Queens 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 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 as good. At this assessment the rating has remained the same. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders were able to explain how they were working to deliver high-quality care. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients.

However, the service did not always have clear responsibilities, roles, systems of accountability or sufficiently robust governance arrangements. Leaders did not always act on the best available information about risk, and opportunities to identify, monitor and improve performance were sometimes limited.

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 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 patients and their communities.

The service aligned with the Trust’s vision of delivering ‘Exceptional Care Together,’ focusing on improving patient experience and outcomes. Patients and staff were treated as key partners in delivering care collaboratively.

Staff told us the senior leadership team had communicated the provider’s vision and values to them. The service aligned with the Trust’s mission through a 5-year strategy structured around key themes. These had included improving quality and safety, enhancing staff experience, strengthening partnerships, promoting sustainability, and supporting research and innovation to improve outcomes.

Staff we spoke to said there was a positive culture within the organisation and that they enjoyed working at the trust. Staff said there was a strong sense of teamwork, and they felt supported by their colleagues.

Staff had a good understanding of equality and diversity, in relation to meeting both patients and colleagues’ individual needs.

Ward staff were reported to support each other. Staff told us that registered nurses supported healthcare assistants with personal care in the mornings before commencing medication rounds. They said this approach fostered good teamworking. We saw evidence of staff engagement in quality improvement, with noticeboards displaying team‑led projects aimed at improving care for older people.

Staff described a generally positive culture across various wards. However, staff across most wards raised ongoing concerns about patient safety when staffing levels were lower than expected. These concerns had been escalated to senior leaders, but staff reported no resulting changes, and ward managers felt limited in their ability to address staffing issues locally.

The trust had undertaken regular cultural reviews across ward areas, with findings used to inform actions to address behavioural concerns, review staffing arrangements, and strengthen communication and accountability in line with organisational values. However, challenges remained in relation to staffing levels, workload pressures, and aspects of staff wellbeing and recognition, with variation identified across ward areas.

Staff felt respected, supported and valued. They felt positive and proud about working for the provider and their team.

The evidence showed a good standard. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, ward staff described feeling disconnected from senior leadership.

Managers and leaders had the right skills to perform their roles effectively. When we spoke to staff they expressed confidence in their leader’s abilities. Leaders understood the challenges the department faced and were engaged in the actions to achieve improvement.

Staff told us that their immediate line managers were visible and provided regular support. However, they reported that senior managers above this level were not routinely present in ward areas. Staff said these limited opportunities for senior leaders to understand day‑to‑day operational pressures and reduced their visibility within the service. Despite this, staff demonstrated a strong commitment to providing high standards of care and supporting one another to meet patients’ needs.

Staff described feeling disconnected from senior leadership, which limited their sense of engagement and visibility of leadership within the ward.

Staff demonstrated a positive and supportive ward culture, which they attributed to strong leadership from the ward manager. Staff described the ward manager as supportive and proactive in promoting effective teamwork.

Leadership development opportunities were available, including opportunities for staff.

Staff demonstrated inclusive practice in their interactions with patients, ensuring care was delivered in a dignified, person‑centred manner. This supported a positive patient experience and promoted fairness and accessibility within the service.

The evidence showed a good standard. The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

Staff could access support from a Freedom to Speak Up Guardian (FTSU). They could raise concerns without fear. A FTSU Guardian worked alongside the trust’s senior leadership team to ensure staff had the capability to speak up effectively and were supported appropriately if they had concerns regarding patient care.

There was a system and process in place to enable staff to be able to speak up about any safety concerns. There was a freedom to speak up policy and a freedom to speak up team. Staff knew who the FTSU was and how to contact them.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Managers told us the service was committed to continuously delivering high quality care, improving services for all patients and the working environment for staff and consultants.

Leaders told us that they continued to promote Freedom to Speak up to empower colleagues to report bullying, discrimination and abuse.

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 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.

Arrangements in place did not always address clinical governance, performance and general management oversight including staffing. Staff had been consistently redeployed across wards to maintain safe staffing levels and to provide additional support during periods of increased demand. While this approach had supported risk mitigation, it had also created challenges, as staff working outside their usual teams had experienced difficulties working at other specialties and this had, at times, resulted in gaps in staffing. However, we were not assured the senior leadership were fully sighted on the risks and performance in the medical care division. This was because we found areas of concern such as staffing, medicines optimisation concerns and storage of control of substances hazardous to health products. We reviewed staffing rotas in various areas and found staffing levels were below required levels in several areas.

