Bradford Royal Infirmary

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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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centered care; supported learning and innovation; and promoted an open, fair culture.

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-centered 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-centered and sustainable, and to reduce inequalities.

There was a breach of good governance relating to the lack of quality assurance audits undertaken.

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.

We scored the service as 3. The evidence showed a good standard of a shared direction and culture within the department. 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.

Staff knew and understood the trust’s vision to be an outstanding provider of healthcare, research and education, and a great place to work. They were able to describe how this vision and the trust’s values – we care; we value people; we are one team – were reflected in the emergency department. Senior leaders were also able to explain how their roles aligned with the trust’s vision and values. However, the focus of senior leaders had been on meeting performance targets although they explained that this focus was changing to include improving patient experience and outcomes.

Leaders and managers in the department operated an ‘open‑door policy’, supported by their offices being located close to the staff room. Staff told us they felt listened to by department and clinical service unit managers and felt encouraged to communicate and give feedback. However, we received mixed feedback about feeling listened to by executive leaders and decisions made by the executive team about how the department was run. Staff told us they did not always understand why decisions were taken or have the opportunity to speak with trust leaders about them. One example related to requests for additional staffing resources, where staff in leadership roles did not understand how or why decisions to decline requests for additional staff had been made.

The trust had several strategies, including those for dementia, equality and diversity, food and drink, patient engagement and experience, and nursing and midwifery. Each strategy linked to the care and treatment delivered in the emergency department. The urgent and emergency care clinical services unit (CSU), which included the emergency department, had its own overarching vision and business‑level strategy for 2025/26. We reviewed this strategy. It aligned with the NHS Long Term Plan and included an assessment of the CSU’s current position, leadership arrangements, aims to improve patient safety and priorities to improve quality, efficiency and effectiveness. These priorities included reducing demand on the department, improving patient experience and improving staff experience.

The paediatric emergency department was part of the Children’s and Neonatal CSU, which had a separate strategy refreshed in September 2025. Although there was no specific reference to the paediatric emergency department in the strategy, it outlined how the CSU aimed to promote wellbeing for staff and children who used the service. Staff in the children’s department described a positive culture. One staff member described the atmosphere as “happy and kind”, and said the hierarchy was “flat”, with support readily available.

We scored the service as 3. The evidence showed a good standard. The department had mostly inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders in the department had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty however, this did not always follow through to the executive team.

Nursing and medical staff across the emergency department understood the key risks to patients. Staff told us emergency department leads were approachable, visible and communicated well.

Staff understood the reporting structures, and leaders understood their roles and responsibilities. Department leaders also had a clear understanding of the key risks and challenges facing the department. Multiple daily safety huddles and bed management meetings supported the sharing of information and escalation of patient risks, capacity issues and resource concerns. Risks were discussed at safety huddles, board rounds and bed management meetings, and leaders were proactive in managing and escalating concerns.

Department leaders demonstrated how they worked as part of a multidisciplinary team within the service and how they collaborated with partners, including the local NHS ambulance trust. They told us they worked well together and met regularly to review performance and identify opportunities for improvement.

Leaders in the department had the skills, knowledge and experience needed for their roles. They were visible and approachable for staff and patients. They had a good understanding of the department and were able to explain clearly how teams worked to provide high‑quality care. A triumvirate leadership structure was in place at departmental and divisional level, with medical, nursing and operational leads.

Leadership development opportunities were available for staff. Staff told us local leaders were supportive. Resident doctors said they felt well supported in their training and development. Emergency department consultants said they had regular meetings with senior leaders and described positive communication and engagement. Nursing staff also told us they were supported in their professional development, with opportunities available to develop their skills.

However, leaders within the department told us they had repeatedly raised concerns about staffing levels not meeting departmental requirements but didn’t feel listened to. They told us this had finally been escalated to executive leaders, and action was being considered at the time of our assessment.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had access to Freedom to Speak Up (FTSU) champions in the department. The trust’s FTSU policy set out the process for raising concerns and how staff could contact the champions. Between September 2024 and September 2025, staff made 9 FTSU reports, which related to staff attitudes within the emergency department. Most staff told us they would use the FTSU route only if they felt they would not be listened to through usual channels or if senior staff were involved. Senior leaders took action in response to these concerns, held discussions with staff and provided additional training and support where needed. The FTSU team also held listening events in the department.

