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 our last assessment we rated this key question good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At the previous inspection the service was not in breach of regulation. At this assessment, the service was in breach of good governance, relating to the management of patient confidentiality.

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.

Leaders had established a clear and shared vision for the medical service. The medicine division followed the trust wide vision and values but also had their own vision and strategy. The vision for the division was commitment to quality care, culture of excellence and learning, focus on health equity and digital transformation and partnerships. The strategy to accomplish this vision was broken down into 6 priorities:

High Quality Safe Care

Patient Flow and Access

Improving Patient Experience

Workforce Development

Digital Excellence and Data

Governance and Assurance

The service did not however, identify when the vision and strategy was developed or whether it was created in collaboration with stakeholders. Staff we spoke with could not remember each individual priority within the vision and strategy but could explain how the service was working to deliver high quality care.

Staff described the culture within the service as positive, with strong collaboration across departments. Staff reported feeling valued and empowered, with access to training and development opportunities to support their ongoing professional growth, such as upskilling courses and the opportunity to be involved in quality improvement projects.

We observed genuine engagement between staff, patients, and carers, with clear communication and a commitment to patient-centred care. Staff demonstrated a well-developed understanding of equality, diversity, and human rights, ensuring that these principles were actively upheld in daily practice. Leaders also worked to support an inclusive environment for both staff and patients.

The service performed at or above trust average in 7 out of 9 areas of the NHS staff survey. This included; we are compassionate and inclusive, we each have a voice that counts, we are always learning, we work flexibly, we are a team, staff engagement and morale. The service was slightly below the trust average in; we are recognised and rewarded, and we are safe and healthy. The service identified themes and actions in response to the staff survey, which included staff feeding into the trust violence and aggression group and ensuring all divisional colleagues are nominated for trust wide awards.

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.

The medical division was led by a triumvirate of a divisional medical director, divisional director of operations and divisional director of nursing and governance. They were supported by clinical directors, general managers, heads of nursing and clinical governance managers.

Leaders in the service had the skills, knowledge, and experience required for their roles. They demonstrated a clear understanding of the service they managed, the risks and could explain how their teams worked to deliver high-quality care, including managing patient flow and maintaining safe staffing levels. The triumvirate reported having monthly meetings and structured systems to access the board. However, the service did not provide meeting minutes to confirm whether there was a standing agenda or what was discussed.

Staff reported leaders were visible and approachable, regularly engaging with staff in clinical areas. Leaders encouraged open communication and made them feel supported in raising concerns or suggesting improvements.

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

Staff told us they were aware of freedom to speak up (FTSU) guardians and processes. They knew where to access information if they didn't know and how to navigate the guidance. Managers and leaders encouraged staff to openly talk about concerns as well as incident reporting.

The FTSU guardian produced a bi-annual report with trust wide data. Data showed that between April and September 2025, the FTSU guardian had received 77 concerns. The themes included but were not limited to; management issues, systems and processes and behaviour and relationship. Recommendations were produced for the trust to take on board.

People and carers had opportunities to provide feedback on the service in ways that reflected their individual needs.

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 service had clear responsibilities, roles, systems of accountability and good governance. However, patient confidentiality was not always maintained.

Staff did not always prioritise patient confidentiality. We observed multiple instances of computers on wheels being left open and unattended with patient records visible, which posed a risk of unauthorised access to patient information. We also observed an electronic whiteboard with confidential patients’ details being left unlocked and visible in a public area, which did not protect people’s confidentiality. This was escalated to senior leaders, and they reported that they would remind staff the importance of confidentiality when using equipment with patient information.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. However, due to increased clinical demand, managers did not always have enough time to complete their administrative tasks in a timely manner. This had been reported to matrons, and they provided support where possible however, due to their own workload this had minimal impact on managers volume of work.

The service had a clear governance structure, with lines of accountability from wards and departments, clinical divisions and through to the trust board. Nursing staff reported that they had monthly ward meetings where they could escalate concerns to management when required. Medical staff reported that they had direct access to clinical directors and felt comfortable escalating concerns. This would then feed into the divisional governance meeting as required.

The service held monthly divisional governance meetings that followed a set agenda. Records of governance meetings demonstrated the quality, performance, and safety of the service were monitored and reviewed. This included discussions on learning from serious incidents and complaints, the risk register, patient experience and national and local clinical guidelines and policies.

The service had a risk register that currently had 34 risks open. Each risk had a risk score, a risk owner and the date for the next review. These risks were reviewed monthly at a risk review meeting. Our review of the risk register showed a majority of the risks we identified onsite, and risks described by staff were included in the risk register. This included patient flow, corridor care and workforce vacancies. The service had mitigations in place for the risks identified on the register.

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.

Staff recognised the importance of collaboration and partnership working to ensure seamless, high-quality care for patients. The service engaged with external stakeholders such as commissioners, specialist healthcare providers, community organisations and their local system. They reported positive and collaborative partnerships with all stakeholders.

The service actively engaged with Healthwatch which is an organisation that works with NHS leaders to ensure the patient’s voice is heard to improve care. Healthwatch regularly visited wards and produced an insight report for the trust.

Patients could meet with members of the provider’s senior leadership team. We saw evidence of patient attending the trust public board to present their ‘patient story’ to members of the board and senior leaders.

The service focused on continuous learning, innovation and improvement across the organisation and local system.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. An example of this was the introduction of the nursing associate apprenticeship project, which was designed to bridge the gap between registered nurses and health care assistants. Of the 126 apprentices trust wide who commenced on the programme, 5 continued their training and are planned to complete and join the NMC register before the end of the financial year 2025/26.

Staff used quality improvement methods and knew how to apply them. The service had a wide Quality Improvement (QI) program that leaders actively championed. For example, the service introduced the rapid diagnostic clinic to assess patients with vague but concerning symptoms of possible cancer. Results showed an improved cancer conversion rate and complex diagnosis’s being identified quicker than through traditional NHS routes.

Staff reported that wards participated in accreditation schemes relevant to the service and learned from them, which improved staff morale.

According to the trust website the service is involved in clinical research however, staff did not inform us of any active research within the medicine division.