Conquest 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

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. We checked whether leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. 

We assessed all quality statements in this key question. 

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance of the service. We found governance, risk management and assurance arrangements were not effective, and leaders did not always act on information about risk, performance and outcomes. Significant risks relating to overcrowding, patient flow, staffing, mental health provision and paediatrics had been identified and escalated but remained unresolved for prolonged periods, and audit findings were not consistently used to drive sustained improvement. This limited leaders’ ability to ensure safe, high‑quality and sustainable care across the service. 

However, local leaders and staff demonstrated positive leadership behaviours, including a clear shared direction for the future of urgent care, a compassionate and inclusive culture, and strong partnership working across the local system. Staff felt able to speak up through effective Freedom to Speak Up arrangements.

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 the service as 3. 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 people and their communities. Staff told us they were able to influence change and contribute to decision-making in the department.

The service had a clear and forward-looking shared vision for urgent care, underpinned by a 5-year plan for the urgent care division. This strategy focused on improving patient flow, safety, and experience through service redesign, including plans to separate the urgent treatment centre from the emergency department, and to expand acute medicine and virtual ward provision. 

Leaders described how this work aligned with wider trust and system priorities to reduce unnecessary admissions and provide care closer to home. Staff and leaders spoke positively about the direction of travel and showed a shared understanding of the challenges facing urgent care, including rising demand and environmental constraints. 

Staff and leaders demonstrated a compassionate and inclusive culture with a focus on learning and improvement. We heard many staff describe the team in the emergency department as “a family”. This culture supported engagement with change and provided a strong foundation for delivering the service’s future vision.

Leaders told us staff had opportunities to contribute to discussions about the service strategy, especially where changes were planned. Staff told us they were able to influence change and contribute to decision‑making within the department.  However, some staff we spoke with said they were unhappy with certain changes and did not feel involved in discussions at the point those changes were implemented. 

We scored the service as 3. The evidence showed a good standard. 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.

Staff told us they felt supported by managers and had opportunities for development. Managers were visible and approachable. Leaders were knowledgeable about the issues and priorities within the service and worked towards change and improvement where possible. Leaders focused on staff wellbeing and promoted a culture of good practice, quality improvement, and an ambition to deliver safe care.

Department managers generally led with integrity, openness and honesty and aligned their approach with the organisational vision when possible. Leaders and clinical staff understood the key risks to the department and were aware of the issues, challenges and priorities within and beyond their service.

Leaders demonstrated collaborative working as part of a multidisciplinary team and worked with partners such as the local NHS ambulance service and mental health trusts. They told us they engaged regularly to review performance and identify opportunities for improvement.

Staff also told us they had not experienced any instances of unfair treatment, discrimination or harassment.

However, senior leaders did not always manage risks effectively. Department managers and leaders had identified, recorded and escalated risks relating to overcrowding and flow, an unsuitable environment, staffing provision, mental health provision and paediatric staffing. Despite this, leaders had not consistently implemented effective mitigating actions, and most risks had remained on the departmental risk register for over five years.

The service did not achieve safe patient flow, despite leaders introducing several mitigating initiatives such as virtual wards, ambulatory clinics, a medical decision unit, urgent community response services, and same‑day emergency care (SDEC). 

Leaders recognised the impact of crowding on staff wellbeing and the associated increase in stress levels. Support services were in place, and leaders acknowledged that further work was required.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a positive culture where most people felt able to raise concerns about their own experience or issues which could compromise the quality of patient care. The service had a Freedom to Speak Up (FTSU) policy which gave staff guidance about how to speak up and raise concerns for the benefit of patient care or where issues affected their working life.

Staff told us if they had concerns or feedback, they would usually escalate these to the nurse in charge or their manager or approach a FTSU guardian. Staff were aware of who the FTSU guardians were and how to contact them. The guardians’ role was to support workers to speak up when they felt unable to do so through other routes. Staff we spoke with said they would not feel anxious about speaking up if they needed to.

Between January 2025 and January 2026 there had been 1 FTSU concern raised, which represented 0.6% of the trust’s overall FTSU caseload for the same period. We saw evidence that actions were taken and learning was identified following the concern. 

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed Duty of Candour was completed appropriately.

We scored the service 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.

