The 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

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement.

The service remained in breach of legal regulations in relation to good governance as systems and processes to monitor and improve services were not always effective.

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. We assessed six quality statements.

Staff were supported to raise concerns, however some staff felt that some senior leaders were not always visible. The senior leadership team acknowledged that further staff engagement and visibility was needed. Some staff did not always feel involved in decision or changes. Senior managers were aware and were aiming to work with teams to develop a clinical strategy and processes as well as opportunities for staff to be involved in quality improvement processes. However, some of these initiatives were not fully in place at the time of the assessment for us to assess their effectiveness.

Where new processes had been put in place there were not effective mechanisms to monitor the effectiveness of them. In addition, the service was not always meeting the fundamental standards of care.

The trust had a set of values which staff were aware of. Staff spoke highly of their managers and told us they received good support and we observed good working relationships. There were new management structures in place and the senior leadership team were aware of the challenges and risks for the service.

There were clear governance and risk management strategies and leaders and staff strived for continuous learning including participating in research projects.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst there was a planned vision and strategy for the service, staff did not always feel positive or actively engaged by leaders so that their views were reflected in the planning and delivery of services and in shaping the culture.

The trust had a set of values which were for all hospitals, services and staff. These were, we are kind, we are open and we pursue excellence. Staff were aware of these values.

Staff from an area within the service told us about suggestions they had made to senior leaders that would improve the timeliness of patient treatment and increase capacity. They considered this would improve flow and capacity but said that senior leaders had not engaged in discussions about these ideas.

Other staff told us they were worried about the escalation of concerns in the service. They told us they felt desperate to make their concerns heard, but did not feel listened to. Staff said they felt that management made decisions without consultation or input from those it would affect, and the team were not visible nor accountable for the decisions they made.

Senior leaders told us they were aware that collaboration with the workforce could be improved and that staff have not always felt involved in decisions or changes. As a result of this they were working with teams opening opportunities to be involved in quality improvement initiatives as well as ensuring all staff had access to the leadership team and executive team. They were open about how staff were feeling and staff now had access to operational managers and clinical manager forums which had an open agenda. Whilst it is acknowledged that actions were being identified and plans to put them in place, at the time of the assessment staff did not always feel actively engaged by leaders so that their views were being reflected in the planning and delivery of services and helping to shape the culture of the service.

The executive team visited ward areas on Friday to speak to senior nurses and patients. Ward managers and matrons had opportunities to put forward ideas on how to improve services, but we were told changes could not always be made immediately and it might appear as though they were not being listened to, but the executive team stated that all ideas were heard.

The medicine care group leadership team has been subject to several staff changes over the past 12 months and recent appointments were just being finalised at the time of the assessment. Improving communication with staff in medical care services was one of the services’ key priorities. Staff told us they were well supported by the executive team.

There were also staff networks in place to support staff, for example, Race Equality Network, Women’s Network and LGBTQ+ Network.

Staff bulletins were circulated to all staff which included updates to policies, trust news, and how to access the executive team blog where executives shared their views and offered personal reflections.

We were told that as part of the trust’s cultural change journey, Our Voice Our Future was launched to discover what it was like to work in the organisation and for improvements to be made based on the feedback from staff. The aim was to make the organisation a place where people want to come to work. We saw the chief executive had sent out an email to all staff, including those in medical care services, to be a change maker to support this work.

The trust provided a workforce and organisational development strategy with aims and objectives. However, this was from 2019 to 2024. At the time of the assessment, the trust had not provided a more up to date strategy.

Staff shared their excitement about the opportunities presented by having a joint safeguarding and complex needs team. They told us that they were codesigning objectives for the team for the coming year and were looking at how they could align team objectives to the regional and national agenda, as well as the trust's objectives. They felt that this had been made possible, in part, due to having key people in key posts that they had not had before. The team expressed passion, motivation and high aspirations for providing the highest quality service to its patients and their families and carers.

The medicine care group senior leadership team included a senior leader of allied health professionals. We were told this has given allied health professionals visibility at executive level. Leaders felt accountability and the collective experience within the service was strong. We observed that they were open and honest and understood the challenges and risks within the service and were working to mitigate risks and put in place actions going forward.

We saw that the new team was supported by the executive team and they were aware and open about the risk and challenges the team faced. They were ensuring support was in place to lead effectively and take forward the new initiatives and plans being put in place. For example, they knew there was a gap between the executive team and staff on the wards and were working at all levels with the new team to ensure improvements would be made. They recognised that this would take time, but we observed there was a commitment to implement change going forward.

Some staff told us that despite working hard they felt unable to give patients the best care they could, due to a pressurised working environment and lack of support from senior leaders, although they did feel supported by their immediate line manager and they were visible.

As the medical care leadership team were new we were unable to fully assess their effectiveness and a lot of the plans were not at the implementation stage at the time of the assessment.

Senior nursing and allied healthcare professional staff spent a morning each week on the wards in what was called "back to the floor". These were aimed to be educational visits that provided support and assurance. However, a number of staff told us that they felt that senior leaders were not visible and the senior leadership team acknowledged that further staff engagement and visibility was needed.

All nursing staff spoke highly of the ward managers as leaders and told us they received good support. We observed good working relationships within all teams.

Leaders felt they had strong relationships, team working and communication with the executive team.

There were processes and systems in place so that staff were supported to raise concerns.

There was a freedom to speak up policy which was in date and due for review in November 2027. It included links to resources and contact details should staff wish to raise a concern should there be a need including guidance on how to raise a concern.

