Royal United Hospital Bath

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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-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation 17 for good governance.

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.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Quality Statement Score: 3

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

Within the emergency department (ED), a strong culture of teamwork was evident; staff described a supportive environment and a clear, shared vision of the high-quality care they wanted to deliver. However, maintaining a focus on service improvement during periods of extreme pressure was challenging. Extreme operational and financial pressures hindered the service’s ability to evolve. Staff within the ED described a state of constant “firefighting” that left no room for meaningful development. These intense conditions led many employees reporting that clinical progress felt like an “impossible goal.” Furthermore, senior leaders told us they lacked direct control over their own budgets due to a ‘triple lock’ framework, which restricted spending during the ongoing financial crisis. A triple lock in this context is a strict financial recovery process. It means external services have taken over the management of budgets in order to meet targets.

Despite these struggles, leaders fostered a collaborative culture by involving staff and patients in the trust’s long-term planning. The trust implemented improvement huddles and performance review meetings to help ensure the lived experience of frontline workers directly shaped executive priorities. Leaders also invited patient representatives to board meetings and utilised Friends and Family Test feedback to keep the trust’s direction grounded in real-world patient needs. By integrating these diverse perspectives, the service aimed to ensure its strategic goals remained relevant and inclusive.

The trust further strengthened its direction by aligning with external partners to manage regional patient surges. Leaders held joint improvement meetings with the local ambulance service to review data and streamline handover processes. These collaborative efforts successfully reduced friction between the different services and created shared goals for the entire region. Consequently, the trust improved its ability to move patients from ambulances into the hospital more efficiently, protecting both patient safety and system capacity.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. Although leaders understood the context in which the service delivered care, treatment and support, consistent ongoing pressures did not aways enable leaders to take a proactive approach to issues and risks.

During our inspection, we observed that leaders had a good understanding of the service’s shortfalls. They demonstrated a genuine commitment to improvement, engaging in open and honest conversations with us regarding current struggles and future goals. However, systemic pressures often tested leaders’ capacity to provide safe and responsive care. They faced daily challenges including high nursing vacancies, a lack of doctors, and a hospital at full capacity. While leaders remained visible and understood these issues, the constant pressure often limited their ability to provide consistent oversight to effectively manage these challenges.

Leaders focused on reacting to problems as they happened rather than preventing them, which allowed known safety risks to persist. Audits indicated ongoing problems, yet these did not always lead to improving trends over time. Key safety measures continued to fall below acceptable standards, for instance, staff were not up to date with their mandatory training, individual ligature risk assessments for patients in mental health distress were not standardised despite an increased cohort in this area and frail patients were situated next to vulnerable patients experiencing mental health problems. Poor infection control, as well as patient dignity concerns all impacted on patient safety and experience within the service, and because leaders did not act quickly and decisively on these concerns, avoidable risks remained ongoing.

However, leaders told us they maintained oversight of these challenges through regular quality walk-arounds and executive involvement in critical incident meetings. These forums allowed senior leaders to request external support and ensured that risks were recognised at both the department and board levels. By maintaining these reporting lines, the trust ensured that the emergency department's struggles remained a central focus for the leadership team.

Emergency department (ED) leaders fostered an open and supportive culture for staff, though a disconnect remained between frontline staff and executive response. To support a strained workforce, ED leaders created a speaking up culture where staff felt safe to be honest. They also held listening events and ensured staff went home on time. However, some senior staff felt their specific concerns about overcrowding were not always acknowledged, leading to frustration. While executive leaders were aware of these risks, they had not effectively shared their response plans with the team.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

Quality Statement Score: 3

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.

Leaders had built a positive culture where most staff felt they could speak up and their voice would be heard. Most staff we met said they felt able to speak up if they needed to and they felt they would be listened to. Those we asked knew about the role of the Freedom to Speak Up Guardian and their team. Some staff said they would approach the guardian if they needed to, but others said they would be more likely to approach their own manager first or a trusted colleague.

Some staff said they did not feel anything changed when they spoke up. They spoke about concerns around safe levels of staffing at times, or specific concerns about their area of work. Some felt speaking up about this did not make a difference.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Quality Statement Score: 3

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 had a commitment to equality, diversity, and inclusion through the You Matter Strategy and the 2025 refresh of the RUH People Plan. These frameworks directly addressed systemic gaps identified in the trust’s Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data. To foster a sense of belonging, the executive team formally recognised and funded 6 primary staff networks, including the REACH Network for ethnic minority colleagues and the Enable Network for disabled and neurodiverse staff. Leaders granted employees dedicated time during work hours to attend monthly meetings, ensuring that lived experiences directly influenced the trust’s diversity agenda and internal policies.

To promote professional growth, the trust launched the Routes to Success positive action programme, which supported Band 5 nursing and midwifery staff from underrepresented groups in progressing to senior leadership roles. This was complemented by a trust-wide network of Inclusion Champions embedded within individual teams to provide localised advice on best practices. Specialised support groups also emerged to address specific health and wellbeing needs, such as the Menopause Support Group and the Neurodivergence Peer Support Group, creating informal spaces for staff to share advice and seek peer-led solutions.

