St Thomas' 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 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.

The service had a clear vision and plans to achieve it. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. There was a clear system of governance and risk management based around delivering safe, high-quality care and treatment. The service worked with stakeholders and partners to drive improvements to care pathways. The leaders encouraged an open and honest culture where people felt that they could raise concerns. Leaders also supported innovation both internally and with system partners. This improved the patient experience and access to services.

At our last inspection we rated this key question as outstanding. At this assessment the rating remained outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved 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.

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 service had a vision to deliver safe, high-quality, timely care for every patient while supporting staff and improving system flow and efficiency. The urgent and emergency care and support services strategy 2025/26 outlined strategic initiatives for staff wellbeing, violence and aggression, quality and safety, mental health, 4-hour standard and flow, and finance and sustainability. Key measures included support for staff wellbeing, sustained improvement against the 4-hour national performance standard, equitable and inclusive care for all patients, reducing waiting times for mental health patients, and delivery of financial efficacy among others. This aligned with the wider trust strategy to deliver ‘better, faster, fairer healthcare for all’.

The trust had a strategic lead for mental health and had developed a mental health strategy which set out a clear vision to provide high quality, compassionate and person-centred care for people living with mental health issues who accessed their services. Sitting beneath this were delivery plans for individual departments including the ED. The delivery plan included work to further improve the emergency mental health pathway in terms of timely, safe and therapeutic treatment. The leadership team had created a culture where staff felt safe to escalate risk and took proactive steps to address it including bringing in different voices such as the local mental health trust and CQC mental health team. Leaders recognised the rising demand and high acuity of mental health crisis care through ED. It was widely recognised that mental health patients often experienced longer waits in the department. The department was working collaboratively with the local mental health trust to find innovative ways to improve the experience of patients and improve length of stay. For example, the Enhanced Care Team (MHECT) was undergoing a restructuring process that would result in an expanded and more resilient workforce, increasing capacity for patients and reducing spend on temporary staffing for mental health purposes.

There was strong emphasis on supporting vulnerable people. The trust had a vision and strategy to support autistic people and the wider neurodivergent community. This included a vision to provide outstanding, equitable and accessible care for neurodivergent patients, and the wider neurodiversity community. The service had strategic priorities aimed at improving access for neurodivergent patients, tackling inequalities, training staff and improving identification systems among others.

The ED outlined its’ departmental values as inclusive, appropriate, innovative, efficient, supportive and sustainable. The service identified the values as the underlying principles for their improvement endeavors. The culture within the service was positive. Staff described feeling part of a cohesive team and demonstrated commitment to delivering good care despite operational pressures. Staff we spoke with reflected pride in their work and in the supportive environment. They also reported strong teamwork between all staffing groups, with an emphasis on keeping people safe while working within the service’s defined scope. Staff knew the trust values and embedded them in their daily practice.

All staff we spoke to informed us there was a positive culture on the unit. They explained that the entire trust worked together to resolve any system issues rather than leaving individual departments or services to resolve them. For example, the service had protocols to involve senior site practitioners to expediate discharges and admissions on the wards to aid patient flow in the ED.

Leaders set out a consistent direction, focused on delivering safe, high‑quality and timely emergency care for all patients, and staff understood how their work aligned with these aims. Staff had opportunities to take part in discussions about service strategies, especially when changes were being made, and could explain how their work contributed to delivering high-quality care. The team recognised the challenges of increasing attendance of patients with complex needs and/or mental health needs. The ED, in collaboration with the trust and wider system partners had developed initiatives to address this, including effective liaison with community teams and mental health providers.

Leaders and staff demonstrated commitment to deliver safe, high quality, timely and inclusive care in the provisions and support offered to vulnerable people and the wider population.

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, openness and honesty.

There was clear management structure with defined lines of responsibility and accountability. The urgent and emergency care (UEC) and support services directorate management team included a clinical director, head of nursing, head of nursing for mental health, general manager and deputy general manager among others. They were supported by the ED service management team which included an ED consultant service lead, operation lead, governance lead, 2 matrons, GP lead, and an emergency nurse practitioner lead among others.

