Newham University 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. The service worked with stakeholders and partners to drive improvements to care pathways. Leaders also supported innovation both internally and with system partners. However, timely action was not always taken to address performance and audit issues.

At our last assessment we rated this key question good. At this assessment, the rating has remained good. This meant the service was well managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 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.

There was a vision and strategy that focused on meeting the needs of a diverse and growing local population, while supporting staff to deliver urgent and emergency care in a challenging environment. Leaders across urgent and emergency care were aligned around clear priorities and worked together to improve patient flow, safety and experience.

Leaders described a clear and consistent strategic direction for urgent and emergency care. This strategy focused on delivering outstanding emergency and acute care, dissolving traditional boundaries between hospital, community and primary care services, and developing neighbourhood models of care to respond to population growth and health inequalities in Newham. Their plans also demonstrated a commitment to partnership working as part of its shared direction, reflecting a whole-system approach and an ambition to improve care beyond the emergency department itself.

Many staff described positive teamwork within their immediate teams, with several reporting that colleagues worked well together and supported one another during periods of high pressure. Staff perspectives on the department’s culture were varied. While many felt that improvements had been made, some employees acknowledged that continued efforts were needed to foster further positive change. This was reflected in the NHS Staff Survey results where a lower proportion of emergency department staff (53.9%) said colleagues were polite and treat each other with respect, compared with the hospital average of 62.3%.

Staff across the department reported an increase in incidents involving violence and aggression, contributed to heightened workload pressures. Security personnel were available around the clock to provide support and intervention as needed. Staff had access to psychology support through monthly sessions as part of resident doctor teaching programmes and sessions held with nurses during development days. Nevertheless, managing aggressive behaviour remained a significant concern for the team.

Leaders demonstrated a strong understanding of current pressures including staff culture and wellbeing and had developed plans to address these through both immediate operational changes and longer-term system transformation.

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.

Leaders were knowledgeable about the service, its risks and priorities, and were actively involved in managing the complex urgent and emergency care pathway. Senior clinical and operational leaders described a shared leadership model across the division, with clear portfolios and regular meetings to address risks such as crowding, mental health demand, and patient flow. Leaders demonstrated strong understanding of the impact of overcrowding on patient experience and staff wellbeing.

There was a clear management structure with defined lines of responsibility and accountability. Local leadership and management were overseen by ED matrons, a general manager, and consultant clinical leads for the adult, paediatric, and Urgent Treatment Centre (UTC) pathways. Most staff described them, as visible and supportive, particularly during periods of escalation. Staff reported being able to escalate concerns to the nurse in charge or matron when required. Our observations confirmed that matrons and senior nurses conducted regular safety walk‑arounds, attended safety huddles and reviewed staffing, equipment and environmental risks across the department. Senior leadership was made up of 2 divisional directors, an associate director of nursing, and a deputy director of operations.

Leaders demonstrated good oversight of governance and operational performance, and staff told us they were confident that leaders provided clear direction and were actively engaged in monitoring standards. There was a developing and pragmatic approach to succession planning which had a focus on growing and retaining staff to create a sustainable workforce. This included enhancing education and professional development by expanding professional development nurses to support newly qualified and internationally recruited nurses and recruitment of a consultant nurse to strengthen advanced practice roles. There were also plans to develop trainee advanced clinical practitioner posts to strengthen workforce sustainability and reduce reliance on temporary staffing.

Leaders were responsive to risks within the service. For example, they worked collaboratively with specialty teams to implement targeted pathway improvements in response to identified delays. They had strengthened the nursing leadership by creating 3 matron roles and recruiting a consultant nurse to improve oversight across urgent and emergency care. In addition, following our inspection feedback, leaders told us they would review compliance with documentation standards weekly and discuss themes from audit activity at urgent and emergency care governance meetings.

Leaders were visible and approachable, regularly engaging with staff in the department, attending team huddles, and supporting problem-solving in real time.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. However, this was not consistent across the department, with gaps in awareness of formal speaking arrangements and some staff expressing reluctance to raise concerns.

The trust had a freedom to speak up policy which highlighted internal and external options available to staff. The provider had arrangements in place to support staff to raise concerns, and many staff reported feeling able to speak up about immediate safety issues within their teams. Staff described using established escalation routes such as the nurse in charge, matrons and Datix reporting. Examples were shared where risks related to staffing, violence or patient safety were discussed in safety huddles and governance meetings.

However, awareness of formal freedom to speak up arrangements was limited. Most staff were not aware of freedom to speak up champions or guardians, nor were they consistently able to describe how to access this support outside of line management structures. While some staff recalled discussions about speaking up during training or induction, this knowledge was not reinforced consistently across the department.

Some staff told us of positive experiences and action taken in response to feedback raised. Other staff expressed reluctance to provide feedback and to use tools such as body‑worn cameras due to concerns about being monitored, which indicated gaps in psychological safety.

Patients and carers were given opportunities to provide feedback on the service, with signage featuring QR codes displayed throughout the premises for this purpose. Both managers and staff had access to this feedback and used it to implement improvements.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had governance systems and processes in place, but these were not always effective in supporting consistent oversight, managing risk or demonstrating sustained improvement.

