Northwick Park 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

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. This means 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.

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.

The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion and engagement. However,not all staff were aware of the vision, and it was unclear if this had been developed in collaboration with staff.

The service had a vision and strategy that worked alongside the trust’s overall strategy, Our Way Forward (2023 – 2028). However, not all frontline staff in the service were aware of the strategy and it was unclear if they had been involved in discussions about the strategy for the service. Local leaders escalated issues that impacted on patient safety to the senior divisional leaders and action was taken to improve patient safety. However, the actions were not always monitored for effectiveness.

Staff knew and understood the trust’s values and how they were applied in the work of their team. Staff we spoke with were able to articulate the values and what this meant to them. They were able to give examples of the values in practice telling us how they supported their colleagues and the importance of raising concerns.

Leaders had a clear direction for the department. At the time of the inspection building work had commenced to redesign areas to improve the patient experience. The departments leaders were able to talk us through the plans, including how the changes would be reviewed and the work that would take place with staff to embed these changes. Staff told us they were excited by these changes as they hoped it would improve the patients’ experience and manage the patient flow better at the entrance to the service. However, this project had not been completed at the time of our visit therefore we could not evaluate its effectiveness.

Not all leaders at all levels understood the context in which they delivered care, treatment and support. Leaders at all levels mostly embodied the culture and values of their workforce and organisation.

Most leaders had the skills, knowledge and experience to lead and perform their roles. The senior divisional leadership team included a clinical lead, senior nurse and senior manager. They understood the pressures in the department and how this could impact on staff. However, some of the actions identified to address issues, were not always monitored for their effectiveness. Therefore, action may not be taken when actions implemented were not effective.

Local leaders had an understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. All staff we spoke with told us leaders were visible and approachable finding them supportive and encouraging, leading to a positive environment to work in. We heard about a number of initiatives staff had felt empowered to raise at team meetings or directly with managers and this made them feel like and important part of the team. For example, the mental health registered nurse had been supported to seek funding for activity boxes for patients to help manage long waits in the department.

Leadership development opportunities were available, including opportunities for staff to attend leadership training courses and develop their skills. Some members of staff we spoke with told us they had progressed their career and found working in the department had supported them to gain promotions.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust had a Freedom to Speak Up (FTSU) policy and FTSU guardian. The service had a department champion; however not all staff we spoke with knew who the department champion was. The FTSU service was advertised on the intranet and staff could speak with a champion or guardian to access support and advice to raise any concerns they may have.

Staff told us there was a positive culture in the department and were confident they could raise any concerns with their manager or other leaders, and they would be taken seriously. Leaders were approachable and there was an open-door policy. A junior clinical staff member told us this was the most supportive environment they had worked in.

People and carers had opportunities to provide feedback on the service in ways that reflected their individual needs, including through surveys such as national NHS Friends and Family test and the Care Quality Commission urgent and emergency care patient survey but response rates were below the national average. Managers and staff had access to this feedback and used it to make improvements, for example, the introduction of buzzers for patients waiting for blood tests to be taken. Patients were given a buzzer to hold which would vibrate when it was their turn to have their blood taken and meant patients were less likely to miss their turn.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear management structure for the Emergency and Ambulatory Care Division. The triumvirate team had oversight of all 3 locations providing emergency and urgent care services and reported to the board. Under the divisional team sat local leadership with oversight at a location level providing a clear reporting line for staff.

The division had a governance structure showing how local meetings fed into the divisional quality board which reported into the trust board standing committees. There was a clear structure for information to flow from ward to the trust executive team. The governance meetings had set agendas, and we saw evidence of risk, performance, audits, learning from incidents and complaints, training and safeguarding being discussed. The trust introduced formal reporting of the TES area as part of the Integrated Performance and Quality Report (IPQR) and data such as use of TES areas was collected so the department could audit changes and track progress.