The organisation also prioritised speaking up by investing in the Report and Support platform, which allowed staff to escalate concerns about bullying or harassment more easily than traditional routes. This sat alongside a new Violence Prevention and Reduction Policy designed to empower employees to challenge discrimination or abuse from the public. Between 2023 and 2025, the trust met specific breakthrough objectives that focused on reducing manager-led discrimination against staff with disabilities and those from diverse racial backgrounds. Progress remained under constant scrutiny, with monitoring occurring during monthly Divisional Performance Review Meetings to ensure these initiatives translated into measurable improvements in staff morale and clinical effectiveness.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The trust operated within a highly pressured environment where their governance framework struggled to effectively resolve long-standing staffing shortages and rising patient demand. While leaders recognised these risks and invested significant resources into temporary staffing, a lack of consistent clinical oversight and updated emergency planning made it difficult to maintain good standards of care. Despite the best efforts of a dedicated workforce, these challenges created a cycle of operational strain that impacted both patient safety and staff wellbeing.

The service faced long-standing difficulties in securing enough staff. Staffing risks remained on the department’s risk register as a ‘major’ concern since 2020. Despite this risk being known to leaders, the department continued to operate with only one registrar at night because locum shifts often went unfilled. Similarly, increased nursing and healthcare support worker vacancies had not been reduced and did not meet the trust target, and staff sickness continued to increase. Managers struggled to maintain safe staffing levels, resulting in a reliance on a depleted workforce that could not meet national operational standards.

Due to failure to meet certain national standards, the trust was referred to a performance management system used by NHS England to provide extra support to help them meet national standards. Actions for improvement were being managed through the Urgent and Emergency Care Delivery Group improvement programme, aiming to ensure better alignment with national expectations. This meant any investment of over £100,000 had to be authorised by the Integrated Care Board and NHS England. Data received from the trust indicated they had spent £2.47 million on temporary staffing in the 2024/25 financial year, including £1.16 million in nursing and £532,000 in medical staffing. High vacancy rates remained ongoing as the nursing establishment was increased and the trust was actively on a recruitment drive. Furthermore, high sickness rates accounted for a portion of the £2.47 million spent on temporary staffing.

The service failed to maintain a comprehensive overview of patient safety, leading to significant gaps in quality assurance. Although leaders held governance meetings every 2 months, these did not provide the leadership with overall effective assurance in several key performance and quality audit areas. For example, there were no audits carried out in certain key performance areas to determine where there were areas of concern and how these were going to be addressed. This included an audit of times to carry out an electrocardiogram (ECG) against the 15-minute guidance. Senior staff said they recognised there were gaps in the audit of sepsis management. Patients’ pain was not audited. This lack of oversight meant there was an ongoing risk that any declining standards would go unnoticed and unaddressed. This directly compromised patient safety and prevented the trust from meeting the Royal College of Emergency Medicine (RCEM) standards for over a long period.

Leaders did not manage critical departmental risks effectively, particularly the safety of the environment. We observed breaches in information governance with patient records left visible on unattended computers and test results scattered on public counters. Our review of the risk register further identified ongoing problems within the service, such as CCTV blind spots, and medicine drug cupboards with broken locks (although we did not observe this on our inspection).

The department lacked a clear and up to date framework for managing large-scale emergencies, leaving the service vulnerable to sudden surges in demand. While the specific emergency department major incident plan had not been reviewed since 2017, the trust stated they would utilise the Trust Incident Response Framework. Senior nursing staff, however, expressed a lack of awareness regarding how to access or deploy major incident equipment. Furthermore, the department had not conducted any ED-specific emergency exercises over the last 4 years, meaning staff had not practiced the coordination required for large-scale emergency situations. This lack of preparation created a significant risk that, in the event of a declared major incident, the team would be unable to respond with the necessary speed and organisation, potentially compromising patient safety during a crisis.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The partnership working with the mental health trust required far more cooperation and responsiveness than was happening in practice. It was in this clinical specialty where many patients remained in the department for unacceptable lengths of time. There were regular calls which included the integrated care system team to review the needs of patients, but this remained an area of concern for safety and wellbeing of the patients and staff.

Representatives from the local NHS ambulance service said they had a good working relationship with the emergency department leadership team and the trust in general. There had been close working over some of the most challenging times for urgent and emergency care. The ambulance service provided a hospital ambulance liaison officer (known as a HALO) to provide a link between both services. This was acknowledged to work well and be of noted value to both organisations.

Staff shared information and learning with partners and collaborated for improvement. Key organisations included the local NHS ambulance service and the local NHS mental health trust. They also included the integrated care system for the region and other system partners who had links with other health and social care services.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was a plan for the service to focus on continuous learning, innovation, and improvement. However, because of shortages of staff, and crowding in the service, staff did not always have creative ways of delivering equality of experience, outcome, and quality of life for patients. Despite obvious skills, experience and clinical knowledge, staff could not always contribute to development of practice and research actively.

There was continuous development available for staff around day-to-day clinical practice. The service had a team of clinical educators across various grades and clinical specialities. Their role was to support with education for staff, including development and advancement, and to help through this with staff retention.

There were opportunities for research which was overseen by an ED Consultant and ED Consultant Nurse. One study currently being undertaken was a review of the rapid assessment and triage process by the ED Consultant Nurse.

Staff and leaders were encouraged to learn about new and innovative approaches that evidence showed could improve the way their service delivered care. However, staff commented how the pressures on the department from managing so many patients did not leave them always enough time to explore other innovative or emerging approaches to care and treatment.