The Princess Alexandra Hospital

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• 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 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating remained requires improvement.

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.

We found that the service was not consistently well‑led. Although leaders promoted person‑centred care and involved staff in shaping future strategy, they did not always provide the support needed to manage ongoing risks. There were gaps in governance, including weaknesses in the risk register and audit systems, and some improvements were not sustained. Communication and oversight were variable, and further work was needed to strengthen accountability and ensure that improvements were fully embedded.

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 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

In early 2025, leaders began developing the Urgent and Emergency Care (UEC) Strategy through workshops with divisional leaders, clinical leads, matrons, and operational teams. These sessions helped shape the first draft of the strategy. In April 2025, the Leadership Operations Team also held an away day focused on thinking about the future direction, encouraging input from staff and external partners.

Shortly after this work began, a large organisational restructure was announced. During this time, leaders continued to align their thinking with national NHS priorities and the long‑term plan. This contributed to the publication of the Integration Strategy: Proposed Integrated Models of Care in July 2025, where the UEC Division played an important role in shaping how urgent and emergency services would fit into the wider vision for integrated care.

Alongside this strategic work, some staff, particularly those in leadership positions, shared that the culture during this period felt unsettled. The restructure created uncertainty, and some colleagues reported feeling that communication was not always clear or consistent. Staff expressed that at times they did not feel fully listened to, valued, or appreciated. Several staff also raised concerns about aspects of leadership behaviour, noting that the standards set by some leaders did not always reflect the professionalism and positive role‑modelling expected within the division. These experiences had an impact on how supported and engaged people felt during organisational change.

The 2024–2027 Strategy set an ambition for UEC to be nationally recognised for delivering outstanding, patient‑centred care within a modern, digitally enabled environment. This vision included working closely with system partners, providing inclusive care in the right place at the right time. Empowering staff to lead with compassion, and delivering safe, sustainable, evidence‑based services that meet national standards. Staff shared that achieving required not only strategic alignment but also a supportive culture where staff felt respected, heard, and able to contribute confidently to change.

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.

Managers and leaders in the department raised risks appropriately, recording and escalating risks such as overcrowding, an unsuitable environment, staffing pressures, infection prevention and control concerns, and the use of temporary escalation areas. Despite this, they did not always receive the support they needed from senior leadership and executive teams, and limited action was taken to address the severity of these risks.

Leaders were not always visible in the service. Staff told us they felt unsettled due to ongoing change management and new leadership. They did not always feel engaged or supported to participate in a fair process. Some leaders were described as unapproachable and difficult to work with, and staff said certain leaders did not consistently model the trust’s values.

The leadership team told us they aimed to foster an inclusive culture through structured induction, mentorship, and professional development opportunities for nurses, healthcare assistants, international recruits, and students.

Staff reported feeling supported by matrons and consultants, and concerns such as mental health staffing gaps were escalated appropriately. Despite financial pressures, leaders advocated for patient safety and mitigated risks through creative solutions. Their approach often demonstrated integrity and openness.

Leaders had a good understanding of the services they managed and could explain clearly how teams were working to provide high-quality care.

We scored this quality statement as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

The organisation’s approach to Freedom to Speak Up (FTSU) and staff wellbeing showed areas that still required improvement.

Clearer reporting structures, dedicated ambassadors, and leadership-driven cultural diagnostics suggested a strong commitment to creating a safer and more open environment. However, persistent challenges, such as high stress levels, bullying concerns, and reduced confidence in raising issues, indicated that the culture was still developing.

The Urgent and Emergency Care Division improved reporting systems in April 2025 by introducing separate processes for the adult and paediatric emergency departments. Additionally, six FTSU ambassadors were appointed to make speaking up more accessible and visible to staff. This demonstrated a proactive effort to encourage open communication and address barriers to reporting.

A FTSU Guardian was employed, ensuring a clear process for staff who needed to raise concerns. Staff submitted 20 concerns in the adult emergency department between October 2024 and November 2025. Covering issues such as behaviour, patient safety, and wellbeing. Managers monitored the drop in reports and sought to understand whether this was due to improved local resolution or a decline in staff confidence.

In the paediatric emergency department, staff raised 12 concerns after April 2025, including bullying, harassment, and one patient safety issue. Six concerns were raised anonymously. In response, the Interim Chief Nurse and Chief People Officer commissioned a cultural diagnostic to strengthen psychological safety and develop more effective leadership practices. Although the concerns were serious, the leadership response was timely and constructive. Leaders told us that the Babies, Children and Young People leadership team were working with individuals and teams, alongside the organisational development team, to strengthen the culture within the children's emergency department.