Leaders used performance measures and governance dashboards to monitor activity and identify issues. However, ongoing concerns regarding poor documentation and deterioration in patient flow metrics indicated that action was not always timely or sufficiently effective. As a result, we were not assured that governance arrangements consistently addressed performance or audit findings.

There were systems to support the availability and confidentiality of data, and staff were able to access information relating to patients’ care and treatment. However, information governance practices were not consistently followed, as computers were frequently left unattended with records open. In addition, leaders did not have reliable oversight of mandatory training compliance in Immediate Life Support (ILS) and Advanced Life Support (ALS). This meant they could not be assured that sufficient numbers of appropriately trained staff were always available to respond to medical emergencies.

Staff and leaders demonstrated awareness of key risks, including crowding, corridor care, rising mental health demand and workforce pressures. A risk register was in place, with risks clearly described, scored and assigned to leads, and subject to regular review. At the time of inspection, there were 16 risks recorded for the emergency department, including 6 high and 9 medium risks. While mitigating actions were identified and monitored, these had not consistently reduced risk or led to demonstrable, sustained improvement.

Risks identified during the inspection, including long waiting times linked to bed pressures and limited paediatric consultant cover, were reflected on the risk register. However, mitigation was not always sufficient to ensure safe and effective oversight. For example, gaps in paediatric consultant provision were mitigated through advanced clinical practitioners completing a secondment through the Paediatric ED to increase their knowledge and skills in paediatrics. Where ED consultant staffing allowed, the service also sought to provide consultant cover for the paediatric ED, although this was not always provided by a consultant with paediatric emergency medicine training. In practice, competing pressures in the adult emergency department meant that consultant cover for paediatrics was not always immediately available. This contributed to a previous incident in which a junior member of staff administered intramuscular rapid tranquilisation to a child without appropriate competence or senior support. This demonstrated that governance systems had not ensured consistent access to appropriately skilled senior decision-makers, or effective mitigation of known risks.

There was a structured governance framework, supported by routine meetings at departmental and divisional level, which provided oversight of safety, quality and performance. These included safety huddles, incident reporting processes, morbidity and mortality reviews, and multidisciplinary governance meetings. Division leaders sat on the hospital quality and safety committee, providing a direct line of assurance to the executive team and board.

The service had a quality improvement programme underway to address identified risks and drive improvement. The service was also developing a more mature quality management system, to better identify early warning signals and track trends over time. However, these were still developing and had not yet demonstrated sustained impact on performance or patient outcomes. Divisional and executive channels provided oversight of both the quality improvement programme and the quality management system

The hospital had a business continuity plan which included a business impact analysis for the emergency department. In addition, there were incident response plans including an emergency preparedness, resilience and response policy.

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 provider worked effectively with a range of partners and community organisations across the health and care system to support improvements in patient flow and access and to meet the needs of the local community. Strong collaboration was evident with mental health providers, primary care services, and specialty teams.

Partnership working was particularly strong in relation to mental health. The service worked closely with community mental health teams, child and adolescent mental health services, and the Newham Centre for Mental Health to support patients experiencing crisis. Staff described good communication and support when transferring or managing complex patients. Collaboration with the local mental health trust led to the development of an innovative model of care for patients requiring mental health support within the emergency department. The enhanced care model provided dedicated staff who were specially trained in mental health to deliver enhanced observations and support for these patients. Staff gave positive feedback on this arrangement.

The provider demonstrated effective collaboration with primary care services through GP redirect pathways. These arrangements supported patients to access the most appropriate care outside of the ED. There was engagement with staff and stakeholders to improve care and develop pathways such as the urgent treatment service. This included participation in the Newham Urgent Care Working Group, collaborating with the local authority, the integrated care board (ICB), and other community trusts.

We saw some evidence of patient engagement to improve patient experience and support the development of the service. Quality improvement projects in the ED focused on enhancing patient and family experience, with some incorporating patient input. In the last year the hospital had also worked with a deaf community outreach worker to improve services for deaf people. However, leaders recognised that patient engagement and involvement in service design needed to be strengthened.

The service referred people to a broad range of voluntary and community sector organisations to support people with complex social, emotional and psychological needs. The service showed awareness of local population needs, including deprivation and health inequalities, and leaders articulated a clear commitment to addressing these through pathway design and partnership working. The trust had an established directory to signpost people to focused services to address their specific needs.

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 ED used quality improvement projects (QIP) to identify areas of improvement and implement change, these quality improvement projects met the needs of the service.

Most staff we spoke with told us there were good learning opportunities. They described regular teaching sessions, including weekly training sessions for medical staff mid-week. With training programmes and placements for doctors to develop broader clinical knowledge and bring learning back to the department.

There was a clear strategy to drive continuous improvement across the service with defined quality improvement work already taking place. The service demonstrated a commitment to innovation through digital developments, including e‑prescribing, ambient clinical documentation and an internal digital webpage to share guidance and learning. Staff described a culture of innovation within the service, although some commented that they felt things changed too quickly and would appreciate if changes were trialled first. In addition, the emergency department actively supported research and improvement beyond the organisation, contributing to multiple national clinical trials and using research activity to inform safer and more effective care.

Feedback from people was encouraged and the service acted on concerns, fostering an environment of openness and improvement.