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 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.

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.

There was a positive safety culture where events were investigated, and learning was embedded to promote best practice. Staff said raising concerns was encouraged and valued. Staff felt listened to. Staff told us that sharing the learning occurred in many ways including emails, at safety huddles or handovers and via a secure messaging app. We saw examples of learning being shared through most of these channels. Staff felt involved in the direction of travel for the department and able to contribute ideas.

Staff were helpful, welcoming and professional in their communication with each other, patients and their relatives. Leaders described a positive and compassionate culture. Staff and leaders embodied a positive, compassionate, listening culture. We saw that this culture promoted trust and understanding between staff, leaders and people using the service and was focused on learning and improvement.

Staff and leaders demonstrated a positive and compassionate culture with a focus on learning and improvement. The trust values of "Respect, Compassion and Inclusion" were displayed around the trust and department. We saw staff lived these values. We heard staff describe the culture as “all one team” and “all are our patients”. We saw numerous examples of this whilst on site.

Leaders fostered a culture of promoting equality, diversity and human rights to prioritise safe, high quality compassionate care. All but one of the NHS Workforce Race Equality Standard (WRES) Survey 2023 questions on Black, Asian and Minority Ethnic (BAME) staff experience scored better than the acute trust average. However, Black, Asian and Minority Ethnic (BAME) staff experienced more harassment, bullying or abuse from patients or relatives than their white counterparts.

Leaders had a shared purpose and strived to deliver and motivated staff to succeed. There were high levels of satisfaction across all staff, despite the challenges they faced. Staff told us that they would bring a family member to be treated in the department.

The leadership of the site and divisional team had changed between July 2024 and September 2025. They were focused on resolving the issues with an overcrowded ED but had had several organisations review the practices within the department to assist them to learn and improve. The team had yet to develop their vision and strategy for the department in a formal sense. The senior team had aligned work programmes to develop a strategic approach. These fell into performance improvement, financial programmes, leadership responsibilities, and a quality programme. The senior team and the wider ED staff understood the challenges of their population and were fully aligned working with partners in the wider health economy, and there was a demonstrated commitment to system-wide collaboration and leadership. For example, working with system partners on alternative pathways to avoid ED attendances. The trust has a draft mental health strategy, which they hope to approve in the next couple of months.

The service was aware of the projected increase in the local population and the pockets of deprivation. The trust was working with partners to develop a strategy to manage these demands. The trust had access to community hospitals which allowed them to increase the flow through the hospital. Services in the community had been developed to support people in their own homes including working with care homes and the ambulance services.

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 service had inclusive leaders at all levels who understood the context in which they delivered care. Leaders were aware of the issues that the department faced and had invited organisations into the department to assist them to resolve or manage these issues. We found that staff and leaders were aligned on the issues that the department faced.

The national staff survey demonstrated year on year improvement in all categories. The directorate scored in line with the trusts scores. The trust performed above average in five domains, at the national average in one domain and below the national average in three domains in the 2024 national staff survey.

There were processes to support staff and promote their positive wellbeing. Staff we spoke to felt proud to work in the service. Multiple staff told us they had worked at Queen Elizabeth Hospital for several years. Several staff stated the reason for remaining was due to the positive work culture. Data provided by the trust showed that the staff turnover rate was below 10% for the previous 12 months. Nearly half of all nursing leavers left due to relocation.

The service had undertaken an incivility and wellbeing survey by selecting a random 12 members of the nursing team to answer questions confidentially. This survey highlighted that whilst less than half of the respondents had occasionally personally experienced incivility they could highlight when, by whom and to whom this occurred. Episodes included being told off and senior staff being rude. However, respondents also reported that they felt able to challenge and affect the behaviour.

There was compassionate, inclusive and effective leadership at all levels. Leaders demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There was a deeply embedded system of leadership development and succession planning, which aimed to ensure that the leadership represented the diversity of the workforce.

There was a triumvirate care group leadership structure at departmental and divisional level with medical, nursing and operational leads in place. There were clear reporting structures and key roles were supported by deputies or associate roles to support succession planning. Staff understood the reporting structures and leaders understood their key roles and responsibilities.

Leaders demonstrated how they worked as part of a multidisciplinary team within the service and how they worked with external stakeholders, such as the local and regional commissioners, integrated care boards and local NHS ambulance and mental health trusts. Stakeholders such as local NHS ambulance and mental health trusts told us they worked collaboratively with the urgent and emergency services. They said they worked well together and there was regular engagement to review performance and identify improvements to services.

Staff told us the departmental leads and senior managers were approachable, visible and provided them with good support. There was support to the team from senior leaders in the trust, including the Chief Executive Officer and Chief Nurse, who were seen in the department.

All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning for the future. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

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

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. However, they didn’t feel that they would use this route as internally within the department they felt that they could raise anything with leaders.

