Queen Mary's 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 requires improvement. At this assessment, the rating was good. This meant leaders of the service created and fostered a culture that ensured the delivery of high-quality care and operated effective governance processes.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 clear trust vision which was focused on high quality, safe and individualised care. Priorities included working in collaboration and partnerships, sustainability, improved patient outcomes and empowered and engaged staff.

Priorities relevant to the surgical treatment centre at Queen Mary’s Hospital included improving sustainability of the estate the service operated from, improved utilisation of theatres and continuing to build an inclusive culture.

The trust had developed a Green Plan to support the delivery of their overall strategy and become an environmentally sustainable organisation. Through this plan the trust aimed to take action to ensure the settings in which they provide care were as low carbon as possible, ensuring energy efficiency, and using renewable energy sources where possible.

Leaders and staff working at the surgical treatment centre demonstrated an inclusive, listening, caring and patient focused culture. There was a strong focus on learning and improvement.

Leaders promoted a positive culture that was focused on effective collaboration and teamwork. Staff worked well together and undertook team building activities. This included days out and working together on fundraising for staff wellbeing.

Staff we spoke with consistently spoke of a working culture that was enjoyable and supportive. Leaders demonstrated that they valued staff, and we saw that professional development was encouraged.

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.

There was a clear structure of leadership and accountability within the service. Within the theatres and anaesthetics directorate there were care group leads that included a matron for Queen Mary’s Hospital Day surgery. Team leaders worked within theatres, taking responsibility for the day to day running of the service, including staffing.

Staff told us that leaders were open, approachable and visible within the service, including trust senior leaders. They told us they felt supported and able to raise concerns directly with line managers. They said leaders cared about staff wellbeing and encouraged wellbeing activities and support to maintain good working relationships.

Leaders demonstrated a good understanding of issues relating to culture and potential poor performance and took action to manage these areas effectively.

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

We saw in the trust Freedom to Speak Up Report 8% of staff from the surgery service had raised concerns with the Freedom to Speak Up Guardian between April 2024 to September 2024. Overall, most concerns raised to the guardian were regarding bullying and harassment (53%) and inappropriate attitudes and behaviour (44%). We did not see evidence of this during our assessment of surgery at Queen Mary’s Hospital and staff we spoke with consistently told us they felt supported by managers.

Staff we spoke with understood how they could raise concerns. They told us they felt able to discuss issues with their line manager but knew how to access the Freedom to Speak Up (FTSU) guardian. They had received awareness training in raising concerns and accessing the FTSU guardian and we saw evidence of this.

There was a clear speaking up policy and staff were able to access this and the contact details required if they needed to raise concerns. There were processes for involving staff in investigations into their concerns and identifying solutions. Staff we spoke with did not have examples of concerns they had raised, telling us there was an open culture within the service and issues were discussed in team meetings and with line managers when they arose.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust had an up-to-date equality, diversity and inclusion (EDI) policy. There were EDI networks open to staff. These included disability, BAME, women’s and LGBTQ+ staff networks. Staff working at the surgical treatment centre were involved in some of these networks.

The trust took action to ensure the workforce were representative of the population using the service. They recognised an imbalance in the proportion of staff in the most senior roles from ethnic minority groups in comparison with those in more junior roles. As a result, they had identified talent management and leadership development as a key strategic priority. This included an equality, diversity and inclusion working group within the trust’s talent strategy implementation plan delivery group. In addition, a pilot project for inclusive positive action was developed, creating opportunities for underrepresented groups to learn, develop and shadow executive and senior leaders for real life, practical work experience. At service level we found that staff from ethnic minority groups were employed, including in senior positions.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear governance framework for theatres across the trust that included Queen Mary’s Hospital. There were clear lines of accountability. The theatres and anaesthetics directorate had consultant, management and nursing governance leads. Operationally there were care group leads, deputy and associate managers and matrons. This included a matron dedicated to theatres at Queen Mary’s hospital. Divisional teams held their own monthly meetings with the care groups or specialities in their divisions. There was a theatres transformation board that met monthly to review performance and theatre utilisation, this included where surgical lists were provided for other Southwest London NHS trusts. Monthly governance meetings were held to review issues such as mandatory training compliance, incidents and risks. Other meetings included directorate meetings, care group meetings and monthly protected teaching for staff.

Policies and procedures were available on the trust intranet and staff knew how to access them. Policies and procedures we viewed were up to date and based on relevant legislation and guidelines. There were business continuity plans, for example, in the event of IT or power failures.

Staff were aware of governance processes and accountabilities. There were regular team meetings where issues such as incidents, safety alerts, key performance indicators and audit results were discussed. We reviewed a sample of meeting minutes and saw that these included evidence of discussions and reviews of theatre performance, risks and feedback processes.

Risks were managed effectively through a risk register system where risk ratings were attributed to each risk and managers were identified as responsible for their risk management. We saw that risks were regularly reviewed in leadership and governance meetings.

Workforce planning was undertaken by service and senior leaders. We saw that information about staffing was reviewed as part of governance meetings. Staff reported that leaders had worked to support the development of staff into roles, and we saw that practice educators worked within the department to support this process.

We viewed data that was collated by the trust relating to quality and performance of the service. Information was visible within the surgical treatment centre including that relating to theatre utilisation and cancellation rates. There was evidence that data was reviewed at both governance and staff meetings, including feedback data from both patients and staff.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

There was a theatre users’ group where relevant stakeholders and surgical teams utilising the surgical treatment centre met to discuss operational matters regularly. This was to collaborate on theatre use to maximise utilisation and productivity and improve access and patient pathways.

Staff and leaders shared examples of learning through collaboration. This included working with other trusts and services on reviewing the use of surgical drapes in relation to the impact on potential skin damage.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff actively contribute to safe, effective practice.

Staff we spoke with told us there were good learning and development and continuous learning opportunities available. Practice educators were based at the surgical treatment centre 2 days a week. They supported the continuous learning of staff by delivering education and conducting competency-based assessments. We saw that other development opportunities were available for staff, including themed education sessions.

We saw examples of innovative approaches to patient care. The trust had pursued a digital transformation project to implement SMART theatres with initiatives to improve patient experience, efficiency and sustainability while reducing theatres energy consumption.

We saw there were clear priorities for improvement at Queen Mary’s Hospital. This included improving theatre utilisation which was between 63% and 67% between October and December 2024, against a target of 85%. A surgical treatment centre working group was working together to improve utilisation. We saw action taken as a result of this collaborative working across surgical teams included reducing under utilised theatre sessions and exploring additional sessions to improve efficiency.