The trust’s equality, diversity and inclusion (EDI) policy set out a commitment to diversity and inclusion for patients, visitors and staff, in line with legislation including the Equality Act 2010. The trust monitored and reported annually on gender, ethnicity and disability pay gaps and met national reporting requirements. Leaders produced an annual equality report and developed equality, diversity and inclusion improvement plans.  Equality objectives included support for neurodiverse colleagues, enabling staff to tailor care towards cultural needs, and embedding reasonable adjustment processes across the trust. 

Leaders told us the trust had taken action to recruit and retain staff. However, the department continued to experience some vacancies. At the time of assessment, the trust was reviewing its organisational structure, which included plans to standardise certain staff roles.

Staff were able to apply for flexible working arrangements to accommodate personal circumstances, such as caring responsibilities or health needs. Managers implemented reasonable adjustments to support staff to carry out their roles effectively.

The trust undertook equality monitoring of the workforce to ensure staff groups were diverse and reflective of the population served.

The trust set equality objectives for 2022 to 2026, which focused on fostering a safe, inclusive and representative workforce. These objectives demonstrated a strategic commitment to creating a positive working environment and ensuring equitable experiences for all staff.

The trust aimed to ensure that workplace environments remained free from bullying, intimidation, violence and aggression. It promoted behaviours that supported dignity and respect and had effective processes to address concerns promptly.

The trust committed to improving workforce representation at all levels and enhancing staff experiences of equality of opportunity. It monitored progress through staff survey feedback and delivered on its responsibilities under the Workforce Race Equality Standard (WRES), Workforce Disability Equality Standard (WDES), and aspirational targets for staff from multicultural backgrounds.

We scored the service as 1. The evidence showed significant shortfalls.  The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service's governance processes were not effective in ensuring patients received care that met expected standards. 

Leaders did not consistently use accurate or complete information to inform decisions about risks, performance and patient outcomes. Communication about operational pressures within the department did not reliably reach senior leadership, and the point of failure in this communication pathway remained unclear.

Leaders did not use governance processes effectively to manage risks or improve performance. Risk escalation and mitigation processes did not adequately address known concerns, including poor patient flow.

Leaders did not always identify, escalate or mitigate risks effectively. The top 4 risks recorded on the urgent care risk register were poor patient flow, delays in out-of-hours assessments, nursing vacancies, and violence and aggression towards staff. The risk register did not include all known risks. For example, audits identified poor compliance with adult sepsis management, but leaders had not recorded this as a risk.

Leaders held 4 daily bed meetings to support patient flow, although the risk register identified poor engagement with these meetings. Leaders also introduced other measures to improve flow, including an action plan for frequent attenders, block-booking temporary nursing staff and a twilight consultant shift to increase senior decision-making capacity. It was unclear how successful these actions were. Despite these actions, patients continued to experience significant delays, overcrowding and extended stays in the emergency department.

Patients experienced prolonged waits for assessment, treatment, admission and transfer throughout their care journey, increasing the risk of deterioration while waiting for care. The persistence of these issues showed leaders had not effectively addressed known risks.

Patients also experienced delays in receiving specialist reviews.  We found specialty input affected patient flow and prolonged waits for treatment and admission. Leaders did not routinely collect or monitor specialty response time data. As a result, they could not assess the extent of delays, identify trends or evaluate improvement.

Leaders did not always use available performance data effectively to monitor quality and drive improvement. Mandatory training compliance did not consistently meet the trust target, and staff had not always completed the training required to deliver safe care and treatment.

Leaders told us they addressed staffing shortfalls in the paediatric emergency department by deploying adult nurses who had completed paediatric competencies. Adult nurses told us they did not feel confident working in the paediatric emergency department despite completing this training. Leaders could not demonstrate that paediatric areas were consistently staffed by staff with the appropriate skills, knowledge and experience to meet the needs of children and young people.

Leaders did not use audit findings consistently to drive improvement. Audit data from December 2025 to February 2026 identified poor compliance in several areas, including documentation, sepsis management, completion of body maps, domestic abuse screening, capillary blood gas monitoring and mental capacity assessments. Although leaders identified these concerns, they did not consistently implement, monitor or evaluate actions to address them.