The medical care directorate had a risk register which was reviewed regularly. The service’s top 3 risks were patients falls, unable to provide bay nursing due to reduction in staffing and stability of medical workforce. There were 9 risks identified on the register. All risks on the register had been reviewed, prioritised and rated. There were systems and processes in place to monitor quality, performance and safety. However, we were not assured that governance arrangements were effective in overseeing the safe management of COSHH substances, medicines optimisation, and staffing to ensure patients received safe care.

Leaders attended directorate and divisional quality and performance meetings. The medicine divisional governance meetings took place monthly. We reviewed the minutes of recent meetings and these included key discussions in relation to various specialties and ward areas.

Leaders were able to explain how they were working to deliver high-quality care. For example, the triumvirate described how risks relating to workforce sustainability, patient flow and discharge delays had been identified within the Medical Care division. Internal processes had been implemented to manage operational pressures and maintain patient safety; however, wider system challenges, particularly those relating to community capacity and inter-organisational coordination, had continued to limit improvement. An ongoing focus had been placed on workforce planning, system collaboration and discharge optimisation to mitigate these risks.

The service participated in local clinical audits. The audits were sufficient to provide assurance and to identify needs for improvement. All audits were managed within a suitable governance framework.

The Trust monitored quality and safety performance through a dashboard. Patient experience data indicated the service was performing well. For example, the results of the Friends and Family Test (FFT) showed 93.3% of patients would recommend the service. However, complaint response times were significantly below target (45.4% against 85% target) from January 2025 to February 2026, and hospital‑acquired grade 3 and 4 pressure ulcers were slightly above target (0.283 vs 0.28 per 1,000 bed days), while venous thromboembolism risk assessment compliance was 90.8% against a 95% target. These areas were recognised through governance arrangements and were subject to ongoing improvement actions.

Information such as learning from incidents was shared through staff meetings. Staff told us they were kept informed through newsletters and ward meetings. However, attendance at ward meetings was reported to be low across various ward areas due to staffing issues.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The service collaborated with 2 integrated care systems (ICS) to support joined up care. Partnerships had been established with NHS organisations, local authorities, and wider stakeholders to deliver joined-up services and improve health and wellbeing, supporting people to start well, live well, and age well.

The division worked closely with a third-party Community Interest Company to develop alternative care pathways that helped reduce unnecessary attendances at the Emergency Department (ED). Leaders highlighted the collaborative work between DHU Healthcare and the trust’s virtual ward services, which enabled patients to receive care within the community, reducing avoidable hospital presentations and supporting care closer to home.

Integrated working was evident through the Same Day Emergency Care service, which accepted direct referrals from community-based teams and provided timely assessment and treatment, helping to prevent avoidable attendances at the ED. Leaders also described strong collaboration with voluntary sector organisations and patient groups, supporting a coordinated approach to care delivery and ensuring services were responsive to the needs of local communities.

There was effective multidisciplinary working, including involvement from hospital social work, community mental health services, the mental health lead team, and the discharge team. Clear and accessible escalation pathways were in place for mental health crises.

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 patients. They actively contribute to safe, effective practice and research.

We saw an example of quality improvement on Ward 4. This was where staff replaced lids of patients’ water jugs with colour‑coded alternatives. This system enabled staff to easily monitor patients’ fluid intake and identify how much each patient consumed. This initiative responded to concerns about increased intravenous fluid use. It also addressed inconsistent fluid balance chart completion. Rising urinary tract infections and acute kidney injury were identified. These issues contributed to longer hospital stays.

Data collected demonstrated that most patients, particularly those admitted without acute kidney injury, showed improvement in their kidney function, with minimal numbers experiencing no change. A small cohort of patients showed a deterioration in kidney function, including those identified as end-of-life, highlighting areas for continued clinical oversight. Patients and their relatives provided positive feedback regarding this initiative, noting that it supported hydration and contributed to improved overall care.

Other examples included Ward 6. Staff were actively involved in quality improvement projects, including a recent initiative focused on reducing patient falls. Staff told us that falls had reduced from approximately 18 to 1 per month. This represented a significant improvement and had contributed to reduced harm and shorter hospital stays. The ward had also undertaken similar quality improvement work to reduce hospital acquired pressure ulcers.

Staff had access to ongoing learning and development opportunities. We observed a clinical practice educator present on the ward providing direct support and guidance to staff, which helped promote learning and safe clinical practice.