St Helier Hospital and Queen Mary's Hospital for Children

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 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 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.

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.

The service had a shared vision and positive culture that supported high-quality care, although some aspects were not fully embedded. This aligned with the group’s overall vision and strategy to provide ‘outstanding care, together’ and was based on the care objectives: Collaboration and partnership, Affordable services, fit for the future, Right care, right place, right time, Empowered, engaged staff. While leaders had identified emerging priorities through the Surgery Clinical Standards and Strategy Group (CSSG) aligning priorities with the group’s transformation programmes and had identified opportunities to improve efficiency, there was no formalised service strategy in place. These priorities included relocating services to create capacity across the group. During the inspection, some staff we spoke with were not fully aware of the organisation’s vision, values, or strategic goals, and could not describe how these applied to their roles.

Staff throughout the service were focused on providing high quality care for their patients. It was clear from observing their interactions with patients they were committed to improving the health of people who used the service. Most staff told us there was a positive culture within the service. Leaders told us there were initiatives to celebrate staff regularly. Staff members largely reported that they were able to offer feedback and suggest improvements to improve the service or staff experience. However, some expressed hesitation in voicing concerns due to potential retaliation and there was a perception that management prioritised mutual support and protected each other’s interests. Additionally, some staff members reported experiencing bullying, harassment and micromanagement which is inconsistent with the trust’s stated values. There were examples of progress towards improving culture and engagement. NHS staff survey results showed some positive trends, such as more staff recommending the trust as a place to work and increased trust in management respect. Leaders had introduced initiatives such as listening events, newsletters, and team-building activities, and departments like Ophthalmology implemented regular meetings and staff awards to improve communication and morale. However, these actions were not consistently embedded across the service, and staff continued to report issues around realistic deadlines, appreciation among colleagues, and raising concerns.

Leaders had the skills, knowledge, experience and credibility to lead effectively and understood the context in which they delivered care, treatment. However, feedback we received indicated leaders did not consistently embody the culture and values of their workforce and organisation and lead with openness and honesty.

Leaders were predominantly characterised as approachable and supportive, with ward managers and matrons actively engaging with staff. Most staff reported that they could approach senior colleagues for advice and felt encouraged to participate in improvement initiatives. However, some feedback from staff highlighted concerns about inclusivity and fairness in some areas. One staff member told us of discriminatory behaviour by certain senior staff, including failure to respect staff with disabilities and protected characteristics in theatres, other members of staff raised concerns about bullying on surgical wards. These challenges were compounded by the perception that senior management tended to support one another and shield each other from scrutiny.

There was a clear management structure with defined lines of responsibility and accountability. Local leadership was provided by matrons and ward managers. Leaders demonstrated the skills, knowledge, and experience necessary for effective leadership. While the service benefited from inclusive leaders who understood the context of delivering care, treatment, and support, further progress was required in relation to organisational culture and values.

The service had invested in leadership development, and some leaders were involved in quality improvement projects, such as reducing delays in sterile equipment and promoting regional anaesthesia techniques. While there were examples of strong leadership behaviours, such as supporting the introduction of Advanced Clinical Practitioners (ACPs) to enhance patient flow and safety, and leading quality improvement initiatives within surgical pathways, these actions were largely reactive and focused on addressing immediate operational pressures rather than formal service level succession plans to support long-term sustainability.

The division’s senior leaders were proactively involved in the group surgical strategy and the divisional improvement plan under the patient safety incident response framework, supported by regular horizon scanning to anticipate and respond to emerging risks and system pressures. Strategic leadership included active participation in the trauma network, the Southwest London Surgical Group across specialties, and the development of a standardised pre‑operative assessment pathway, including the digitalisation of pre‑operative assessment. Leaders also provided strategic oversight of the expansion of robotic surgery and the Engage project, which focused on tackling health inequalities and improving equitable access to care.

