The Princess Alexandra 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

This means 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance of the service.

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.

We scored this quality statement as 3. The evidence showed a good standard. 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 surgical division had a clear vision and strategy. The service vision was to provide excellent care for patients and staff and these aligned with the trusts core values. The clinical areas we visited promoted these values. There were posters displayed with the trust and divisional objectives identified for staff and patients to see.

Staff we spoke to were aware of the vision and values and took pride in their teams’ work. Staff told us the culture had improved, and morale was improving. We observed a positive culture between colleagues, a strong team with good care aspirations. Leaders were proud of the compassionate staff and told us there was a focus on patient care and experience.

Theatre staff told us the physical environment they worked in was challenging, due to space constraints and infrastructure difficulties but praised the support from managers within theatres. Staff generally told us they were proud to be part of the team.

Almost all staff told us they felt respected and valued by their colleagues and the leadership team within the division. There was a strong sense of teamwork, which encouraged candour, openness, and honesty. This was an improvement when compared to the NHS staff survey results of 2024 where the trust scored lower than the average for all People Promise Elements. The trust provided us with an appropriate action plan that was in place to address concerns raised from the staff survey.

We scored this quality statement as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

During our assessment the trust was undergoing a period of restructuring with a number of staff groups in a job consultation process. Staff shared with us this was unsettling. Leaders and staff within the surgical division told us they were actively supporting team members wellbeing but told us the trust board did not support them with this.
Staff told us they had good working relationships with their ward managers who they described as approachable and visible. Staff feedback in relation to senior leaders’ visibility and helpfulness was mixed. Some staff were complimentary about leaders, especially the matrons and lead nurses but they did not always feel acknowledged by the senior leadership team. Ward managers we spoke to told us they were supported by the lead nurses and senior leaders within the division.

The division had processes to support staff and managers to develop their skills. We were told succession planning formed part of individual appraisals. The appraisal rate for the division was 72.62% against a trust target of 90%.

Leaders were knowledgeable about challenges and priorities for the service and told us they could access appropriate support from the executive board. They explained challenges such as bed capacity, patient flow elective surgery backlogs.

Staff could access mental health first aiders within the division and we were told of support being offered following departmental incidents. Operating theatre staff told us of senior leaders being supportive following a recent traumatic event within the department.

We scored this quality statement as 3. 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.

Patients and carers were able to provide feedback in ways that suited their individual needs. Feedback cards were available throughout the areas we visited, and responses were overwhelmingly positive.

Staff could also access the Freedom to Speak Up (FTSU) Guardian in the trust if they were not able to speak to their manager. Themes from FTSU referrals for the division included behaviours and processes and we were provided with actions being taken by the division alongside the People Team to address these.

Leaders we spoke to said they welcomed feedback, investigated concerns sensitively and shared lessons learned appropriately.

Healthcare support workers had the opportunity to attend a support forum to speak openly, offer feedback and raise concerns. This forum was due to be attended by the previous chief nurse and deputy chief nurse. We spoke with healthcare support workers on the wards we inspected who said they had previously attended these forums and hoped they would continue with the new leadership team.

The service promoted a positive culture by encouraging staff to speak up supported by up to date policies. However, staff feedback in relation to feeling confident in speaking up was mixed. Some staff felt confident raising concerns with managers whilst others did not always feel concerns were listened to.

We scored this quality statement as 3. The evidence showed a good standard. 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.

Diversity and inclusion were valued in in the workforce. Leaders supported work towards an inclusive and fair culture by improving equality and equity for staff. Staff came from a variety of ethnic backgrounds and there was an inclusive culture.

Staff said they felt like part of a family and were recognised for their contribution by both their managers and their peers.

Staff could apply to work flexibly for example, flexible working agreements to accommodate personal circumstances such as caring responsibilities and health issues. Managers approved reasonable adjustments for staff members to help them effectively carry out their role.

Leaders told us that the senior nursing team within the division did not reflect the diversity of the staff across the service. The division has developed a secondment programme for nursing band 6, 7 and 8A roles to support staff. This initiative had changed the diversity of the senior nursing team to better reflect that of the wider teams.

Equality diversity and inclusion training had been completed by 90.8% of staff within the surgical division against a trust target of 95%.

We saw opportunities for nursing staff to develop with Band 5 and Band 6 development programmes advertised on the wards. We saw examples of staff across the division having completed the Chief Nursing Officers fellowship programme.

We scored this quality statement as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were issues and risks in the service requiring further action from leaders. These were around the documentation standards and NEWS2 and the inability to effectively audit these were due to the EPR system. The trust had highlighted this on the internal risk register and monitors internal assurance through the incident reporting system and workload of the critical care outreach team. We did not see an action plan to support improvement with documentation standards and NEWS2.

