Nuffield Health Leeds Hospital

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

Leaders strived for an inclusive and positive culture of continuous learning and improvement. Leaders used data and information to drive improvement through setting a future vision. However, not all staff felt that leaders fully understood the day-to-day challenges of service provision. Leaders did not always ensure to proactively seek views of a diverse range of staff and people using services. There were clearly embedded governance and management systems. However, these were not always used effectively to ensure information about risks, performance and outcomes drove continuous improvement of care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us about the vision for the year. Leaders told us they listened to staff and held forums for staff to share views and ideas for the future direction of the service. Leaders told us about a 'back to the floor 24' initiative whereby leaders aimed to spend more time in the clinical areas to be more visible and available to staff and to gain a greater understanding of the challenges faced on a daily basis to delivering high quality care.

Staff we spoke to were positive about prioritising safe, high quality, compassionate care. Staff told us about staff forums and events for sharing information. However, not all staff felt that leaders had an open and transparent approach. Some staff told us they felt leaders did not fully understand the complexities to the services being provided and the challenges to providing high quality care.

We also heard some staff felt there was a lack of equity when recruiting to some positions within the organisation. This was understood to be a perceived lack of openness and transparency regarding job opportunities and recruitment processes.

We saw there was a strategic vision and objectives for 2024. This had been presented to staff in January 2024 with a progress update in July 2024. Staff forums were in place to share information with staff and provide staff with opportunity to become familiar with the vision and strategy. Leaders used data, for example, through incident reporting, staff surveys and patient feedback to determine areas of development.

We did not see clear processes for ensuring the values and strategy had been developed through a structured planning process in collaboration with people who use the service, staff and external partners.

Senior leaders we spoke to placed value in understanding the daily challenges and risks in delivering care on a daily basis. Leaders told us they aimed to be visible within the organisation and did this by daily walk arounds. For example, we heard senior leaders would plan to go into the theatres first thing each morning. However, not all staff we spoke to felt senior leaders were visible within the departments. We also heard senior leaders did not take the time to fully understand the clinical issues or complexities of service provision and, therefore, were not always able to prioritise needs to ensure quality of services provided.

Staff told us that heads of department were visible and approachable and understood the challenges to provision of care within their own areas.

We heard about training provided to team leaders and heads of departments to support effective leadership. Team leaders and heads of department we spoke to told us they felt supported to progress in their roles. We heard examples of staff who had progressed within the organisation, for example, healthcare assistants had progressed to associate nurse practitioners and nurses had been supported to progress through completing advanced practitioner courses.

Job descriptions were in place for senior leaders. Training and development was provided as required within roles.

All staff we spoke to told us they were aware of the freedom to speak up guardians (FTSU) and they would know how to raise concerns through this formal route. We also heard there was access to speak up guardians at different locations should staff wish to speak up outside of the Leeds service.

We heard the Freedom to Speak up provision at Leeds had grown and developed since it started in 2021.

All staff we spoke to felt that they would be able to raise concerns either through the FTSU process or directly with managers and senior leaders. We heard examples of concerns raised and saw positive outcomes. We heard mixed views about whether staff always felt their voices had been fully heard. Some gave positive feedback whilst others expressed less confidence in knowing that action would be taken in a timely way. For example, concerns about safety within theatres due to repairs required to the environment.

We saw there was a clear process in place for receiving and reviewing concerns raised regarding the freedom to speak up route. There was a monthly call with the national FTSU lead and regional monthly meetings for review of themes and trends. The FTSU guardian at local level had designated time for the role. There was regular training provided for those carrying out FTSU roles.



We saw themes were anonymised and raised in meetings at all levels throughout the service allowing for transparency from board to ward. The FTSU team worked to engage with staff and offer support quickly. Any new FTSU concerns were anonymised and type of concern noted at each daily senior leadership oversight meeting. FTSU remained as a standing agenda item for all team meetings.



We saw openness and transparency in sharing themes with appropriate processes in place to ensure that sensitivity and confidentiality was maintained.

Most staff told us there was a positive culture of diversity, equality and inclusion within the workforce. Leaders told us they believed there was a positive culture of equality, diversity and inclusion across the workforce and that there was diversity across staff groups that matched the diversity of the patient group population.

Training was available for all staff in 'equity, diversity and inclusion' (EDI). This was a mandatory requirement. We saw the compliance rate for this was 98%.



There was a policy and standard operating process for equity, diversity and inclusion. This identified staff would be recruited from a diverse range of networks. This referred to a range of different job websites. However, we did not see evidence that leaders took active steps to ensure staff and leaders were representative of the population of people using the service.