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

The leadership team endeavoured to foster a positive culture where most people felt they could speak up, and their voice would be heard. Staff were encouraged to raise concerns. Formal mechanisms for reporting concerns were in place, listening events were held across all specialties, and we saw information displayed about raising concerns.

The service had established Freedom to Speak up arrangements. The trust had an up-to-date Freedom to Speak Up Policy and a Freedom to Speak Up (FTSU) Guardian with whom staff could raise concerns about any issues. Information about the guardians and how to contact them was readily available. Telephone numbers and email addresses were included in the information along with a national helpline for whistleblowing. Most staff were aware of how to raise concerns but stated that they would more likely raise issues with their line manager. However, there was no data supplied which indicated how the surgical service used this pathway to raise concerns. Therefore, it was unclear if there were themes and trends relating to the surgical service staff concerns. 

While most staff reported that they would be listened to if they spoke up, others described a culture of fear and retaliation. The staff survey highlighted some areas for improvement, including raising concerns and constructive disagreements, and these were reflected in the division’s action plans. Initiatives such as sexual safety workshops and signing the sexual safety charter demonstrated a commitment to creating a safe environment for staff to speak up about sensitive issues.

The service did not always work towards embedding an inclusive and fair culture by improving equality and equity for people who work for them.

The trust demonstrated a strong commitment to promoting equality, diversity, and inclusion (EDI) within its workforce. However, some staff shared concerns about workplace culture, including allegations of racism and discrimination.

The service implemented systems and initiatives to support equality, diversity, and inclusion among staff. Leadership showed commitment to tackling disparities identified by the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES), which revealed that ethnically diverse and disabled employees were under-represented in senior positions. Additionally, the data highlighted inconsistencies in local disciplinary actions, resulting in varying approaches to management across different areas. The division had an action plan which set out broad objectives and commitments, such as improving representation, standardising reasonable adjustments, and promoting inclusive recruitment. However, actions such as “develop a more inclusive culture” and “improved staff survey metrics” were aspirational but lacked measurable targets or timelines and there was no detail on who would deliver each action and by when, making it difficult to track progress.

Staff were offered flexible working arrangements, with 26 out of 30 formal requests approved during the year. Adjustments were made for staff with caring responsibilities and for religious observance, such as longer lunch breaks for prayer and shift-swapping options. There were examples of support for staff with neurodivergence and veterans, and managers explored alternative roles when full accommodation of flexible working requests was not possible.

The division promoted an inclusive culture through initiatives such as RESPECT training, sexual safety workshops, and signing the NHS Sexual Safety Charter, reinforcing a zero-tolerance approach to harassment and discrimination Actions to improve civility and reduce incivility in theatres were also in progress, supported by simulation training and wellbeing boards.

Most staff we spoke to were aware of the available staff networks and knew how to access. All staff had access to multiple staff networks including:

• REACH (Race Equality and Cultural Heritage) Network
• Enabling Network
• LGBTQ+ Network
• Women and Allies Network

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.

The service had established clear governance structures and systems of accountability. Regular governance meetings were held, attended by appropriate personnel, including divisional directors, nursing management, and clinical leads. These meetings were documented, with minutes showing discussions on current and future performance, risks, and quality management. Governance processes involved reviewing incidents, patient safety alerts, and complaints with findings used to update the risk register and guide quality improvement. Although monthly governance meetings occurred, they did not consistently provide effective assurance across key areas. Due to the implementation of the patient electronic record system the service and the trust had had some difficulty in obtaining reliable data to audit some aspects of care effectively. Where audit data was available it was not always presented or discussed, and meeting minutes lacked documentation of concerns or follow-up actions where local audits indicated poor compliance. Data we reviewed identified several areas needing improved audit compliance, including VTE, NEWS2, and pressure ulcer prevention. In some instances, we did not see evidence of action plans to address gaps in auditing and compliance. Although some audits, including those of WHO surgical safety checklists, had resulted in specific recommendations, corresponding measurable actions to ensure adequate follow-up had not been implemented.