The service completed a Royal College of Paediatrics and Child Health Facing the Future audit in October 2025. The audit identified significant non-compliance with workforce and training standards (29%) and mental health standards (10%). Leaders told us they were undertaking a gap analysis; however, the audit did not include clear action plans, timescales or identified leads. Leaders could not show how they would address these gaps or monitor progress.

Leaders met regularly with system partners to discuss pressures relating to mental health provision and delays in assessment and onward placement for patients experiencing mental ill health. Despite this, patients, including children and young people, continued to experience delays in accessing mental health assessments and onward support. Leaders could not show that partnership working had improved pathways or reduced delays.

Leaders did not maintain effective oversight of reasonable adjustments for people with additional communication needs. The service did not have a functioning hearing loop system for patients with hearing impairments. Although a hearing loop should have been available at reception, leaders only became aware during the inspection that it had been out of service for an extended period.

However, there were established governance structures in place. The service held a range of meetings to review performance, quality and safety. Governance records showed leaders monitored incidents, complaints, performance, staffing, clinical effectiveness and divisional risks. Leaders used quality and safety data to inform discussions, reviewed specialist reports and escalated concerns through governance structures to divisional leaders and the trust board.

Leaders also shared information with staff through newsletters, email updates, handovers and huddles, including learning from incidents, audit findings, complaints and quality improvement activity.

 We scored the service 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.

The service worked collaboratively with external system partners to support admission avoidance and facilitate timely discharge. This approach relied on effective use of community-based services to provide appropriate alternatives to hospital attendance. Directorate leaders engaged with external stakeholders and ensured patient feedback informed wider trust learning and improvement.

The emergency department met regularly with key external partners, including the local mental health trust, to promote shared learning, improve oversight of clinical risks and performance, and support joint service development. These meetings enabled partners to work collaboratively to improve service provision and patient outcomes.

Staff worked effectively with the local ambulance service and demonstrated flexibility and responsiveness when notified of incoming trauma cases. They valued the information provided by ambulance crews and used it to support structured and detailed handovers, which enabled safe, coordinated, and timely care for patients.

The service also worked with local police in response to the increase of incidents relating to violence and aggression in the department, supporting joint approaches to safety and incident management. 

The service worked closely with the local mental health trust to improve the psychiatric liaison service within the emergency department. In addition, the service worked to expand on-site mental health specialist support in response to an increase in patients presenting with acute mental health needs.

We scored this service a 2. The evidence showed some shortfalls. The service did not always fully focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering improvements in a continuous and sustained way. They did not always actively contribute to safe, effective practice and research.

Although the service demonstrated a commitment to learning and improvement, we found shortfalls which meant learning was not consistently embedded or translated into sustained improvement. While staff engaged positively with incident reporting and leaders promoted a culture of openness documentation audits, sepsis audits and observations audits continued to show ongoing concerns, including poor compliance with body maps, domestic violence screening, monitoring of urine output for sepsis management, and significant delays in recording and responding to NEWS2 scores. Despite action plans, performance did not consistently improve over time.

In addition, several longstanding risks remained unresolved, with some having been on the risk register for more than 5 years, including risks related to overcrowding, paediatric sepsis management, mental health provision, and delays in medical reviews. Although leaders identified mitigating actions, evidence demonstrated these had not been effective in reducing risk or improving outcomes. 

However, the service had implemented an artificial intelligence (AI) enabled patient tracking system across the trust’s emergency departments and wards. Leaders told us the system supported clinical and operational staff by automating repetitive administrative tasks and providing real‑time oversight of patient pathways. They told us the tracker improved timely visibility of high‑risk patients, identified blockages within pathways, and delivered data‑driven insights to enhance operational planning, patient flow, and service delivery.

Leaders reported that since the introduction of the AI tracker, the median time patients spent in the department had reduced by over 21%, and spoke positively about the system, noting it had recently received an award in recognition of its impact.

Leaders told us they had introduced a service for patients with chronic headaches to receive treatment at home. This was intended to reduce attendance at the department and help manage patient footfall.

The service had also taken action to reduce the risk of violence and aggression. Leaders told us security staff had introduced body-worn cameras, which they said had reduced incidents. Staff had access to handheld alarms, and patients’ records included flags to identify previous markers for violence and aggression.