Queen Elizabeth 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 there was an inclusive and positive culture of continuous learning and improvement, that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At this assessment we rated this key question as good. We saw evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted 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 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.

The service and the trust 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.

The service reflected the trust’s vision and values of being responsive, working together, learning, respect and compassion, and improving quality. The strategy for the trust’s diagnostic imaging service had a core priority which included extending the provision of X-ray services in the local area.

Leaders and staff told us values were embedded in training and were built into appraisals. This ensured everyone knew what was expected.

All staff we spoke with felt supported, respected and valued. This was reflected in the 2025 staff survey results, which showed an increase in staff agreeing that their work was valued by the organisation. It was clear from speaking to staff that they felt their work was important to them, and they felt passionate about their contribution to the care and treatment they provide for people.

The service had 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 did so with integrity, openness and honesty.

Whilst we understand that there were vacancies within the leadership team which were being recruited to at the time of the assessment, we found that the leaders were inclusive and understood the context in which the service delivered care, treatment and support. They consistently demonstrated the values and culture of the organisation and led the service with integrity, openness and honesty. Leaders had the appropriate skills, knowledge and experience to lead effectively and were credible to staff working within the service. This supported a positive culture where staff felt respected, valued and encouraged to deliver high‑quality care.

The service had a clear management and leadership structure, with defined lines of responsibility and accountability. Leaders understood their roles and how these contributed to the safe and effective running of the service. Robust recruitment processes were in place to ensure staff were appointed fairly and had the necessary competence and experience for their roles. These arrangements supported effective leadership and ensured staff were appropriately deployed.

Leaders met regularly through established governance and management meetings to review performance, risks and priorities. Minutes from governance meetings showed leaders had good oversight of the service and were knowledgeable about key issues affecting care delivery. Leaders used these forums effectively to make decisions, agree actions and cascade information to staff within the service, ensuring communication was timely and consistent.

Leaders and staff told us they felt well supported to carry out their roles. Staff said leaders were approachable and visible, and that they felt listened to. Concerns raised by staff were taken seriously and acted on where required. This demonstrated a compassionate leadership approach and contributed to a supportive working environment where staff felt confident to speak up and raise issues.

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

The service had a Freedom to Speak Up process supported by an up-to-date policy and named Freedom to Speak Up Guardians. The service’s policy provided information on how to raise concerns internally and external to the service. Staff knew how to access support and raise concerns.

Staff and leaders actively promoted staff empowerment to drive improvement. The culture supported staff to speak up without fear of detriment. Leaders encouraged staff to raise concerns and promoted the value of doing so. Staff told us that they felt comfortable to raise any concerns and were confident that their voices would be heard and demonstrable action taken.

The service had established freedom to speak up arrangements. Information about the guardian and how to contact them was available on the intranet. Whilst not all staff knew the name of the trust’s freedom to speak up guardian, they knew how to raise a concern.

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.

Staff understood equality and diversity and its importance in building a strong workplace culture. Staff felt they were treated equitably, which was reflected in the latest staff survey. The service promoted equality and diversity in daily work and provided opportunities for career development.

Staff had training in equality and diversity. Staff understood the need to give everyone the same rights and opportunities and to value and respect people's differences. Recruitment practices were inclusive. The provider recruited staff through a range of processes.

Leaders took steps to ensure that staff and leaders were representative of the population of people using the service. Staff told us they had equal access to ongoing professional development. Opportunities to develop were advertised and staff completed an expression of interest.

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.

The governance and management structure of the service was part of the trust’s wider structure. This meant that management, risks and planning of the service included all of the trust’s diagnostic services.

There was a clear management structure. Leaders and staff understood their roles and responsibilities. Leaders monitored the quality and safety of the service and identified where actions should be taken. Risks were monitored and reviewed. There was a clear reporting structure, from the service to the trust’s board, with various meetings reviewing the quality and safety of the service. The service held specific meetings relating to the provision of ionising radiation services.

There were processes to monitor the performance of externally contracted support services. Information was kept secure between referrer, the service and the third-party provider reporting on out-of-hour scans.

There were capital investment plans across the trust’s diagnostic imaging services that included purchasing a second MRI scanner for the department. Leaders encouraged staff to report concerns, incidents, and breakdowns to support decision making on capital investments.

The service had business continuity plans should the service be impacted by power cuts, fire or floods. Leaders told us the service was accessible and people who used the service provided positive feedback.

Information gathered about patients or others was held in secure systems which met data protection legislation requirements. Access to computerised patient records was password protected with a secure login.

Managers ensured radiation incidents were fed into risk management structures, and for accidental and unintended exposures, they notified the CQC in line with legislation.

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.

Leaders understood their duty to collaborate and work in partnership so that diagnostic and screening services worked seamlessly for people. The service worked constructively with internal departments and external partners to support coordinated care and timely access to imaging. This included primary care referrers, clinical services within the trust and system partners involved in diagnostic pathways.

Leaders and staff shared information and learning with partners to support service improvement and continuity of care. Relationships with partner organisations were used to identify pressures within the diagnostic pathway and to agree actions that supported safer and more effective services for people. Staff understood how partnership working supported person‑centred care and improved outcomes, particularly where people required care across multiple services.

The service engaged with local systems and network partners to support planning and delivery of diagnostic imaging services that meet the needs of the local population. Leaders demonstrated an understanding of the local communities they serve and used partnership arrangements to contribute to service development and improvement. Learning from system working was shared within the service and used to inform local decision‑making and priorities.

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.

There were effective systems in place to ensure leaders had oversight of incidents in the service, through trust radiation incident review. The meeting minutes we reviewed showed evidence of incidents being reviewed and lessons learned shared across all sites within the trust.

Leaders had created a culture where learning, continuous improvement and innovation were encouraged and embedded within diagnostic imaging services. Staff were supported to develop professionally, extend scope of practice and contribute to service improvement activity.

The service invested in workforce development and sustainability, including advanced clinical roles, practice development teams and apprenticeship pathways, to address capacity challenges and support high‑quality patient care. These initiatives were aligned with local and national priorities for diagnostic services. The service supported innovation in clinical practice, including role development within sonography and imaging, and encouraged staff to test and adopt new ways of working safely. This helped improve access to diagnostic services and supported timely care.

Leaders had used structured impact reporting to evaluate whether learning and innovation activities improved staff capability, patient experience, service resilience and clinical productivity. Findings were shared to inform future planning and improvement work. Staff were encouraged to participate in learning beyond mandatory training, including communication skills, leadership development and specialist clinical education. Learning opportunities were tailored to service need and staff roles.