University College Hospital & Elizabeth Garrett Anderson Wing

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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

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.

The service had a clear vision and plans to achieve it. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. There was a clear system of governance and risk management based around delivering safe, high-quality care and treatment. The service worked with stakeholders and partners to drive improvements to care pathways. The leaders encouraged an open and honest culture where people felt they could raise concerns.

At our last inspection we rated this key question as Good. At this assessment the rating remained Good. This meant service had a shared vision, strategy and culture. 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.

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, engagement, and understanding challenges and the needs of people and their communities.

Leaders demonstrated that they had established a clear and logical strategic direction for urgent and emergency care, aligned to organisational priorities and supported by a structured transformation programme. They implemented a trust-wide Emergency Pathway Programme to improve patient flow, clinical outcomes, and staff experience, with defined objectives including delivery of the 4-hour standard, reduction in long waits, and improvements in patient and staff experience.

Leaders promoted a strong and inclusive organisational culture, underpinned by values of safety, kindness, teamwork and continuous improvement. They used staff feedback and engagement activity to inform cultural transformation and service improvement. Staff were actively involved in shaping improvements through a range of forums, including team-level engagement, workshops, and organisation-wide initiatives, which supported shared ownership of the strategy and its delivery.

Leaders demonstrated a positive learning culture and provided timely, visible support to staff, particularly following serious incidents. They worked well with and across leadership teams to ensure timely senior presence, coordinated responses, and immediate actions to maintain safety and support staff wellbeing.

Leaders aligned cultural and operational improvement programmes effectively and supported this through structured communication plans and regular leadership engagement. This approach enabled leaders to drive improvements in patient flow, performance, and staff experience while reinforcing organisational values and behaviours.

However, although leaders had clearly defined the strategic direction at organisational level, this was not consistently embedded across frontline teams. Some staff we spoke with during the inspection were not aware of the strategy or its associated priorities, and leaders recognised the need to strengthen how strategic objectives were communicated and translated into day-to-day practice.

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.

Leaders demonstrated they were capable, inclusive and compassionate, and had the experience, skills and credibility required to lead the service effectively. They understood the operational context of the service and reflected organisational values in their leadership approach. Leaders acted with integrity, openness and transparency, and promoted a positive and supportive culture for staff and patients.

Leaders worked together within a well-established triumvirate structure (3 professionals share operations and clinical control), providing clear clinical, operational and nursing leadership at departmental level. They demonstrated shared accountability and strong team cohesion, which supported effective decision-making and oversight of service delivery. Governance and reporting arrangements were clearly defined, and staff understood their roles and responsibilities. Leaders maintained oversight of performance, patient flow and staffing, and could clearly articulate the key risks facing the service and the actions taken to mitigate them.

Leaders were visible and approachable, and staff consistently described them as supportive and responsive. Staff spoke positively about their immediate managers, matrons and consultants, highlighting the strong working relationships and the supportive culture within teams. Many staff reported long lengths of service and expressed pride in working within the organisation, attributing this to the positive working environment and team culture. Vacancy rates in the Emergency Department ranged from around 1.6% to 6.9% for most of 2025, indicating effective recruitment and retention during that period.

Leaders prioritised staff wellbeing and demonstrated a compassionate leadership approach, particularly during periods of sustained operational pressure. They had a range of practical and psychological support mechanisms, including access to occupational health services, psychological support and structured debrief processes.

Leaders invested in workforce development and supported career progression through education programmes, leadership development, and structured pathways, particularly within nursing and paediatric services. These initiatives contributed to workforce stability and increased internal recruitment and retention.

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

Leaders demonstrated that they promoted an open and transparent culture where staff felt able to raise concerns and contribute to improvement. There was a strong freedom to speak up approach aligned to national policy. This focused on making speaking up “business as usual” and encouraged staff to raise concerns which affected patient care, safety, or their working environment.