Whilst we heard and saw that there was a diverse workforce with a positive sense of inclusion, staff were not aware of an EDI policy or any ongoing EDI work within the organisation. We heard that there had been an active EDI group that had become less active and lost focus over recent years. Leaders did not take action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion.



Whilst we heard about clearly defined freedom to speak up processes, we did not see evidence that leaders ensured there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff with protected equality characteristics or those who were excluded, marginalised or who may be least heard within the service.

Staff and leaders identified clear governance, management and accountability arrangements. A range of committees and operational meetings fed into the quality and safety quarterly meeting. This meeting shared information backwards and forwards to the quarterly Medical Advisory Committee (MAC) and the monthly Hospital Board meeting.

The agenda for the MAC was populated by the senior leadership team. We heard that this did not always assure the members of the committee that the most appropriate issues were being taken to that committee for discussion. There was a raising and responding to Doctor concerns policy in place, however, we heard there had been some medical issues dealt with by senior leaders without involving medical staff. We also reviewed complaints made regarding medical care and saw that some Doctors had responded to their own complaints.

Quarterly clinical governance meetings were in place. We reviewed minutes from the previous two and saw that relevant areas of concern were raised. However, we did not see clear systems for follow up actions from these meetings.

There was an information governance policy in place. Training was mandatory for all staff. During the inspection we saw there were a number of data errors reported. We were provided with evidence that demonstrated these errors had reduced in number from 2023 to 2024 and there was an information governance action plan. It was unclear how frequently this plan was reviewed. We saw the risk was recorded on the hospital risk register with a review date for the risk. The risk was recorded to have been identified in June 2018, however, was created In August 2023. The score was recorded as significant risk with no change to the score at the most recent review in September 2024. The risk register identified there were controls outstanding. There was nothing recorded against controls implemented. Therefore, it was not clear whether incidences had reduced by chance or because of actions put in place.

Safety alerts were received and reviewed to identify any necessary actions.

Risk registers were in place for each department. We reviewed departmental risk registers and saw that some risks were also recorded on the hospital wide risk register, for example fire warden training. The risk registers varied in format across departments. The ward risk register used a different format to the theatre risk register. There was no evidence of completion date for actions or review date noted on the theatre department risk register.

We did not gather feedback from people regarding partnerships and communities. However, we heard about opportunities available to people that were viewed by partners as positive experiences.

Leaders identified partners in care provision and told us about local links the Leeds Nuffield service as a whole had with the local community. We heard evidence of improved pathways to support demand in orthopaedics. Leaders told us they had received positive feedback regarding their work on supporting management of long waiting lists for elective surgery. We also heard about partnership working that supported fitness and wellbeing whilst patients waited for surgery within NHS services.

We received feedback from the local Critical Care Network and the Integrated Care Board (ICB). The service worked with local networks participating in peer reviews that supported service development in areas identified, for example through a critical care network peer review process. We reviewed details and actions identified from reviews. We also heard that there was active engagement in forums such as transfer forums that had led to improvement such as revision of guidelines.

We heard that the service was involved in a local Planned Care Delivery Board. This board was in place to support a local population health management approach across agencies and ensure access to planned care for all members of the local population.

We reviewed aspects of joined up working and shared care. We saw that there were effective processes in place for transfer of patients to other hospitals as needed. We also saw there was a tracker update system for partner organisations to track progress of patients on waiting lists.

Leaders told us that there were popular lunch and learn sessions provided for staff. Staff spoke positively about these sessions.

Staff and leaders told us there were opportunities for external learning and development. We saw a range of staff across grades, departments and professions were supported in completing training ranging from healthcare assistant apprenticeships to courses such as advanced clinical practice.

Physiotherapy staff told us about shared learning opportunities with other sites.

Processes were in place to identify learning opportunities, for example the senior leadership teams daily update meeting and the weekly safety meetings. We saw that all incidents from the previous week were taken to a weekly safety meeting.

We saw there was a hospital quality improvement plan that identified areas of improvement through review of guidelines, incidents and audits, review of regulatory compliance with areas of practice and external information received such as MHRA information.



Many of the quality improvements related to regular day to day practice such as ensuring documentation guidelines were followed and the booking process followed policy.

Staff and leaders were working towards achieving outcomes based on the improvement plan. Actions were identified for each issue identified, however there were no expected outcomes recorded. For example, one issue was identified as no established MDT for key areas. The action was to establish links with the local NHS trust. There was no expected outcome or rationale for benefit of this action and no detail regarding how this would be monitored and reviewed.