Queen Elizabeth Hospital Birmingham

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 there was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of people who used services and wider communities. We checked leaders proactively supported staff and collaborated with partners to deliver safe, integrated, person-centred and sustainable care, and to reduce inequalities.

At our last inspection, this well-led was rated as requires improvement. At this assessment, the rating remained unchanged. There was a shared direction and strategy, but it was yet to be written down in terms of how it would be delivered. It did not therefore have formal agreement within the trust’s overall strategy, which did include urgent and emergency care as a focal point. The leaders were growing in confidence and experience, but there was more to do to have a cohesive and strong team.

There was a lack of strong assurance from governance, quality and safety management with many key topics not being addressed for development and improvement. There needed to be time for governance to flourish and for learning, improvement and innovation to be moving beyond day-to-day clinical work.

However, most staff said they felt able to speak up when something was concerning them. There was good partnership working, although some of this needed to be more effective, particularly for patients with mental health needs.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Senior leaders said the service was developing a shared vision and strategy but had no programme for delivering the strategy in line with trust strategic priorities. Senior leaders said this would be developed with key input from the teams across the service to produce a vision and strategic direction which everyone had been given the opportunity to be part of.

However, the more informal strategy employed in recent months was based on providing safe and effective care for patients. The department had adapted to expand in size and worked hard to ensure patients received care and treatment in the right place. This was beginning to make a difference for patients, but more work was needed to make this safe and inclusive for all staff. The changes had included creating a re-launched rapid assessment and treatment service for patients arriving by ambulance known as RAT 999. The hospital had a medical and surgical same-day-emergency-care service where certain patients could be diverted to alleviate the pressure on the emergency department. There was an emergency observation unit created for specific patients who were expected to be in the department for between 6 and 12 hours, but no more than 23 hours. There was an agreed protocol for patients who could be treated in this unit to alleviate pressure in the Majors’ areas.

There was an improving culture in the department with staff focused on the patients in their care. Most of the staff said they felt the culture was improving and moving in the right direction. However, in the 2024 NHS Staff Survey, only 19.6% of those staff who responded in the emergency department (51 staff) said they felt the organisation valued their work. The trust average was 40%.

Staff understood equality and diversity and its importance in a strong culture. They talked with us about patients and staff being individuals and needing different inputs into their care and treatment or working life to meet their needs. However, some staff did not feel as included in the emergency department team as others. The footprint of the department which ranged over quite a number of different areas was one factor which staff said could make them feel isolated at times. Staff also commented on the high number of non-medical vacancies meaning it was not always easy to maintain a strong ethos around culture and team building.

Although the service had inclusive leaders who understood the context in which they delivered care, treatment and support, there was more to do around culture and values. All the data in this category in the 2024 NHS Staff Survey responded to by 51 staff was worse than the overall trust average and NHS national averages. Nevertheless, the leaders had good skills, knowledge, and experience to lead the service but were on a pathway to improvement which had been made increasingly difficult with staffing shortages, high levels of nursing vacancies, and full capacity overwhelming the service too often.

Leaders were generally visible and available to their staff and teams. They were clear on the issues they were facing, but not always alert to areas of poor culture having a detrimental impact on staff. Complaints to the service and to CQC continued to relate to staff attitude, compassion and behaviour. Communication with patients was also a recurring theme.

There had been some significant progress in the service since our last inspection. Safety was no longer rated inadequate, and those areas where we found a breach of regulations had been mostly addressed. All the band 7 nurses were completing a leadership programme, and an external review had been commissioned from a highly qualified and experienced emergency practitioner to look more closely at the whole service.

The leadership team endeavoured to foster a positive culture where most people felt they could speak up and their voice would be heard. Most staff we met said they would not be anxious to speak up if they needed to and they felt they would be listened to. However, this was not the case for all staff, and some admitted they were not confident to speak up. Those we asked knew about the role of the Freedom to Speak Up Guardian and their team. This was a role introduced to health and social care organisations after the events and a failure to speak up at another NHS trust and the subsequent report from Sir Robert Francis KC. The guardian’s role was to support workers to speak up when they felt they were unable to in other ways. Some staff said they would approach the guardian if they needed to, but others said they would be more likely to approach their own manager first or a trusted colleague.

Some staff responded though with saying they did not feel anything changed if they did speak up. They spoke about concerns around safe levels of staffing at times, or specific concerns about their area of work. Some felt speaking up about this did not make a difference. However, one member of staff told us how they had spoken up about an issue, and this had been handled by senior staff with sensitivity and confidentially. A couple of other nursing staff said they did not feel their concerns would be handled with confidentiality and things they had spoken up about in the past had been shared with others by those they had confided in.

Staff we asked said they knew about whistleblowing and how they might approach organisations beyond the trust, such as the CQC, if they felt this was needed.

However, in the 2024 NHS Staff Survey, although 62% of staff in the department who responded (overall 51 staff responded) said they would feel safe speaking up about unsafe clinical practice (against a national NHS average of 70% and trust average of 66%), only 36% said they felt the concerns would be addressed.

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.

Although not helped by the pressures on the department, the service and leaders did not always have a clear and well-understood overview of the quality and safety of the whole department. The Royal College of Emergency Medicine recommended in its guidance around managing crowding that safety huddles were held at regular intervals throughout the day/night. All key staff should attend or be represented and there be a multidisciplinary approach to the process. The expectation was this would help to see and acknowledge emerging risks, consider patient experience and who might be better supported. Also to share the pressures across the wider hospital for enhanced support for the department. Following our feedback to the trust leadership about our concerns given the size of the department and the pressures across the emergency care pathway, we were advised safety huddles were urgently reestablished. They were to be added to the emergency department standing operating procedure and we were provided with a template as to what would be discussed. We will ask the department to provide updates as to the effectiveness of the revised process in due course.

