patient bays and at mobile workstations. There was access to main hospital records, pathology and blood reporting systems, and patient records. Information governance systems included confidentiality of patient records.

However, we heard from some teams employed by another trust but that actively supported this services’ patients, that they were unable to access all systems such as the staff intranet and UEC patient tracking.

There was a clear framework of what must be discussed at a team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff had implemented recommendations from reviews of deaths, incidents and complaints.

Senior staff maintained and had access to the risk register at a departmental level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. We reviewed the risk register for the department and saw that this contained concerns raised by staff such as staffing and the use of escalation areas.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. We saw evidence that resilience planning had taken place. This had been used recently in the hospital following an outbreak of contagious illness.

The service used systems to collect data from the department that was not over-burdensome for frontline staff. The patient record system in use was able to collect and retain information to monitor safety. Local leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. This was actively used in huddle, safety and risk meetings.

During ‘Green QI Month’ staff were invited to contribute ideas for sustainability improvements via a QR code and direct email contact. The initiative was linked to national RCEM accreditation, encouraging team-wide participation and ownership.

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.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch. There was evidence of sharing information with stakeholders to improve patient outcomes. This included pathway planning, redesign and implementation.

There were quality reviews of the department, where information was shared to encourage collaboration across departments and providers to improve quality, effectiveness and safety for people using the service. The department had undergone a review of patient experience via Healthwatch, but this had not been published at the time of assessment. Healthwatch is an independent government organisation responsible for ensuring that people's experiences and views are heard by decision-makers to improve services. The service was also working in partnership with the General Medical Council to improve the experience and meet guidance for international medical graduates employed at the trust.

We saw evidence of initiatives with other agencies that demonstrated multi-agency collaboration. These initiatives involve collaboration with housing, mental health, addiction services, and local authorities to support vulnerable patients.

We scored the service as 3. The evidence showed a good standard. 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.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff were actively engaged in quality improvement and evidence-based practice, which are foundational to research-informed care. Staff used quality improvement methods and knew how to apply them.

The UEC department actively promoted service and quality improvement projects that were developed and undertaken by their staff. We saw evidence of multiple Quality improvement projects that had been developed that covered clinical and patient experience improvement.

Staff we spoke with were able to tell us about quality improvement projects in the department such as improving the time it takes to assess a patient on arrival. Quality improvement projects were supported by the quality improvement lead in the trust. Projects were linked across departments and formed a strategic approach with increased executive support.

Mortality review group meetings were held monthly. Minutes showed appropriate discussion of identified cases and identified learning to feedback to teams. This included patient case studies and organisational learning.