Leaders within the surgical division told us they monitor risks within the division monthly and received data packs that were shared with wider teams. These data packs enabled the division to ensure safety standards were met and provided assurance to the trust board. The division had monthly Patients Safety and Quality meetings; however, these took place virtually in May, June and July 2025. We have not seen the minutes of these virtual meetings and are not assured information was shared with the wider surgical staff.

Staff told us that the divisional governance structure was unclear and there was uncertainty around roles and responsibilities. This had been recognised by the divisions’ leaders and we saw an action plan to ensure the governance structure was shared with the wider team.

During our onsite visit we found 11 out of 14 patient VTE risk assessments were not completed. Following the inspection we requested 3 months of VTE compliance audit data. The trust informed us that data from the EPR could not be validated and advised that for the last quarter the compliance figure reported was 68.0%. This is below the trust target of 95%. Leaders informed us that a trust-wide VTE improvement project had been initiated prior to this inspection, highlighting the need for strengthened governance to ensure accurate monitoring, accountability, and sustained compliance.

During our assessment we were unable to locate risk assessments for patients cared for in corridor spaces and were not assured their suitability to occupy such a space was fully assessed.

The trust had completed an internal review of its surgical divisional governance. We reviewed the report published in November 2025 which highlighted that 39 risks were documented on the register and of these 25 were overdue. The trust acknowledged that the open risks had not been prioritised correctly and as such this increased exposure to risks to patients and people that could have been mitigated.

We were notified of 2 never events between 2023 and 2025 directly relating to surgery services. A never event is wholly preventable because guidance and safety recommendations exist and should be implemented by all healthcare providers.

Staff demonstrated safe practice aligning to national guidance during our on-site assessment and followed the WHO checklist in theatre. However, we received a notification from the trust regarding another never event in theatres post assessment. Therefore, we are not assured of robust governance processes to ensure patient safety.

We saw examples of shared learning on the surgical wards and a matron’s newsletter for the PACU. These shared the outcome of incident investigations and lessons learnt with the wider team departmental teams as well as audit results to celebrate successes and highlight where improvement was required. However, we were not assured that lessons learned had been embedded as we witnessed an incident on site that mirrored a similar incident that occurred in August 2025.

Information governance and data security awareness training had been completed by 90.2% of staff within the surgical division against a trust target of 95%.

Managers and ward staff could describe the risks associated with their areas and we were told information was shared through daily safety huddles and staff meetings. Ward team meetings were held on the surgical wards and in the operating theatre department and allowed for shared learning and dissemination of pertinent information.

We scored this quality statement as 3. The evidence showed a good standard. 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.

The service gathered feedback from staff through discussions and scheduled meetings which were minuted and available for those that could not attend. Along with staff meetings, the service used the daily safety huddles, held in all areas including wards and theatres, as the main method to share important messages.

Staff provided patients the opportunity to provide feedback about their care and we saw patient feedback cards that had been completed by patients. We spoke to staff on the wards and they were unaware of changes that had been implemented because of this feedback.

The division also had complaints clinics where complainants were invited to meet with the divisional director to hear their complaint and share learning.

There was some evidence that the views and experiences of patients and others were gathered and acted on to shape and improve the service. For example, staff had commenced work with the deaf community to improve information sharing. The service was initiating the launch of British Sign Language training for staff.

The surgical division was working alongside the University of Hertfordshire to develop a reporting tool for allied health professional staffing requirements within surgery. The tool was designed to highlight where there may be shortfalls in allied health professional staffing numbers to adequately meet the needs of surgical care patients. This work has been presented to the trust board for consideration.

We scored this quality statement as 3. The evidence showed a good standard. 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.

Staff were encouraged to complete quality improvement (QI) training and 133 members of staff from the surgical division were trained in QI. The majority of the staff trained were medical or nursing staff but there was inclusion of other staff groups.

Innovation projects included the establishment of the theatre improvement board in May 2025 to support the delivery of more efficient flow through theatres. The trust has not submitted theatre utilisation data to the NHS England (NHSE) since 2024, so we were not aware, at this time, if this initiative was having a positive impact. The trust has told us they have introduced a clinical digital practitioner role to improve reporting and allow submission to NHSE.

On the wards we inspected we saw learning and support materials displayed for staff. The ward staff could access Clinical Practice Educators for support with clinical skills, core competencies and career development.

The surgical wards were part of the Princess Alexandra Clinically Excellent (PACE) ward accreditation scheme. The scheme focused on 14 fundamental standards of patient care, with monthly QI projects identified to bring improvement such as patient risk assessment completion. The wards we inspected had achieved a bronze award; we did not see an action plan to improve performance.