Diana Princess of Wales Hospital

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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 remains Requires Improvement. This meant the management and leadership were inconsistent. Leaders, and the culture they created, did not always support the delivery of 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.

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.

Evidence shows a good standard and while improvements were being made, these need to become fully embedded and sustained over time. 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.

During inspection all staff reported confidence in raising concerns or suggestions and that they felt heard.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Senior leaders were able to articulate how their role aligned with the trust values.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. We were given examples of how staff were able to ask questions regarding plans for the future and the trusts overall strategy. We saw work that was ongoing to implement and improve culture within the NLAG ED Cultural Transformation Plan 2025.

Staff could explain how they were working to deliver high quality care. All staff could articulate the trust values and how they fitted into delivering high levels of patient care.

Evidence shows a good standard, with improvements that need to be fully embedded and sustained. Inclusive leaders at all levels understood the care context and reflected the organisation’s culture and values. All demonstrated the skills, knowledge, experience, and integrity to lead effectively.

Nursing and medical staff across the emergency department understood the key risks to patients within the department. Staff told us the emergency 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 also fully understood the key risks and challenges faced by the emergency department. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as the local NHS ambulance trust. They told us they worked well together and there was regular engagement to review performance and identify improvements to services.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate leadership structure at departmental and divisional level with medical, nursing, and operational leads.

Leaders understood but did not always have resources and space to manage the priorities and issues the service faced. Capacity constraints and issues with partnership working with other specialities within the trust and across other parts of the hospital impacted on patient flow in the emergency department.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

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

Leaders fostered a positive culture where people felt that they could speak up and that their voice would be heard. They were able to describe how staff reported concerns and how these were investigated, then feedback given to staff, via various forums. Leaders described an open-door policy and had an eagerness to want to help and support staff.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. We saw staff offer patients opportunities to provide feedback. We also noted that the department conducted patient surveys to provide more opportunities to seek feedback.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Staff were aware of the freedom to speak up policy (FTSU) 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 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 and diversity in daily work and provided opportunities for all staff to develop. Staff survey results showed that staff felt there were opportunities for career development.

Policies and processes were in place to ensure the service was inclusive and fair in the way it operated. 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.

Governance structures were in place but inconsistently applied and not always used effectively. The service was previously in breach of the legal regulation in relation to governance, management and sustainability. Insufficient improvements were found at this assessment, and the service remained in breach of this regulation.

Staff had sufficient time and resources to support effective governance and risk management. However, data collection processes were inconsistent. In addition, some completed audits were either not provided or were of insufficient quality to support effective oversight. As a result, there was limited assurance that reliable information was consistently available to monitor performance, quality, and service improvement.

We saw a slow pace of action with issues highlighted during inspection, such as staff compliance with the principles of infection prevention and control. Senior leaders had been aware of the issue as it had been repeatedly highlighted in audit, but we were not assured that the pace of action for improvement was effective.

We highlighted areas of concern where the department did not meet national guidance in relation to paediatric provision, in that the paediatric waiting room was not compliant. We saw no mitigation or identification within the departmental risk register despite senior leaders being aware of the issue.

We noted that the department held a significant amount of risk for the whole hospital and that there was inconsistent support across the hospital. We did note that senior leaders were aware of this and work to improve was ongoing but at the time of inspection this was not yet fully embedded.

We saw that there were regular and effective meetings for safety, audit, quality, and governance. These had been discussed and had started to address key areas of performance, risk, audit and workforce. We saw that recorded minutes of these meetings had highlighted the areas of concern and actions were being taken to learn and improve.

Monthly governance meetings were held 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, that included capacity, flow and issues that had been picked up on audits, such as risk assessments, access to services and mandatory training compliance.

Processes were in place to escalate issues to the hospital leadership team. We saw evidence of effective escalation from the department to senior leaders and then to the executive team. We also noted that information was effectively disseminated from the executive level to the department.

Daily safety huddles and bed management meetings enabled sharing of information and escalation of patient risks and capacity and resource issues. Risks were discussed at safety huddles, board rounds and bed management meetings and staff and leaders were proactively managing and escalating any concerns.

Risks were captured on a divisional risk register and were rated in terms of likelihood and consequence. The trust had risk management processes which meant that risks were escalated appropriately from the emergency department up to board level when required.

Staff and leaders at all levels demonstrated a good understanding of the risks within the emergency department and we saw an increased pace of change that was being taken to mitigate or remove risks. We discussed the top risks for the service with the leadership team and reviewed the emergency department risk register. We saw that the main risk was that of capacity and demand.

Staff received feedback from incident reporting and risks during nursing huddles. We saw examples of meeting minutes held for all grades which provided a forum for learning from incidents and risks.

Good practice was recognised and celebrated.

The evidence showed a good standard. 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 duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The leadership team understood how their staff felt about delivering care that met both the physical and mental health needs of patients.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care, such as the local mental health trust. Partners we spoke with informed us although communication between services was challenging there were no performance issues, and the teams worked well together.

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.

The evidence showed a good standard. 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 contribute to safe, effective practice and research.

All senior leaders were aware of the issues that faced the department and the areas that required improvement following the previous inspection.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. We saw that the department had empowered staff to make changes, such as layout of the department to maximise the patient journey. Staff were empowered to trial new ideas but to also speak up if they did not feel that it was working.