Staff survey data indicated improvements in addressing bullying and in providing support during sickness. However, stress levels remained high, and staff reported that their confidence in raising concerns still needed improvement. These mixed results pointed to cultural progress, but also to ongoing systemic pressures affecting staff wellbeing.

Patients provided feedback through the Friends and Family Test, with 78% of 1,376 responses in November 2025 being positive, slightly above the national average. This reflected that most patients reported a good experience of the service. A smaller proportion of responses (189) were negative, and these comments mainly related to pressures during peak demand. While representing a minority view, this feedback highlighted areas where patient experience can be affected by operational pressures and continues to inform ongoing improvement work.

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.

There was an Equality, Diversity and Inclusion (EDI) Strategy 2023–2030 setting out its plan to build an inclusive and fair culture for staff and patients. The strategy was led and monitored by the Equality, Diversity and Inclusion Steering Group (EDISG). The Trust employed around 3,500 staff serving a diverse population. The strategy focussed on respecting all protected characteristics, removing barriers, and making sure everyone felt valued and supported. Staff can expect fair treatment, person‑centred care, and access to equality networks such as the Disability and Wellbeing Network, Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) Staff Network, and the Race, Ethnicity and Cultural Heritage (REACH) Network.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

We reviewed trust wide workforce diversity data. In 2024, non-clinical roles were mostly White, with Bands 2–4 showing some diversity (e.g., Band 2: 66.7% White, 33.3% BME). This pattern remained in 2025, though Band 3 saw a slight increase in BME representation (from 10.5% to 16.7%). Senior non-clinical bands stayed 100% White across both years.

Clinical roles were significantly more diverse. In 2024, Band 5 was 90.1% BME and 9% White; in 2025, it remained similar at 88.3% BME. Bands 6 and 7 also showed strong BME representation (78.4% and 38.9% in 2024; 78.4% and 38.2% in 2025). However, Band 8A shifted from 35.3% BME in 2024 to just 5.1% in 2025, indicating reduced diversity at senior clinical levels.

Medical roles consistently had high BME representation: consultants were 76.2% BME in 2024 and 77.3% in 2025; trainees rose slightly from 74.6% to 77.9%. These figures show sustained diversity in clinical and medical positions, while senior non-clinical and some senior clinical roles remain less diverse.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

The international nurses we spoke with shared that they felt supported and had a network of colleagues. The international nurses were supported by a dedicated practice development team. International nurses were offered access to training and development programmes, opportunities to rotate through different clinical areas, and a multi‑professional learning environment.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

Leaders collaborated with an independent partner agency to meet their obligations under the Equality Act 2010 by supporting employees with mental health challenges. This partnership promoted open communication, raised awareness of mental health conditions, and identified reasonable adjustments to remove barriers and create an inclusive environment.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders provided assurance through incident reporting, complaints monitoring and corridor care data, but audit and improvement systems were not always reliable. One example was children’s care record audits over the past year showed variable documentation quality, with overall compliance at 76%. While some records met required standards, others were inconsistent or incomplete, meaning the care provided was not always clearly documented. This reflected wider issues, as other audits also showed repeated low results with little evidence of sustained improvement.

Learning from incidents, audits and complaints was not consistently shared, and many clinicians were unaware of the top risks facing the department. Patient feedback systems were underdeveloped, which meant leaders were not always working with the best information to drive improvement. Staff wellbeing concerns were also not addressed, even though they contributed to risk and performance pressures. Taken together, these issues showed ineffective governance, poor oversight of risks, and a lack of reliable systems to ensure accountability or improvement.

Leaders managed the Emergency Department risk register, but it contained gaps. Key details such as controls, actions, owners and completion dates were often missing, and some risks had remained unresolved since 2019. Although risks on the register, such as the IPC team escalated concerns, increased spot checks and began regular monitoring in November 2025, compliance still fell short of expected standards. This showed that even when risks were recorded, follow‑through was inconsistent and improvement was not assured. This highlighted gaps in ownership and accountability, and a risk register that did not consistently drive action or provide assurance that risks were being effectively mitigated.

Leaders recorded key risks, including the four‑hour standard, long waits, harm from delays and crowding. Corridor care was also listed as a risk, although controls such as staffing, equipment and privacy were not always in place. Staffing for corridor care was not funded, length of stay was not monitored, and leaders acknowledged that protocols were not consistently used and required review.