The Paediatric ED was under the children’s medicine and neonatology directorate of Evelina London Children’s Hospital. The paediatric ED was led by a head of service, matron, service manager and assistant service manager.

Leaders had the skills, knowledge, and experience required for their roles. They demonstrated a clear understanding of the service they managed and could explain how their teams worked to deliver high-quality care, including managing patient flow and maintaining safe staffing levels. Leaders demonstrated strong oversight of governance and operational performance, and we saw evidence of this in minutes of meetings and from our discussions with staff. Senior staff could clearly describe the top risks facing the service and had processes to monitor and mitigate these.

Leaders were proactive about implementing innovative solutions to address emerging risks. For example, leaders consistently reviewed ED capacity to care for increasing attendances of patients with mental health needs. A decision was made to create additional roles and leadership oversight to address this, this included the role of the ED head of nursing for mental health and other specialist mental health roles. Leaders were also prioritisng improving sepsis screening within the department.

Staff felt supported by all levels of their leadership team. Staff spoke positively about the immediate managers, matrons and consultants, and the way they supported them. Senior staff spoke about how proud they were of their teams, their dedication and compassion to deliver high quality care. Staff knew who the executive leaders were and told us they were visible and approachable. Staff told us leaders in the service responded to any concerns raised. Leaders at all levels were visible, experienced and well regarded by staff. Evidence from meetings and staff interviews showed that the nursing leadership, consultant oversight and management presence were strong, and staff consistently described leaders as supportive, approachable and invested in their development. Staff survey results for the Integrated and Specialist Medicine clinical group and the Evelina London Clinical group were generally positive in comparison to the national benchmark.

We saw evidence of succession planning and support for aspiring senior leaders. This included workshops and development opportunities to support talents within the directorate to develop the skills and knowledge to progress. Staff had access to training programmes such as the operational improvement training programme which was open to all bands 6-8a clinical or operational staff. The training programme supported staff to develop skills in operational management with practical tools they could apply in their day to day work and future careers. Staff informed us they received good support to advance in their role and had good opportunities to progress. Some of the medical staff we spoke with had started their foundation training at the trust and progressed through the grades.

Leaders demonstrated a compassionate and inclusive approach. They made reasonable adjustments to accommodate staff needs, including flexible working arrangements. Leaders were passionate about the wellbeing of staff and had implemented measures to mitigate against rising incidents of violence and aggression against staff. Staff informed us they felt listened to and empowered by the leadership team.

Leaders acted to continually review and improve the culture of the organisation in the context of Equality, Diversity and Inclusion (EDI). All staff had access to multiple staff networks including disability staff network, neurodiversity staff network, lesbian gay, bisexual and trans staff network (LGBT+) and multicultural staff network.

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.

The trust had a freedom to speak up policy which highlighted internal and external options available to staff as well as wellbeing support for staff. The Trust had appointed a lead freedom to speak up guardian and 2 deputy freedom to speak up guardians as well as part-time guardians, who acted independently and impartial to provide advice to staff at any stage of raising a concern.

All staff we spoke to felt they could escalate concerns and knew about the freedom to speak up guardian. Staff informed us that the service used to have freedom to speak up champions, however, they are implementing new initiatives to replace them with freedom to speak up advocates. One of the staff we spoke with was a freedom to speak up champion and had commenced training for the new initiative.

Staff described the culture and team in the ED as amazing. They said, “everyone genuinely wants to do the best for patients”. One medical staff member said they “loved all the consultants they worked with”.

Most of the staff we spoke with informed us they had been working in the service for significant lengths of time and they enjoyed working there.

Staff survey results showed that the division performed better than the trust average for the statement “we each have a voice that counts”.

Patients and carers had opportunities to provide feedback on the service in ways that reflected their individual needs, including through surveys such as Friends and Family Test Survey. Managers and staff had access to this feedback and used it to make improvements.