The number of contacts to the freedom to speak up service from the medicines directorate which includes the emergency department had 10 concerns raised in 2024/25 and 8 in the half year 2025/26. The freedom to speak up team received most concerns around systems and processes followed by management issues and behavioural issues. However, due to the confidential nature of this process these could not be identified as originating from within the ED. Anonymous concerns were at 12% which was slightly higher than the national average. In the year 2024/25 50% of staff wanted to remain anonymous. However, in the following six months this had risen to 66%. Whilst this may suggest that staff had less confidence in raising concerns within their area it reflects the national picture in that staff often feel empowered to raise concerns independently when supported by the guardian.

Patients knew how to make a complaint or raise concerns. The service clearly displayed information about how to raise a complaint. Managers investigated complaints, identified themes and shared feedback with staff. Learning from these was used to improve the service. Staff understood the policy on complaints and were able to give examples of learning from complaints.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed Duty of Candour was completed appropriately.

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. 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. However, we did see that staff did not always remove their access cards from computer terminals which allowed anyone to access information.

Governance arrangements were reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes. Governance was used to learn, improve and innovate.

Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, were clearly set out, understood and effective. Staff were clear about their roles and accountabilities. Audits undertaken included clinical effectiveness and compliance with guidance from the National Institute of Health and Care Excellence (NICE). The service was also complying with the 3 audits commissioned each year by the Royal College of Emergency Medicine, which included the administration of time-critical medicines.

The service had policies and procedures for escalation and care of patients to mitigate the main risks from crowding. The hospital had processes to monitor performance and quality against national targets and standards.

Data systems enabled a good oversight of performance as evident in meeting minutes and in our discussions with staff. The trust had an effective digital system for logging risks that linked directly to the incident reporting system. Leaders tracked the risks in the ED effectively using this and had oversight of the risks and their mitigations. The trust’s corporate risk register includes a mental health pathways and patient management as a risk. Remaining actions include the recruitment of mental health nurses and completion of the estates work to update the room in paediatric emergency department.

There were monthly emergency medicine clinical governance meetings. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Changes had been made when needed to improve the service. Good practice was recognised and celebrated.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. The risk register was held centrally on an IT system all could access. We reviewed the risk register and saw that issues we had raised or noted had been identified by the service. Risks were regularly reviewed, had a named owner and new or closed risks were identified.

Information held about patients was held in paper and electronic copy. We saw a number of times that staff did not remove their access cards, and anyone could use the computer to access patient records. Paper records were stored in trays behind the nurse or doctor station. We saw these from discharged patients being collected at regular intervals for coding. On the electronic patient board, patients were not always discharged in a timely manner as doctors needed to complete discharge summaries and were being called to give advice on other patients. This meant that it was not always clear how many patients were in the department. Staff were aware of the issue of leaving id cards in computer terminals and removed them promptly when they returned to the terminal. Staff were part of the emergency preparedness network, and they had the strategies and guidance to respond to major incidents.

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 told us they felt listened to and heard by the relevant stakeholders and external partners. They were supported by clinical partners. For example, there was a good partnership with the local NHS mental health trust providing support to patients with mental health needs in the ED and staff said they were responsive and supportive.

The trust worked in partnership with the local system. This included the local community trust, the local ambulance trust, GP’s and the Integrated Care Board (ICB). They met monthly to discuss system initiatives to ensure processes and schemes were joined up as well as to discuss healthcare safety investigations.

There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the people. There were learning events scheduled for after the winter period with system partners to identify what worked well and areas for improvement for the next winter period.

Staff reported positive relationships with the local police force and urgent treatment centre (UTC) which was co located but run by a different NHS provider.

The trust worked in partnership with the ICB and local GPs. For example, trying to increase shared care uptake. Shared care is a particular form of the transfer of clinical responsibilities between different healthcare partners.

Staff listened to patients using the services to improve services and the environment for patients and their loved ones. We saw in the patient experience annual report that this feedback was used to drive meaningful improvements. For example, the introduction of mobile charging stations in the emergency department to ensure patients could stay connected to family and friends. The department utilised the youth board to assist in the redesign of the department. Following feedback from patients the department now had volunteers who ensured patients were provided with hot or cold meals and drinks during their stay in the department.

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 was a systematic approach to improvement, which made consistent use of a recognised quality improvement (QI) methodology.

Innovation was celebrated through award ceremonies and recognition in departmental newsletters. Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff. Staff were supported to prioritise time to develop their skills around improvement and innovation.

The trust introduced a Compassion in Care Model (CIC) to support a trust-wide focus on common care themes raised by patients. We saw evidence of improvement from this approach in addressing the concerns of women having a miscarriage.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation.

The Queen Elizabeth Hospital urgent and emergency care improvement programme has been in place for just over a year. The programme consists of 3 structured workstreams, the front door redesign, SDEC (Same Day Emergency Care) and short stay, Improving inpatient flow and discharge. Each workstream had an executive champion. Workstreams were supported by a central quality improvement hub. Improvements follow a PDSA cycle and were evaluated. The service had invited several partners into the department to assess and learn from others to drive improvements for patients. This had improved flow and streaming to different pathways to assist the department in managing capacity verses demand.