There was a lack of comprehensive and systematic governance for the service. Although there were governance meetings held monthly, these did not provide the leadership with overall effective assurance of a number of key areas. There were no audits presented to the governance team to determine where there were areas of concern and how these were going to be addressed. Some audits were presented in the quality assurance report, but with limited actions. For example, medicines management spot checks showed some significant shortfalls in compliance (although the report was not clear what the `compliance' related to), but it was not clear how this very variable performance was going to be tackled. The quality assurance report discussed hand hygiene (which was 1 of our concerns) and commented on "a significant improvement in compliance and standards" in the March 2025 report when the results from January of 87.7% fell in February to 79.8%.

There was a discussion at some meetings, but not all, about the risk register, but this did not include evidence of a discussion about emerging risks or gather feedback from those who were responsible for the existing risks.

There were no metrics used to gain assurance around staffing including culture, wellbeing and safety. These metrics should have reported staffing vacancies, safety of rotas, skill mix, turnover, sickness, and all aspects of training, development and review but there was limited data provided. The NHS Staff Survey 2024 was not discussed. Medical staffing was not discussed, and the only staffing data was related to nurses and not wider. This was despite the medical staffing levels not meeting the recommended numbers indicated by the Royal College of Emergency Medicine.

There was no comprehensive review to provide clinical assurance. For example, there was no review of patient outcomes, avoidable harm, comparison data, or mortality and morbidity reviews. There was a presentation on harm reviews in the monthly emergency department quality assurance review, but no trend analysis or reports showing improvement and learning. There was commentary on what might have happened to cause harm, but no assurance provided of how this would be addressed to reduce the risk of recurrence.

There was limited comprehensive data provided for the leadership team to review. For example, 1 governance report stated how computed tomography (CT) scans were not being undertaken on time. However, there was no data to support this or other key metrics, and therefore no actions being required to resolve the issues. In the 2024 NHS Staff Survey, of the 51 staff who responded, 76% said the organisation encouraged them to report errors, near misses or incidents. The trust average was 82.2%. However, just 48% said the organisation took action to ensure they did not happen again and 43% said they were given feedback in response to their reports. This was significantly worse than the trust average in these questions.

There was some feedback from patients, friends and families, but no identifiable action around concerns. This was not a discussion held as part of the monthly governance meetings but was part of the nursing quality assurance review. For example, in the March 2025 report, there was almost a full page of positive feedback from patients, but just 5 bullet points about negative comments and no consideration whether anything should be done to address patients' concerns.

We were concerned about the expansion of the department to meet both the COVID-19 pandemic requirements, but also the growing demand for emergency care. The footprint was now fairly extensive and this meant some of the areas felt too autonomous from the department as a whole.

The department now had a full capacity protocol. Following the avoidable death of a patient in the department, CQC's investigation asked for the guidance being used around escalation of safety concerns when the department was at capacity, which as described above, was much of the time. This protocol did not exist and without safety huddles there was no assurance for the leadership team of what process to follow to get immediate and effective support. This protocol had now been produced and approved in January 2025. Alongside this, the hospital trust went on to declare a major incident in January 2025 when the hospitals in the organisation were at maximum capacity, beds were full, ambulances were facing long handover delays, and patients were held in temporary escalation spaces. Actions to establish major incident status were taken and with around 4 days of intensive support from across the hospital sites, the situation was brought into safe management and stood down.

The service understood the duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement. Key organisations included the local NHS ambulance service and the local NHS mental health trust. They also included the integrated care system for the region and other system partners who had links with other health and social care services. Community teams we met at other trust locations, specifically at Solihull Hospital, talked about their work with local care homes. This work related in part to supporting care homes to avoid sending people they looked after to emergency departments unless this was unavoidable.

Representatives from the local NHS ambulance service said they had a good working relationship with the emergency department leadership team and the trust in general. There had been close working over some of the most challenging times for urgent and emergency care over particularly the winter months. The ambulance leaders said they felt the department understood their pressures as much as their own. The ambulance service had a hospital ambulance liaison officer (known as a HALO) at the department at the recognised busiest times to provide a link between both services. This was acknowledged to work well and be of noted value to both organisations.

The partnership working with the mental health trust required far more cooperation and responsiveness than was happening in practice, but we were told it was improving. It was in this clinical specialty where many patients were being held in the department for unacceptable lengths of time. However, the 2 organisations now met monthly to discuss performance. There were also daily calls which included the integrated care system team and mental health trust to review the needs of patients.

There was a plan for the service to focus on continuous learning, innovation and improvement. However, for reasons already described above including shortages of staff, crowding in the service, and a relatively junior workforce, staff did not always have creative ways of delivering equality of experience, outcome and quality of life for people. Despite obvious skills, experience and clinical knowledge, staff were not able to always contribute to development of practice and research actively.

The service had a passionate and committed team of clinical educators across various grades and clinical specialities. Their role was to support with education for staff, including development and advancement, and to help through this with staff retention. The team were supportive to each other and looked out particularly for the new or newly qualified staff. Members of staff were given training programmes which were both mandatory and role-specific depending on their role and experience. The work of the clinical education team also included supporting the international nurses.

However, our concern with what was an excellent programme of education was in it not meeting the urgent needs of the department at the present time. With our concerns around patient records for nursing, the nursing staff being a very junior and inexperienced team at certainly band 5 level (and more new staff to join) this was not being addressed by the experienced clinical educators with bedside teaching.

There was a consideration underway for a rapid musculoskeletal assessment and discharge service to be run by a physiotherapist. This was being assessed along with a grant to provide funding. This would involve a physiotherapist assessing patients with simple sprains and basic fractures in triage and arranging treatment for them so they could be then immediately discharged.