The service maintained a risk register to monitor key risks; each assigned a score and a responsible lead. Risks were actively reviewed and updated during governance meetings, ensuring that the service had continuous oversight of issues that could have potentially affected the quality of care. We found that risks identified within our inspection such as inaudible emergency call bells on B3 and escalation bed spaces were identified and recorded on the service risk register. Risks from introducing the trust’s new electronic health record system and related challenges affecting multiple services were documented in the trust risk register. Meanwhile, specific risks like operating lists from the electronic health record system lacking relevant or complete procedure details were noted on the divisional risk register. The service risk register showed key risks and control measures were identified to mitigate risks appropriately. Risks had a review date and an accountable staff member responsible for managing each risk.

Staff we spoke with had a good awareness of governance processes and knew how and where to escalate their concerns. Staff had access to a range of policies, procedures and guidance which was available on the provider’s intranet. Ward and theatre teams held regular team meetings, and the minutes we reviewed showed discussion of incidents, audit results, and shared learning was cascaded to teams.

There was data and information available to understand performance and quality within the service. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through team meetings and newsletters.

There was effective workforce planning including for managing major incidents or emergencies. The service had business continuity plans in in the event of an issue which would impact on the service. However, they had not always been signed off by the senior responsible officer.

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 understood its duty to collaborate and work in partnership so that care was joined up and seamless for people. Multi-agency discharge events were held with multiagency staff and teams from across the local health system to support patient discharges and improve bed capacity within the trust. Senior leaders told us the events were successful in improving bed capacity although timely discharges for patients with complex needs were not consistently maintained afterwards.

Staff used secure systems to exchange clinical details with other providers, which helped maintain continuity of care when people moved between services. There were examples of joint initiatives, such as quality improvement projects with external partners, aimed at reducing delays and improving patient experience. These collaborations demonstrated a commitment to learning and improvement beyond organisational boundaries.

Patients and staff had opportunities to meet with senior leaders and commissioners to provide feedback on services. This engagement helped shape decisions about service development and ensured that the voices of people using the service were heard. While there was scope to strengthen community involvement further, the evidence showed that the provider worked well with partners and shared learning to improve outcomes for people. Leaders actively participated in regional and system-wide forums to strengthen collaboration. For example, the perioperative medicine programme introduced a digital triage tool for early health screening, developed jointly with clinicians across Southwest London. This innovation aimed to reduce face-to-face clinic requirements, improve pre-operative optimisation, and help prevent late cancellations, benefiting both patients and staff.

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.

The service demonstrated commitment to learning and improvement. Staff could describe how lessons from incidents were used to drive improvement, and there were examples of quality improvement projects. The quality improvement projects developed met the needs of the service, for example enhancing tissue viability care through structured teaching sessions, audits, and the creation of ward-based resources, which led to improvements in staff knowledge and patient outcomes on ward B3. Similarly, introduction of an audit to improve the documentation of blood loss in operative notes following the implementation of the new electronic health record system. This ensured initiatives were aligned with the priorities of both staff and patients, leading to increased engagement among the workforce and improved clinical outcomes.

There was a clear strategy to drive continuous improvement across all surgical services supported by a quality and improvement champion and an ongoing transformation programme which aimed to increase efficiency within theatres. Staff and leaders gave examples of quality improvement projects such as waiting list validation clinics and telephone triage. They also informed us about service improvements as a result of these projects, including the introduction of a direct-to-theatre policy that specifies when a patient can go to surgery prior to being assigned an inpatient bed. This modification resulted in enhanced performance in time to theatre for hip fracture cases, where the provider achieved the highest national standard.

Staff we spoke with told us they were supported by their managers to access development opportunities and develop their leadership skills. Leaders encouraged innovation and participation in research and informed us that technology enabling robotic surgery will soon be introduced within the trust, with delivery expected at the end of January 2026.

Leaders encouraged feedback from people and acted on concerns, fostering an environment of openness and improvement. While some challenges remained, there was a commitment to learning and innovation which continued to evolve.