Leaders described internal oversight mechanisms for corridor care, including executive and Non-Executive Director walkthroughs and reporting through the Patient Safety Group and Quality and Safety Committee. However, at the time of the assessment, we found that patients continued to be cared for in unsuitable areas and that the Trust’s own corridor‑care policy was not consistently followed, including for patients who were exempt due to clinical need.

Executive leaders were seen as distant, which affected accountability. Important operational updates were sometimes delayed, leaving staff unsupported when pressures were extreme. This led to difficult decisions such as admitting patients to corridors. Martha’s Rule was displayed, but staff said escalation was sometimes still difficult.

Leaders introduced Internal Professional Standards for referral and response times, but staff said these weren’t being met. They also struggled to find the guidance.

Leaders had an operational governance framework intended to oversee quality, risk and performance, and there were processes in place for reporting and escalating issues. Staff contributed to committees that reviewed information, explored concerns and made recommendations to senior leaders. Executive teams set overall direction and aimed to align operational work with national standards. However, while these structures existed, they did not always give a fully accurate or consistent picture of how risks were managed in practice.

Leaders monitored sepsis audits, which showed poor compliance of around 47–49%. Training varied across roles, which did not meet NICE guidance and risked delayed assessment and escalation. Leaders acted on known risks, including sepsis delays, by bringing in the Sepsis Six pathway, regular audits, coding reviews, education programmes and appointing clinical sepsis leads. A Sepsis Mortality Improvement Group met fortnightly. They also created action plans, reviewed escalation processes, updated procedures and scheduled the end of corridor care after estates changes.

Staff led improvement work, such as reducing unnecessary intravenous paracetamol use, and shared results in meetings and emails.

Staff worked with internal and external partners to meet patient needs and documented this appropriately. For example, they worked with adult social care teams to plan discharges.

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.

In December 2025, staff worked with local providers and the Integrated Care Board to align priorities for population health and resource sharing, resulting in joint plans for integrated service delivery.

The Board approved a Host/Lead Provider Framework, positioning the trust as the lead organisation for multi-partner contracts in June 2025. This change enabled streamlined governance and coordinated care pathways across acute, community, and primary care services. These actions demonstrate tangible progress toward joined-up care and improved patient experience.

We saw hospital volunteers actively supporting patients and visitors. They offered drinks and snacks, creating a welcoming and reassuring presence. Volunteers were approachable, friendly, and easy to recognise, which helped patients feel comfortable asking for assistance. Their contribution added value to the patient experience by providing practical help and emotional support in a busy environment.

The mental health lead sat with peers across a mental health network to share information, learn from each other and collaborate of improvements.

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 used a quality improvement approach led by the Patient Safety and Quality Lead and the Quality Improvement Lead. Staff tracked iterative Plan-Do-Study-Act cycles using a visual tool focused on five areas: ambulance handover, initial assessment, non-admitted workflows, medical Same Day Emergency Care, and acute medical flow.

Leaders acknowledged sustainability challenges, noting some improvements were temporary due to demand pressures.

Staff provided clinical guidance through a mobile app covering antibiotic stewardship, sepsis management, and key pathways. Leaders reported the app was highly successful and now used beyond urgent and emergency care.

Staff used an alert-based referral app for faster communication and escalation, praised for ease of use and audit trail, though response times from some specialties remained slow.

Staff participated in national audits and shared learning through mortality and morbidity meetings. Leaders initiated pathway mapping and commissioned reviews of screening tools to make improvements. Actions had clear ownership and target dates.

Quality improvement was embedded in practice. Leaders encouraged staff to share plans through emails and meetings. For example, a recent initiative reduced unnecessary intravenous paracetamol use as part of a cost improvement programme, showing a structured approach to change.

Ensure that all patients are treated with dignity and respect (Regulation 10)

The provider was in breach of Regulation 10 (Dignity and respect) because people were not consistently treated with dignity, their privacy was not always maintained, and staff did not always demonstrate respectful or person‑centred interactions.

Ensure care and treatment is provided in a safe way to patients (Regulation 12)

The provider was in breach of Regulation 12 (Safe care and treatment) because people were not protected from avoidable harm and the systems in place did not ensure care was provided safely.

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care (Regulation 17(1))

The provider was in breach of Regulation 17 (Good governance) because systems and processes were not established or operated effectively to assess, monitor and improve the quality and safety of the service.