Hospital of St John & St Elizabeth · Jackie Groom, Director of Patient Safety and Quality Improvement
One Good rating, resting on three generations of evidence
The position anyone can verify on the public register today: Good on all five key questions, published 28 March 2024. Underneath it, six service-level ratings earned at three different inspections — the oldest at the October–November 2016 comprehensive visit, almost a decade ago. This read covers what the register actually says, what changes as hospitals move onto their own assessment framework, and the honest gap in between.
The 30-second read
Position
Overall Good, with all five key questions Good (report published 28 Mar 2024, from an October 2023 inspection of part of the service). But two of the six service ratings — Medical care, and Outpatients & diagnostic imaging — still date from the 2016 comprehensive inspection, and the whole hospital has not had a comprehensive inspection since.
What's changing
Hospitals move onto their own Hospital Assessment Framework (draft), piloting now and live end-2026 — built around evidence CQC reads continuously from your systems, not a visit every few years.
The pattern
The 2021 report kept the rating at Good but recorded specific observations — incident-learning loops in end of life care, audits "not always systematic and meaningful", un-integrated record systems. No later published inspection has revisited those services.
The 30 minutes
We map where your day-to-day evidence sits against the framework being written for hospitals now, and you leave with the three gaps worth closing first.
Medical care and Outpatients & diagnostic imaging were last rated in the report published 7 June 2017, from fieldwork in October–November 2016.
Breaches / enforcement
0 / 0
No breaches and no enforcement action recorded against the hospital on the public CQC register.
Inspections since 2016
3 focused
2019, 2021 and 2023 were all inspections of part of the service. Each looked at a slice; none re-examined the whole hospital.
What’s changing under hospitals
Hospital Assessment Framework (draft)
The six shifts from the guide you downloaded are the rules this read is scored against — CQC is replacing the cross-sector Single Assessment Framework with four sector frameworks, and independent hospitals sit inside the draft Hospital Assessment Framework, piloting June–October 2026 and live by the end of the year. For a hospital whose rating is a patchwork of focused visits, the shift that matters most is the move to continuous, intelligence-led evidence — statutory notifications, complaints, workforce returns, read from your systems between inspections. Silence between visits stops reading as a clean record.
Continuous, intelligence-led monitoring — not point-in-time visits
Outcomes over process — a policy alone stops being enough evidence
Pilots running now; the new frameworks are live by end-2026
Where the record actually stands
Live CQC register · verified 12 Aug 2026
There is no peer score table here — deliberately. The hospital’s Good was earned under CQC’s legacy inspection methodology, and no scored quality statements exist for this location on the public record. That means there is no per-statement number to benchmark against other hospitals — a league table here would be manufactured, not real. It also means the “judged, not calculated” recalculation from the guide cannot be computed for this hospital yet: the first time its evidence is scored against the new descriptors will be the first time anyone knows. What follows is what the live register and the published reports actually say.
11 Jan 2011
Registered with CQC at Grove End Road (earliest published report on the register: December 2011).
Oct–Nov 2016
The hospital’s last comprehensive (routine) inspection — rated Good overall; report published 7 June 2017. Still the current rating basis for Medical care and for Outpatients & diagnostic imaging.
21 Mar 2019
Unannounced focused inspection, responding to two concerns raised with CQC. Unrated, no regulation breached — but named improvement points on record-keeping, incident-reporting timeliness, root-cause-analysis practice and shared learning. Published 12 July 2019.
Aug–Sep 2021
Focused inspection; the rating stayed Good. The report also recorded a detailed list of observations — several echoing 2019 (see below). Published 15 November 2021.
10 Oct 2023
Focused inspection of part of the service; the register dates the Critical care and Surgery ratings to its report. A clean, positive summary: effective governance, open culture, safety incidents managed well. Published 28 March 2024.
Today — 12 Aug 2026
Overall Good. Two of six service ratings unrefreshed since the 2016 fieldwork; end of life care and urgent care last inspected in 2021; the hospital framework CQC will judge all of it against is piloting now.
