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

There is an inclusive and positive culture of continuous learning and improvement. This is based on meeting the needs of people who use services and wider communities, and all leaders and staff share this. Leaders proactively support staff and collaborate with partners to deliver care that is safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good.

The service was previously in breach of the legal regulations relating to good governance. Improvements were found at this assessment and the service was no longer in breach of this regulation.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers collaborated with the local community to deliver the best possible care and were receptive to the latest ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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.

Leaders had a shared vision, strategy, and culture. This was based on transparency, equity and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patients and communities.

The trust had a vision and values and leaders described how this impacted the department. The trust values were – ‘We are kind, We are open and We pursue excellence’. An urgent and emergency care strategy was produced for ‘2024 -26 and beyond’. An unscheduled care improvement programme was at the heart of this. The focus at the time of assessment was to reconfigure the department so that patients received the right care in the right place at the right time.

Leaders were able to explain the improvement measures that had been undertaken and were able to describe their plans to improve capacity and flow issues within the department. However, not all staff described a positive culture of transparency and openness. Some staff reported that they felt unheard by leaders and that changes were thrust on them without consideration. Leaders acknowledged staff frustrations, challenges and issues. A project proposal to enhance teamwork, improve communication, reduce burnout, and ensure patient centred care was in the pipeline but had not been rolled out at the time of assessment.

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.

Nursing and medical staff across urgent and emergency services understood the key risks to the department. They were aware of the challenges faced by the emergency department and were able to explain the improvement actions being undertaken to improve capacity and patient flow in the department. Staff told us the departmental leads and senior managers were approachable, visible and provided them with good support. Staff understood the reporting structures and leaders understood their key roles and responsibilities.

Leaders fully understood the key risks and challenges faced by the department. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they interacted with external stakeholders, such as the local and regional commissioners, integrated care partnerships and local NHS ambulance and mental health trusts. Regular engagement to review performance and identify improvements to services occurred frequently.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. A leadership structure functioned at departmental and divisional level which represented medical, nursing, allied health care professional and operational leads. There were clear reporting structures and key roles were supported by deputies or associate roles to foster succession planning. Leaders held routine monthly governance meetings to discuss governance, risk and performance. Risk registers were reviewed during these meetings. The governance and reporting processes enabled leaders to understand the key risks and challenges to the service and to identify improvement actions to address key risks, such as capacity and flow issues.

Daily safety huddles and bed management meetings enabled sharing of information and escalation of patient risks and capacity and resource issues. Leaders understood the capacity constraints within the hospital but did not always have resources and space to manage the priorities and issues the service faced.

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

The Trust had a substantively employed Freedom to Speak Up (FTSU) Guardian covering all sites. There were also ‘fairness champions’ in the department. The FTSU Guardian reported directly to the trust chief executive at monthly meetings to escalate any themes or concerns.

Staff were aware of the Freedom to Speak Up policy and how to use it. A poster was on display in the staff room to alert staff of FTSU and how they could act on concerns. The contact details of the FTSU Guardian and the fairness champions were widely shared using postcards, business cards, screensavers and via trust communications.

Leaders were able to describe how staff reported concerns and how these were investigated then feedback given to staff via various forums. They described an open-door policy and had an eagerness to want to help and support staff.

Themes from feedback provided through the FTSU Guardian was provided through a report to the board of directors.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and processes were in place to ensure the service were inclusive and fair in the way it operated. The service promoted equality and diversity in daily work and provided opportunities for all staff to develop.

Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work. Leaders took action continually to review and improve the culture of the organisation in the context of equality, diversity and inclusion.

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

Staff had time and resources to undertake effective governance and manage risk. There was a full range of accurate and timely data and information available to understand performance and quality and improvements made when needed. Governance was used to learn, improve and innovate.

There were regular and effective meetings for safety, audit, quality and governance. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Good practice was recognised and celebrated. There was effective workforce planning including for managing major incidents or emergencies.

Monthly core meetings were chaired by a clinical governance lead. These meetings had a set agenda. There were 3 strands to governance at these meetings: patient safety, operational standards and education. The nursing team and medical staff attended meetings during protected time. These events were held offsite to allow focus and minimise disruption. Meetings usually hosted a guest speaker with topics based on emerging themes and trends. For example, presentations on forensics, urology, pharmacy had been given. A quality and safety report was produced from this meeting that fed into trust divisional meetings.

Information on governance was shared via a newsletter emailed to all staff and staff received feedback from incident reporting and risks were shared at the nursing huddle.

The ED dashboard had a tracker for overdue investigations and treatment plans. The tools used within the dashboard assisted in managing capacity and demand. Heat maps helped to plan and change staffing according to pressures highlighted by this system.

Following the previous CQC inspection, actions had been undertaken to improve compliance and to mitigate and manage risks to patients presenting at the emergency department with mental health needs. Leaders acknowledged, however, that this process needed embedding and staff required further training in the risk assessment and management of patients with mental health needs in the department.

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

Strategic partners commented on the trust’s improved collaboration, communication, and information sharing with system colleagues. Partners actively engaged in improvement initiatives with the Trust. Partners were aware of quality and safety metrics developed for the unscheduled care assurance group, which provided a clearer picture of the effectiveness of the work completed and ongoing. However, they suggested initiatives would benefit from further structure, governance and reporting arrangements linking both the trust and the wider system’s strategic aims.

The trust’s strategy aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population.

Patients’ views and experiences were gathered and acted on to shape and improve the services and culture. This included patients in a range of equality groups. Patients who used services, those close to them and their representatives actively engaged and involved in decision making to shape services and culture.

The leadership team understood how staff felt about delivering care that met both the physical and mental health needs of patients.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contribute to safe, effective practice and research.

A weekly update known as ‘Safety Brief’ was discussed at each shift change. Different topics were highlighted each week and then shared for all staff to review. The information was also emailed to all staff within the department.

The governance team, in conjunction with the senior team, co-ordinated learning to be shared to ensure that staff did not experience ‘information overload’. The focus was on cross-site learning, sharing education time and encouraging the teams to contribute to learning no matter what job role that they had within the department.

Leaders and staff participated in research projects and recognised accreditation schemes. There were standardised improvement tools and methods in use, and staff had the skills to use them.

Staff from the trust had visited other emergency departments to examine their access and flow models. They were keen to develop and improve by engaging with other emergency care specialists nationally.