Staff told us the FTSU process was promoted within the department, and they knew how to raise concerns using this route. None of the staff we spoke with had personally used the FTSU process. Staff also told us they did not always feel their voices were heard about issues affecting the running of the department outside the clinical service unit.

In the 2024 NHS staff survey, the unplanned services unit scored similarly to other trusts, which indicated that staff generally felt safe to raise concerns.

The trust’s Freedom to Speak Up policy and whistle blowing policy were combined into a single document. We reviewed the policy and found it to be comprehensive, with clear information about roles, responsibilities and how concerns should be raised and managed.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service promoted equality, diversity and inclusion in daily work and provided opportunities for all staff to develop. The trust had introduced a leadership development programme and encouraged staff from ethnic minority groups—referred to by the trust as the global majority—to apply. The programme had been designed to develop leadership confidence and capability.

The trust had a range of policies relating to equality and diversity, to support workers with protected characteristics, including disability and transgender identity. There was also an active staff network with groups available for all staff to access depending upon their specific requirements.

Most staff told us they felt everyone was treated as an individual and with respect. However, one person told us they felt treated differently by some medical staff because they were a woman. We raised this with the clinical lead, who told us they were not aware of any previous concerns. They said they would follow this up with the staff member and offer support.

We scored the service as 2. The evidence showed shortfalls in the governance processes in the department. The service did not have clear responsibilities, roles, systems of accountability or good governance. Information was not gathered to manage and deliver good quality, sustainable care, treatment and support. However, leaders acted on information about risks and share this securely with others when appropriate.

We reviewed how the department monitored patient experience and measured compliance with clinical standards, including through clinical audit. Although some clinical audits had been completed, activity was limited. There was no medical lead for clinical audit, and the department had not taken part in mandatory national audits required by the Royal College of Emergency Medicine. For audits that had been completed, the information shared with us did not provide robust evidence of changes or impact. The trust could not demonstrate a strong emphasis on clinical audit to inform the quality of care delivered against clinical standards. This was a breach of good governance.

Managers acknowledged that historically greater emphasis had been placed on meeting national performance targets, but reported a shift towards balancing operational performance with patient experience, safety and quality of care. This was reflected in the service’s strategic focus on improving outcomes through enhanced patient and staff experience, learning, risk management and a supportive working environment.

Clinical leaders recognised the risks in the department and had documented strategies and plans to address them. Risks were recorded on both local and trust‑level risk registers and were rated according to likelihood and consequence. Staff and leaders at all levels demonstrated an understanding of the key risks in the emergency department. We discussed the highest risks with the leadership team and saw there were six risks rated as extreme. These related to weekend medical staff cover, surges in the paediatric emergency department, general overcrowding, consultant review of test results, patient and visitor violence and aggression, and long waits in the department. The risk register also described actions underway to mitigate or reduce these risks. Staff had opportunities to raise concerns about risks they identified within the department, and there was a process to ensure these concerns were reviewed and added to the departmental risk register when appropriate. Risks were discussed across management levels, and staff knew who was responsible and accountable for specific risks.

There was a system to escalate operational concerns and challenges to the unplanned care clinical service unit (CSU), which included the emergency department. Leaders escalated challenges affecting the department and thought the board had some awareness of the pressures the service faced however expressed concerns that the executive team did not always understand the seriousness of challenges or their impact.

The department used several methods to communicate information to staff, such as quality assurance huddles, departmental meetings, posters, newsletters and email updates. Meetings such as the Quality and Safety Committee were attended by managers from the department, the CSU and the trust, up to executive‑level representation. The department also discussed safety concerns, serious incidents and patient deaths. Leaders told us the involvement of the Medical Examiner—a senior independent doctor who scrutinises non‑coronial deaths—was valuable in identifying deaths that required further investigation or where learning was needed.

