Nuffield Health York 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

Managers and relevant leads were clear about the hospital and service’s strategy and vision. Hospital leaders and staff at all levels were competent, skilled and trained for their roles and responsibilities. The service and staff were well-led by strong leaders who embodied the cultures and values of their workforce. Hospital leads promoted and encouraged a speak up and blame free culture indicative to learning where staff could raise concerns. Hospital leads and staff treated everyone fairly and equitably. The hospital had a robust and positive governance and risk management culture. Staff shared good practice and learning, and sought partnership working, collaboration and integration. Staff had good awareness of their environmental initiatives and impact.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and relevant leads were clear about the hospital and service’s strategy and vision. The registered manager told us they always started any presentation with the provider objectives and how they related to the hospital. This helped ensure consistency and staff understanding of their shared direction and purpose. The hospital’s mission statement was to provide an open transparent and first-class service. This meant every patient who left their hospital felt all their needs had been met. The statement had five main objectives to achieve this.

Hospital staff were nominated and awarded monthly for the provider’s we CARE values recognition scheme. We saw the latest awards displayed from March 2024.

Leaders and staff at all levels were competent, skilled and trained for their roles and responsibilities. Leaders were capable, accountable and safely recruited as per CQC’s fit and proper person’s requirement (FPPR). Recruitment processes were in accordance with Schedule 3 requirements of the Health and Social Care Act 2009 (Regulations) 2014. Leaders evidenced their compassion for staff support and development, as well as improving services for young people and their families. Staff told CQC the hospital had created a culture where teams could confidently approach their line manager, or other managers individually. All staff we asked said everyone was friendly and approachable, including management.

Staff files contained all appropriate documentation and background information. CQC requested and reviewed six sets of staff files across a mix of departments and seniorities. The files were comprehensive with individuals’ relevant experience to the job roles. They had evidence of robust sickness management and support for staff. Files included requests for flexible working which managers had reviewed and granted. All included current disclosure and barring service (DBS) checks appropriate to their role, professional registrations and references. This excluded one staff member who had completed work experience at the hospital. CQC reviewed the resident medical officer’s CV and found no gaps. The provider had appointed a national CYP lead shortly before CQC’s assessment. The hospital had also appointed a surgical safety champion in February 2024.

The hospital had a staff forum. Leads would consider a service specific CYP forum if they had enough demand. They also held heads of department meetings with no agenda. This meant staff could feedback any issues informally. Radiology had quarterly continuous personal development (CPD) meetings to improve team building and learning. Staff teams held social events which tried to involve everybody. The provider had an employee forum. Staff could apply to join, and be interviewed. They could then feedback from and into them as representatives, as well as to the executive team. The team fed into the hospital quality and improvement panel (QIP).

The hospital had appointed two FTSUGs. Both were managers in different departments in post since early 2024. The governance lead promoted them and encouraged staff to use them. FTSUGs also attended the staff induction meetings. Their photos were on staff and information noticeboards.

A hospital staff member sat on the provider’s equity forum. This included representatives from across the provider’s networks such as neuro-divergent, Muslim, Pride and social mobility. However, no CYP service-specific matters were discussed. The hospital’s wellbeing champions had recently set up a menopause support group. This facilitated open and inclusive discussions around the menopause and woman’s wider health. The group was well attended and appreciated by staff.

The hospital had a staff forum. Leads would consider a service specific CYP forum if they had enough demand. They also held heads of department meetings with no agenda. This meant staff could feedback any issues informally. Radiology had quarterly continuous personal development (CPD) meetings to improve team building and learning. Staff teams held social events which tried to involve everybody. The provider had an employee forum. Staff could apply to join, and be interviewed. They could then feedback from and into them as representatives, as well as to the executive team. The team fed into the hospital quality and improvement panel (QIP).

Directors described the hospital’s governance and quality structure. Above them was a regional quality network and then a national network to share learning. All heads of department had a network to share learning nationally, to close the loop. They disseminated learning to all department staff. Every head of department wrote a report, which they summarised in meetings. The minutes were embedded into department meeting agendas, so were easily accessible to all staff. The hospital’s governance lead was a fairly new post. This lead attended national governance and IPC forums. Hospital staff held monthly meetings open to all with representation from nearly all departments. Here staff shared good and best practice discussions, with guest speakers and incident learning which could include CYP.

The hospital had a very strong governance culture. Leads shared documentation with all staff in accessible formats. Staff had a voting button to confirm they had read all policies and updates. This helped ensure compliance and clarity with procedures. Meeting minutes evidenced open discussions where all staff could raise issues and challenges, with no hierarchy. Children and young people (CYP) was a set agenda item at all the hospital’s governance meetings. CQC reviewed meeting minutes which showed discussion of CYP services. For example, the quality and safety meeting minutes from 17 June 2024 detailed the discussion of safeguarding actions which flagged the “was not brought“ patient. The outpatients manager was commended on following up and completing this process. The clinical governance meeting minutes of 8 April 2024 noted paediatric patients were highlighted in the outpatient department. The resuscitation meeting minutes from 9 January 2024 mentioned staff’s need to discuss any 16 17-year-olds being admitted, and the gap analysis undertaken. The hospital held monthly governance meetings. The DCS reviewed and submitted updates to the provider’s regional quality director. They then discussed issues centrally, which were escalated to the quality board. The regional quality leads, chief nurse and medical director reviewed any issues, which informed any training required. The DCS felt this governance structure was safe and secure. The hospital had a children's and young person policy which outlined the management structure, accountabilities and responsibilities for individual roles. They also had a quality governance framework policy (GOV 04 v3.3) which clearly outlined the governance pathways. The provider had a children and young people's expert advisory group. They also had a designated nurse and subject matter expert with clinical governance responsibilities was identified for children and safeguarding.

The governance lead had done their own related research and created a resource file. This contained posters, charities information and QR codes around CYP mental health. The codes helped parents access when they should seek guidance, such as for potential bi-polar disorder or if recently bereaved. The lead planned to display these resources in the outpatients waiting area. Hospital staff were mindful their small children and young people’s (CYP) service needed to collaborate with other external organisations, stakeholders and partners. As a result, staff sought continuous learning and improvement from all available avenues, including their local integrated care board (ICB) and NHS hospital. For example, the governance lead had reached out to their ICB about CYP services and information sharing. This helped build relations for partner working opportunities. They also planned to contact their local GPs and authorities. The hospital’s senior leadership team attended meetings with this ICB at least yearly.

Leads were aware of the importance of mental health to children and young people (CYP). They had adapted the service accordingly. The provider website contained lots of mental health information and signposting for parents of CYP. Hospital staff also had a multi-agency referral form they could use if they were concerned about a young person’s mental health. The hospital undertook community projects. One example was the resuscitation lead delivering PBLS training for the public in underprivileged areas of the region

The hospital’s registered manager had held an informal CYP education session for staff. This entailed any subjects staff requested as refreshers or for group discussion.

The provider and hospital were very environmental conscious. Leads had various initiatives in place around sustainability, energy emissions, recycling, financial updates and survey feedback. CQC saw the hospital’s April 2024 (year to date) combined energy usage (CEU) and total carbon emissions displayed. This showed they had met their target reduction of 3% against the 2023 CEU figures. However, their electricity usage had risen by 46.48% over the same period. CQC also saw the hospital’s monthly recycling rates. As of May 2024 this met their 2024 target of under 35%.