There was an identified senior lead and non-executive director responsible for freedom to speak up. There were regular meetings between the freedom to speak up guardian and the identified senior lead.

When a staff member had concerns, they were encouraged to speak in the first instance to their line manager. Staff could raise concerns verbally, by letter, email or by completing an incident form. They could also contact the freedom to speak up guardian in confidence via email. Information was available on the trust intranet.

Staff we spoke with were aware of the freedom to speak up processes and had been supported by their line manager, but some staff told us that they did not always feel their voice was heard by more senior leaders.

Whilst there were clear responsibilities, and systems of accountability and good governance the service did not always effectively act on information about risk, performance and outcomes.

There was a clear governance structure in place within medical care services. It was managed by senior leaders which included a care group director, associate chief nurse, associate lead allied health professions and an associate chief operating officer. There was further support available from clinical leads, Human Resources and finance. The care group board meet monthly as well as for informal weekly meetings. The board received reports from other groups, for example the care group patient experience group and the care group IPC group, both of which had clear terms of reference.

There were also risk management structures and escalation processes in line with the trust risk management policy. The risk register highlighted risks across medical services and actions were to address concerns for example staffing, and length of stay. This risk register was reviewed regularly and highlighted controls and mitigations in place together with a review of the risk score.

There was a performance reporting structure in medical services and the main performance meeting was held monthly which the service feeds into. During the meeting a review of risks, incidents, infections, audits, and complaints were undertaken.

However, where new processes had been put in place, clear audit processes had not been fully identified to ensure these were being implemented in line with policies and procedures. Also, areas of non-compliance with regulations were still occurring despite actions being put in place. Actions following audits had not always been fully effective as improvements in scores had not been achieved. For example, infection control and prevention standards.

The service collected information on demand and unmet demand daily. It moved some resource to try to balance service provision and meet demand equitably across their two sites.

The trust had in place an emergency preparedness, resilience and response policy and associated procedures and processes which gave a framework to follow in responding and managing a wide range of incidents and emergencies that could affect health and care. This applied to all areas of patient care and other departments within the trust. There were clear roles and responsibilities. We also observed a business continuity pack on one of the wards we visited.

We were shown dashboards that had been developed to allow a comprehensive view of complaints and patient safety incidents. The dashboards were used to provide oversight of themes and numbers of incidents and work with matrons and managers to progress completing the processes.

Health and safety updates and performance reports were given monthly to the trust health and safety committee, patient safety and clinical effectiveness committee, and in medical care service reports to performance review and improvement meetings.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. The service shared information and learning with partners and collaborated for improvement.

Staff told us they had been working closely with the previous Integrated care board (ICB) programme lead for urgent and emergency care, but the post holder had recently changed and engagement had stopped. As a team they were replicating the ICB same day emergency care (SDEC) model so they were standardised across the region. They were also working closely with the director of adult social services and had received positive feedback about the relationship and partnership working.

As part of the unscheduled care improvement programme (UCIP) the trust was reviewing and improving processes relating to and/or contributing to effective discharges. This group met regularly to discuss discharge processes together with update on the improvement programme and identify any further actions. We reviewed the minutes of these meetings and whilst we found they contained a comprehensive summary and actions; the actions did not have a timeframe. Some of the initiatives included simple board round posters for wards, criteria lead discharge stickers and discharge to assess pathways.

The service held workshops with community partners to progress the discharge to assess model of care. Hospital discharge is the final stage in a patient’s journey through hospital following the completion of their acute medical care and move to an environment best suited to meeting any ongoing health and social care needs.

Year of Quality had been launched by the chief nurse; topics had been co-designed with the nursing and allied health professional teams to promote the delivery of evidence-based practice. The patient quality standards group had recently been introduced to reinforce professional standards across nursing, midwifery and allied health professionals.

An aligned policies and clinical guidelines working group had been set up to align policies around palliative and end of life care with a neighbouring trust. The working group was also reviewing the quality management approach within the trust.

Leaders and staff strived for continuous learning which included participating in appropriate research projects. For example, developing a palliative care outcomes registry, bladder tumours in kidney transplant patients, PhD offered by the local university and Masters by Research in Biomedical Sciences. Staff from medical care services attended the annual research event which facilitated staff to showcase their work and encourage others to get involved.

The trust had a pressure ulcer improvement group and an associated improvement plan including actions relating to improving documentation, review of available pressure–relieving equipment, and supporting best practice. This included the tissue viability team delivering training.

A review of pressure damage had recently been conducted by the lead tissue viability nurse. This identified an emerging theme in relation to skin checks, a need to improve awareness of skin changes and requirements towards a patient’s end of life, also inadequate skin checks on patients who appeared to be independently mobile. These findings had recently been added as a focus for improvement on the trust-wide improvement plan.

There was a process for mortality and morbidity reviews which included structured judgement reviews. We saw evidence of these being completed together with identified areas of good practice and where care could have been better. Actions and recommendations were made following these reviews and discussed through the service clinical governance meetings. We also saw evidence of the outcome being shared with family members where appropriate.

Patients and those close to them knew how to raise concerns or make a complaint. There was a system to review themes and highlight any areas to escalate to the trust board. We reviewed several complaints and saw that learning had taken place and actions had been put in place.

The trust had a discharge improvement group, which had oversight of actions taken to improve processes around discharge. Trust staff also contributed to a group chaired by the deputy place nurse director North Yorkshire, within the integrated care board footprint. The purpose of which was to improve quality standards in relation to discharge and the trust was planning to meet with a neighbouring trust to collaborate and learn with a view to improvements in the timely discharge of patients.