The department had business continuity plans for events outside its control, such as severe weather, infectious disease outbreaks and information technology failures. There was also equipment in place to respond to major incidents such as chemical spills.

The emergency department was part of the unplanned care CSU. Morbidity and Mortality (M&M) meetings were held at CSU level. These meetings provided a safe and non‑punitive environment for clinicians to review adverse outcomes, medical errors and patient deaths, with the aim of improving standards of care and preventing future issues.

We scored the service as 3. The evidence showed a good standard or partnership working. 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.

Leaders understood their responsibility to collaborate and work in partnership so that services operated in people’s best interests. They shared information and learning with partners and worked with them to improve the safety and quality of care. The department collaborated with a range of stakeholders to support joined‑up care.

Staff told us they liaised frequently with ambulance staff to review issues, concerns and opportunities for improvement between services. For people experiencing a mental health crisis, the department worked closely with the local mental health trust to support a joint approach to assessment and care. The department also worked with the local police and local safeguarding hubs. Staff shared information appropriately to support safeguarding, promote consistency of care and ensure concerns were identified and acted on.

People’s views and experiences were gathered and used to shape and improve the service and its culture. This included feedback from people across different equality groups, people using the service, and those close to them. The trust provided examples of how feedback had informed improvements in the department. Direct patient quotes were sometimes used to help staff understand the impact of people’s experiences.

We saw evidence of initiatives developed with other agencies, including organisations from the voluntary and community sector. These demonstrated effective multi‑agency collaboration. Initiatives included joint work with housing services, mental health teams, addiction services and local authorities to support vulnerable people, families and young people.

We scored the service as 3. The evidence showed a good standard of innovation, learning and improvement. 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 contribute to practice and research.

Staff described quality improvement projects and clinical audits that had taken place in the department over the previous three years. Outcomes and learning from these projects were discussed and used to make improvements. Projects were evaluated using the PDSA (Plan, Do, Study, Act) methodology. Resident doctors and advanced clinical practitioners completed quality improvement projects as part of their roles.

There was evidence of innovation in the department and a clear willingness from staff and leaders to improve. Much of this improvement work was prompted by the significant challenges the department faced, including high demand, patient acuity, staffing levels, limited space and delays in transferring patients out of the department. Innovation was often driven by these pressures and developed within the constraints of the estate and available staffing. For example, the department trialed a Same Day Emergency Care (SDEC) area and fit‑to‑sit spaces to move patients through the department more efficiently. These initiatives enabled some people to receive same‑day care in a monitored seating area rather than in cubicles, which helped increase capacity and supported patient flow. This meant some patients were treated and discharged more quickly, improving their experience.

Staff were encouraged to take part in new initiatives and told us leaders welcomed their ideas for improving the department. Most staff were aware of ongoing quality improvement work, including the EXCEL initiative. However, some staff said it was difficult to take part or lead on new initiatives because of workload pressures in the department.

The department had launched two significant initiatives for future improvement: Moving to Outstanding and EXCEL, which began in July 2025 shortly before our inspection. We discussed the EXCEL project with the project leads. The service had a clear vision for what it wanted to achieve and a strategy to turn this into action, developed with input from relevant partners. The strategy focused on sustainability and aligned with local health and care plans. Leaders described ambitions to involve the wider health and social care system, including community leaders and housing providers, to improve connections between services and deliver more coordinated support based on people’s overall needs.

Most staff we spoke with were aware of the EXCEL project, understood its aims and felt positive about the direction of the work. They were optimistic that, if delivered successfully, the project would improve both staff and patient experience. A small number of staff were unaware of the project, and others were unsure whether such large‑scale changes could be achieved. Some staff told us the scale of the ambition made them uncertain about how much impact the project would have.

Leaders described EXCEL as an innovative, overarching quality improvement programme designed to improve care, treatment and health outcomes for the population of Bradford. They told us the project aimed to take a holistic approach by involving health, housing, social care and community services, and by engaging community leaders and local businesses. Leaders believed that if successful, the programme would reduce pressure on the emergency department, improve wider hospital flow and have long‑term benefits for the Bradford community.