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

The service had a governance framework which was supported by a structured programme of meetings that provided oversight of safety, quality, and operational performance. This was positive and demonstrated a clear commitment to monitoring risk, escalating concerns, and supporting safe service delivery. Minutes demonstrated that meetings were well attended by senior clinicians, operational leaders and governance staff, with clear agendas covering quality, safety, incidents, policy updates, and service pressures. Information from these meetings, including changes in practice or additional learning was disseminated down to staff in various ways. For example, at handovers, meetings and via emails. Staff were able to tell us key information shared from these meetings.

Within the ED, daily safety huddles were held and attended by senior leaders. This allowed immediate risks, staffing concerns, and patient flow issues to be identified and addressed promptly. Staff collaborated with internal and external teams to meet the needs of patients.

Staff we spoke with were able to identify the main risks around the department. Staff indicated that the main concerns were around the care of patients with mental health needs, violence and aggression towards staff, and queues for triage. Staff felt that leaders had taken appropriate action to mitigate those risks.

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. 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.

There were 22 risks recorded on the adult ED risk register. Of these, 4 were identified as catastrophic, 3 major, 9 moderate, 4 minor and 2 insignificant. There were controls to mitigate the risks and the risks were regularly reviewed by senior staff. All risks we identified during the assessment were known by leadership with appropriate mitigations already to address them. For example, sepsis screening and mental health waits.

Catastrophic risks were mostly regarding the risk of patient absconding, ligature points and patients at risk of self-harm. Controls included risk assessments, enhanced care for high-risk patients, door controls, use of ligature-lite rooms, and staff training amongst others.

The service had an escalation plan to allocate an additional streaming nurse once there are up to 6 people on the queue for triage.

There had been increased security presence in the ED with dedicated security staff for 24 hours in the triage area. Staff showed us their personal alarm tool which they could use to escalate any aggression they faced. This prompted senior staff and security staff to immediately identify their location and attend to them.

There was 1 open risk on the Paediatric ED risk register. This involved potential delays in the appropriate placement of children and young people with mental health needs. The trust collaborated with system partners and mental health providers to facilitate transfer to specialist mental health services.

The trust had a mental health board which reported through the vulnerable persons assurance group to the risk and assurance committee. Sitting beneath the mental health board were several committees providing governance for the mental health in the trust. These committees included a monthly operational meeting attended by staff from the trust and a mental health trust looking at the flow of patients with mental health needs including adults and young people. There was also a governance meeting attended by staff from the trust and the mental health trust reviewing incidents; complaints and identifying areas for learning and improvement. Other meetings included the review of people who frequently attended with ED with mental health needs and the interface between the ED and the health-based places of safety.

The service had clear performance measures, which were recorded and monitored by the service and wider trust. There was a programme of internal and external audits to monitor quality, and operational processes in the department. This helped leaders understand and analyse performance issues and implement measures to address them. Leaders were proactive in how they used audit information to identify areas of improvement for the department and fed this into their quality improvement programme.

The service could monitor its performance on a live basis through an electronic patient dashboard. For example, monitoring the 4-hour targets, patient waits in the department, and the patient decision to admit status. The dashboard was constantly monitored by staff who could see the department’s live activity and operational performance.

The trust had an emergency preparedness policy with multiple incident response plans including an emergency preparedness, resilience and response plan.

There were effective arrangements for the availability, integrity and confidentiality of data, records and data management systems. Staff could access relevant information about patients’ care and treatment.

The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The trust worked effectively with a wide range of partners and community organisations to help meet the diverse needs of people using the service. Evidence showed effective relationships with local trusts, mental health providers, GP services, the ambulance service, and specialty teams, which supported safe pathways and timely transfers. Staff described strong communication with paediatrics, speciality and mental health teams, ensuring people received the right care in the right place.

The service collaborated with a mental health trust which provided mental health nurses to care for patients in the crisis assessment unit. Staff from the psychiatric liaison team who were employed by the mental health trust, described positive working relations with the service and the willingness of staff from service to share issues and work together to make improvements.

ED staff actively participated in the strategic work led by the integrated care system to meet the needs of people with mental health needs. There were formal governance structures including monthly or quarterly meetings with system partners, local trusts and regulatory bodies.