Ratings for specific services — live register, 12 Aug 2026
Critical care — Good28 Mar 2024
Surgery — Good28 Mar 2024
End of life care — Good15 Nov 2021
Urgent & emergency services — Good15 Nov 2021
Medical care (incl. older people’s care) — Good7 Jun 2017
Outpatients & diagnostic imaging — Good7 Jun 2017
Dates as shown on the live register (“last inspection date”); 7 June 2017 is the publication date of the October–November 2016 comprehensive inspection. Every rating is Good — the spread is in the age of the evidence: 2.4 years at one end, 9.2 at the other. Aged ratings sit alongside never-assessed services among the re-assessment priorities CQC has named for the transition.
From the inspector narrative
3 strengths · 3 watch items
Strength
Governance the 2023 inspectors endorsed
The latest report records that “leaders operated effective governance processes” and identified, escalated and reduced risks “effectively and in a timely manner”.
Strength
An open, improvement-focused culture
Inspectors recorded “an open culture where patients, their families and staff could raise concerns without fear”, with all staff “committed to continually learning and improving services”.
Strength
Safety incidents managed well — where inspected
In the services the 2023 visit covered, “the service managed safety incidents well and learned lessons from them” — the inspector’s words, not ours.
Watch
Incident-learning loops in end of life care
The 2021 report noted staff “did not always receive feedback from investigation of incidents”, with action plans “not always clear” and owners not always assigned. A shared-learning point was also recorded in 2019.
Watch
Records and IT systems not integrated
In 2021, hospice community and inpatient teams used different patient record systems; “IT systems and records across the hospital were not integrated”, causing duplication and delays. The report notes integration work was under way.
Watch
Audit rigour
Inspectors recorded in 2021 that “not all audits were carried out in a systematic and meaningful way” and that resulting action plans were not always clear.
The watch items are the inspectors’ recorded observations, in a report that kept the rating at Good and noted fixes already in motion — not a verdict we are adding. The point is narrower: end of life care and urgent care have had no published inspection since November 2021, so nothing on the public record says whether those loops closed.
What this analysis can’t see
The reason for the conversation
Everything above comes from the public register: what inspectors found, on the dates they looked. What it can’t show is where the hospital’s day-to-day evidence sits right now — whether the 2021 incident-loop and audit observations read as closed in today’s records, what a fresh look at the two services last examined in 2016 would find, and what continuous monitoring would read from your systems on an ordinary Tuesday. That isn’t a criticism; it is simply outside what any outside document can verify. That gap is the thirty minutes.
What we’d work through together
6 items · the agenda for the call
Not a homework list — the agenda we’d work through with you, drawn from the hospital’s own published record and the framework CQC is now building for hospitals.
01
What a fresh look at the two services rated on 2016 evidence would find today
NowPre-pilot
02
Whether the 2021 end-of-life-care incident-loop observations read as closed in the records
NowPre-pilot
03
The audit-to-action trail behind “not always systematic and meaningful”
High2026
04
What un-integrated record systems mean once evidence is read continuously
High2026
05
Where a hospital-plus-hospice estate keeps evidence the new framework can read
Medium2026–27
06
The governance strength the 2023 inspectors named — and what protecting it takes
MediumOngoing
Show what each item involves on the call
Which answer holds for Medical care and Outpatients depends on evidence only your side can see — what has changed in those services since October 2016, and what of it is documented.
Whether feedback, action plans and named owners now flow from every incident investigation is a question your incident system answers — not the register.
Turning “we audit” into a written trail of what each audit found and what changed depends on where your audit results currently live and who closes them.
The 2021 report described separate record systems across hospital and hospice; what continuous evidence looks like on top of the systems you actually run today is something only a walkthrough of those systems can settle.
Notifications, complaints, workforce returns — which systems hold each today, and who owns each, is the guide’s “list every system” step made specific to your estate.
What keeps the 2023 governance finding true as the evidence bar moves is a question about your forward plan, not your history.
We’d cover each of these against your actual records on the call — not hand them over as homework.
Be evidence-ready before the framework is
GreenM are healthcare data and AI specialists. We connect the fragmented evidence behind a service — incident systems, audits, complaints, records — so it reads cleanly against the framework CQC is writing now, not assembled the week before a visit. The hospital frameworks are piloting between June and October this year, with CQC targeting 9,000+ reports by September; a hospital whose Good spans evidence from 2016 to 2023, across two record systems the 2021 inspectors described as un-integrated, is exactly the case continuous assessment is built for. In thirty minutes you’ll leave with the six items above narrowed to the three worth closing first, and the first action on each.