The staff survey highlighted 69% of staff felt safe to speak up about anything that concerned them and 59% of staff said they felt confident their concerns would be addressed. This was higher than the average result.

Leaders ensured that multiple accessible routes were available for staff to speak up, including line managers, senior leaders, dedicated support services, and the Freedom to Speak Up Guardian. The Guardian service provided confidential and independent support, including access to external arrangements where required, enabling staff to raise concerns in a way that felt safe and appropriate. Staff also had access to additional support through wellbeing services, staff networks, and trade unions.

Clear processes were in place to respond to concerns. Leaders ensured that all concerns were acknowledged, appropriately triaged, and managed through the most suitable pathway, including early resolution, mediation, or formal investigation where required. They ensured staff received feedback and updates, and that learning from concerns was shared to improve practice and prevent recurrence. Formal processes, including whistleblowing arrangements, provided additional protections for staff raising concerns in the public interest, including confidentiality and protection from detriment.

Leaders demonstrated oversight of speaking up through regular monitoring and reporting to senior committees and the Board, which included thematic review of concerns and actions taken. This supported organisational learning and ensured that issues raised by staff informed service improvement and governance arrangements.

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. Staff 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.

Leaders demonstrated that effective governance systems were in use to ensure the service was well managed and delivered high-quality care. They established clear and structured governance arrangements with defined reporting lines from departmental meetings through to divisional and Board-level oversight. Governance forums operated at regular intervals, including weekly clinical governance meetings, monthly performance reviews, and divisional board meetings, enabling consistent monitoring of quality, safety, and performance across the service.

Leaders ensured that governance processes were embedded across all levels of the service, with multidisciplinary involvement from clinical, nursing, operational, and quality teams. Meeting structures supported effective escalation, shared decision-making, and accountability, and included specialist groups such as incident review groups, patient safety forums, and violence prevention and reduction meetings. We reviewed a range of minutes from several of the governance meetings and found these arrangements enabled leaders to identify themes, review incidents, and drive improvements through coordinated governance pathways.

Risk management processes were effective and well embedded. Leaders maintained departmental risks on a divisional risk register and reviewed them regularly through governance forums, ensuring risks were escalated appropriately to senior leadership and Board-level committees where required. Structured mitigation plans were developed and monitored through project workstreams, with oversight provided through regular performance and governance meetings. Leaders demonstrated proactive management of emerging risks, including those associated with new models of care and operational pressures.

Leaders used a range of data sources to support governance and drive improvement, including audit programmes, performance metrics, and real-time operational data. They triangulated information from audits, incidents, and staff feedback to inform decision-making and ensure that improvements were evidence-based and effective.

Governance systems demonstrated a clear focus on continuous improvement and sustainability. Leaders embedded quality improvement into governance processes through regular review cycles, action tracking, and monitoring of outcomes. Evidence showed improvements in patient flow, compliance with pathways, and staff experience, supported by structured governance oversight and performance management arrangements.

Leaders promoted environmental sustainability through a range of practical initiatives. Staff reduced waste through digital innovation. They implemented digital training records, a digital IV passport and virtual induction packs, which significantly reduced paper use across the department. More than 4,500 pages of printed material were avoided through the digitisation of competency and training documentation. The department also supported the trust-wide 'Gloves Off' initiative, which reduced unnecessary use of disposable gloves, and used the MyCare digital platform to minimise paper-based communication with patients. Leaders embedded a digital-first approach to operational management, using Microsoft Teams and OneDrive for communication, collaboration and document management.

However, while governance arrangements were detailed and in general effective, leaders recognised that key risks remained, including violence and aggression, workforce pressures, mental health demand, and ongoing system flow challenges. These risks required continued oversight, sustained mitigation, and long-term strategic solutions to ensure the ongoing resilience and sustainability of the service.