The morbidity and mortality meetings were held monthly and the whole clinical team were invited to join the meeting. It was recorded for those who couldn’t attend. There was a standing agenda including a review of patient deaths, patients admitted to the intensive care unit and re-attending patients. Learning points were discussed, and the meeting was minuted.

The division held a monthly emergency planning meeting with the trust’s emergency preparedness, resilience and response (EPRR) lead to ensure the department was prepared to respond to a wide range of incidents that could affect patient care. A tabletop exercise was carried out 18 months ago to test the division’s preparedness. The EPRR lead was working with partners including the Hazardous Area Response Team, a division of the ambulance service to improve how the service responded in an emergency.

Leaders maintained the directorate risk register and knew and understood the risks to the department. The leadership team were able to discuss the top risk and what mitigation had been put in place to try and reduce the risk score. However, mitigating actions were not always evaluated to demonstrate their impact. The risk register was reviewed and updated regularly at the clinical governance meeting. The risks staff identified matched what was on the risk register, for example, staff were concerned by the temporary escalation areas and waiting times for patients. This meant the concerns staff had about the department were reflected on the division’s risk register.

The trust transitioned to the Patient Safety Incident Response Framework replacing the previous Serious Incident Framework for investigating incidents. The department conducted after action reviews and multidisciplinary team discussions to reflect and share learning. This was seen in the ‘Big 4’ which was sent to staff sharing learning and helping to embed change into practice.

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 was aware of the communities they served and were working with some patient groups to improve the service. For example, the sickle cell working group carried out a review of the department and had helped leaders to create and implement a sickle cell standard operating procedure.

The service worked in partnership with some external agencies, engaging with them to improve care for patients. For example, with a charity who worked closely with the paediatric ED and UTC department to support patients aged 12– 15 who were at risk or vulnerable. The trust had secured funding for a pilot project to have youth workers in the trust, who ED could access. As this pilot was ongoing its effectiveness had not yet been evaluated.

There were support teams within the department to help patients such as the homeless team and frailty team who worked with patients to assist them once they were discharged from the service. The department had worked in collaboration with a local charity to provide warm clothing for patients on discharge who were homeless or suffering financial hardship. This not only provided physical comfort but also restored the patient’s dignity.

The service had improved the working relationship with some local health partners, such as the local ambulance service. We were told the trust met every two weeks with the local ambulance service to discuss issues. We were not provided with any evidence of any changes that had been implemented as a result of these meetings. The only example of change being made was regarding returning trolleys to the ambulance service and not about improving flow.

The UTC worked with local GP services, if it was more appropriate for the patient attending the department to be seen by a GP. A working relationship had been established with a local primary care centre and UTC staff could help patients book appointments with a GP at the centre, support them to register with a GP if they did not have a GP, helping patients access the right care and improve waiting times in the department.

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 contributed to safe, effective practice and research.

Some staff told us they were given opportunities, time and support to develop projects for improvements and innovation. Staff told us they were encouraged to suggest new ideas and ways of working and to implement pilot studies to see if they could improve the service. We saw a new handover process being piloted where if a patient met a certain criteria, they were eligible for a telephone handover to the ward. This meant a staff member did not have to leave the department to handover to staff on the ward therefore increasing the time spent seeing patients in the emergency department. We saw other examples of innovative practice, such as the sepsis room, and staff were proud to show us and discuss improvements that they had been involved in.

The trust was participating in three national Royal College of Emergency Medicine Quality Improvement programmes for 2025: Time Critical Medications, Care of Older People, and Mental Health to help improve care for patients. We were not provided with evidence of the impact these improvement programmes have had.

The mental health nurse was a new role in the department, having started in early 2025. The RMN had been encouraged by senior leaders to assist the department in improving care for patients experiencing a mental health condition. They had recently developed a risk assessment for staff to use when escorting patients outside the department for fresh air and was involved in creating training for staff to develop their practical understanding of caring for mental health patients.

Leaders encouraged staff to share their appreciation of colleagues through an online platform where staff could leave messages such as highlighting good team working, helping build a positive culture.