The trust had various teams to meet the needs of different population groups. This included a community health inclusion team (HIT) that supported vulnerable people who had difficulty accessing primary care services, for example, homeless people, refugees, asylum seekers or people with addiction. The service collaborated effectively with the health inclusion team to ensure continuity of care.

A broad range of voluntary and community sector organisations were available to support people with complex social, emotional and psychological needs. Staff used established directories to signpost people to trauma focused services, domestic abuse support, counselling, youth activities, community food provision and legal advice, helping people maintain wellbeing beyond the hospital environment. These included organisations offering culturally specific support, activities for families, interpreting, mental health groups and specialist services for survivors of abuse.

The service referred people to organisations that could address their specific needs. Staff used established directories to signpost people to trauma focused services, domestic abuse support, counselling, youth activities, community food provision and legal advice, helping people maintain wellbeing beyond the hospital environment. These included organisations offering culturally specific support, activities for families, interpreting services, mental health groups and specialist services for survivors of abuse.

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 contributed to safe, effective practice and research.

The ED used quality improvement projects (QIP) to identify areas of improvement, implement change and measured the impact of interventions to support continuous learning and improvement. The service had launched several QIP initiatives on various topics for 2025/26. This included sepsis management, deep vein thrombosis (DVT) pathway, the green ED initiative, rapid tranquilisation, pain management, asthma, trauma call activation, procedural sedation and management of mental health patients among others. The service took part in the Royal College of Emergency medicine (RCEM) QIP. With the last three RCEM QIPs being care of elderly, mental health and time critical medication.

The service launched several initiatives aimed at supporting people with complex social and psychological needs. The service had a frequent attender clinical review team consisting of an emergency medicine consultant, speciality doctor, physician associate and staff nurse. The team held monthly review meetings and worked with a wider group of support teams such as the homeless team, alcohol and substance misuse teams and the mental health liaison among others. The team existed to bridge the gap between the ED and a dedicated network of support services in the community.

There were several initiatives to support mental health care in the ED. This included the introduction of a mental health emergency response procedure, suicide awareness training for staff, and a program to reduce ligature risks across the ED. The service worked collaboratively with a mental health service to improve the use of restrictive interventions across the ED. This led to the introduction of safety pods with the intention to eradicate instances of patients being physically restrained on the floor, as well as providing a more holistic and less restrictive way of therapeutically holding patients who may be at risk of harm to themselves or others.

A review of the enhanced care team was undertaken to improve service delivery, patient experience, and safety and wellbeing (for both patients and staff). This resulted in the development of specialist mental health roles including a mental health practice development nurse and 4 mental health wellbeing practitioners to support care planning and therapeutic engagement. The mental health practice development nurse was schedule to start their role in early June. The focus of their role is to develop a training programme for the mental health enhanced care team (focusing on both adult and paediatric mental health), as well as developing training for the wider non-mental health workforce, working across the directorate.

The trust had submitted a paper to the Operations Board in January 2026, where recommendations had been made to make further changes to improve the safety of the ED environment. Since then, further work had taken place to replace hooks and curtain rails so they cannot be used as ligatures. Funding was approved to make bathrooms ligature free across majors areas.

The service established a multidisciplinary Green ED working group to improve environmental sustainability with participation from ED consultants, residents, senior nursing and management teams and the trust sustainability team. The service had included sustainability in staff inductions and teaching sessions. Staff received training on Green ED initiatives and were encouraged to support projects either through daily clinical practice or more directly by working on quality improvement projects. There were initiatives to improve waste segregation, implement energy saving measures, reduce the environmental impact of paper, reduce single use plastics, reduce unnecessary pathology or radiology requests and reduce staff travel by providing hybrid options for non-clinical administrative roles among others.

The service also developed new approaches in response to complex or emerging risks. For example, a pilot of restorative practice with the aim of reducing violence and aggression and self-endangerment incidents and a pilot of e-registration which was in development.

Leaders encouraged innovation and participation in research. The service took part in national research to support patients. We saw evidence of collaboration with external partners to support improvement. This included joint work with primary care networks, the local ambulance Service, local smoking cessation services and community health teams.