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

Leaders demonstrated that effective and collaborative partnerships with other services were well established across the urgent and emergency care pathway, supporting coordinated, person-centred care. They maintained strong operational relationships through regular and structured engagement, including daily interactions to manage flow and patient safety, and formal meetings at local and system level to address performance, escalation, and service improvement. These arrangements enabled timely escalation of pressures, shared decision-making, and a coordinated response to operational challenges across the system.

Leaders worked well with other services to improve key aspects of the patient pathway, including ambulance handover processes, discharge planning, and mental health care provision. Joint working arrangements supported improvements in communication, pathway design, and clinical processes, including enhanced parallel assessment for mental health patients, improved discharge documentation, and stronger interface working with community-based services. These initiatives contributed to improved patient flow, reduced delays, and more effective delivery of care across organisational boundaries.

The service demonstrated a positive and structured approach to partnership working through clearly defined governance arrangements, including regular system partnership meetings, operational flow groups, and multidisciplinary discharge forums. These forums enabled shared oversight of performance, identification of system barriers, and implementation of joint action plans to improve discharge processes and patient outcomes. Leaders ensured that actions were formally recorded, monitored, and reviewed, promoting accountability and continuous improvement across the wider system.

Partnership working extended to the development of alternative care pathways and community-based services, including virtual care models and out-of-hospital provision, which provided safe alternatives to admission and supported timely discharge. Leaders actively participated in wider system forums and strategic groups to drive transformation and share learning, demonstrating system leadership and a commitment to integrated care delivery.

Partnership working was well established and effective, and leaders recognised that variability remained in access to services across different areas and continued to work with system partners to strengthen out-of-hours provision, particularly for vulnerable patient groups, to ensure equitable and consistent support across the pathway.

The service had strong focus 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 contributed to safe, effective practice and research.

Leaders demonstrated that a good culture of continuous learning, improvement and innovation was embedded across the service, supported by structured programmes, data-driven approaches, and active staff engagement. They had a coordinated two-year improvement programme, underpinned by organisational development and quality improvement, which included diagnostic listening events, behavioural and values-based interventions, and process improvement workstreams. This programme enabled leaders to identify priorities, respond to staff feedback, and make targeted improvements across culture, patient flow, and operational processes.

Leaders had a range of effective improvement initiatives, including the development of the Extended Emergency Medicine Ambulatory Care (EEMAC) model, pathway redesign, and targeted quality improvement projects, which contributed to improved performance against the 4-hour standard, streamlined patient pathways, and enhanced patient flow. They used structured approaches such as process mapping, driver diagrams, and improvement workshops to identify inefficiencies and deliver sustainable change. Improvement work was overseen through formal governance routes, including the Emergency Pathway Programme Board and regular performance meetings, ensuring clear oversight and accountability.

The service actively promoted innovation and research, with ongoing participation in national and local studies, research collaborations, and regular dissemination of findings through newsletters and presentations. Research activity contributed to improvements in clinical pathways, early diagnosis, and patient care, and staff were supported to engage in research through dedicated roles and protected time within their job plans. The trust had been ranked among top recruiting sites for research and had been recognised with a Goodeve medal in the journal of Operational Research Society. A research project around the Rib Fractures Pathway undertook a retrospective analysis conducted of patients for 12 months which highlighted gaps noticed in availability to access regional blocks. A new guideline was developed in response with anesthetic teams which was rolled out trust wide.

Leaders also supported innovation through workforce development initiatives, including education programmes, quality improvement training, and structured career development pathways such as the internal staff transfer scheme, which enhanced staff retention, skills development, and organisational flexibility.

Staff were effectively supported to contribute to improvement work through a range of engagement mechanisms, including workshops, improvement forums, multidisciplinary meetings, and digital feedback tools such as QR codes. Leaders ensured that improvement work was visible and accessible through multiple communication channels, including governance meetings, newsletters, and local team briefings, which supported staff involvement.

Leaders had established multiple systems to support improvement and learning and recognised that further work was required to strengthen consistency in how outcomes, learning, and improvements were communicated and fully embedded across all staff groups to provide consistent assurance of impact at frontline level.