University 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 was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of people who used services and wider communities, and all leaders and staff shared this. 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.

Feedback from staff and leaders

Staff spoke positively about the management team and told us they were supportive, and approachable. Staff felt they could escalate any concerns and felt listened to. Staff we spoke to said there was a positive culture within the organisation and that they enjoyed working at the trust. Staff said there was a strong sense of teamwork, and they felt supported by their colleagues. They were offered support if they had a difficult day and managers supported and debriefed.

Patients were encouraged to give feedback and raise concerns. The service followed the trust values of compassion, openness, pride, partnership, improve, learn, and respect. All staff had a good understanding of equality and diversity, in relation to meeting both patients and staff's individual needs.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff and leaders shared the same vision for the service which was putting patients first.

Managers had a good understanding of the risks to the service; they worked on them as a team to manage the risks.

Processes

There were processes which identified the vision and strategy for the service, and this was supported by strategic objectives for how the trust intended to achieve its ambition.

Feedback from staff and leaders

The 2023 NHS Staff Survey reported the medical care service scored well for compassion, culture, equality and diversity, and motivation. However, the low scores were for workplace burnout, health and safety work climate and appraisals. We saw action plans following the survey to improve the uptake among staff in completion of the survey and improve staff satisfaction in areas such as appraisals, flexible working, and support for work-life balance.

Processes

The service had processes to address staff concerns and for staff to raise any issues. Staff reported incidents well and said they felt safe to do so and that they would be supported by managers.

Feedback from staff and leaders

Staff and leaders acted with openness, honesty, and transparency. Staff were encouraged to raise concerns with their managers. There was a Freedom to Speak Up Guardian, although not all staff we spoke to were aware of them. Staff said they felt confident to raise concerns and had received feedback and progress reports from managers.

Processes

There was a Freedom to Speak Up Guardian and most staff we spoke to were aware of how to access the guardian and some staff had used the service previously. Evidence we saw following our assessment showed the Guardians was promoted by the trust and staff were encouraged to contact them.

Feedback from staff and leaders

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity, and inclusion. The service promoted diversity in the workplace and understood recruitment of international nurses. Staff received support from clinicians to support development in their roles. Leaders took action to ensure there were effective and proactive ways to engage with and involve staff. This had a focus on hearing the voices of staff with protected characteristics and those who might be excluded or marginalised, or who may be least heard within their service. Staff felt empowered and confident their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation.

Processes

The service had processes to receive, review and act upon staff feedback. There were processes to promote and increase the engagement of staff in surveys, raising concerns and giving feedback. Leaders acted swiftly and appropriately to address the concerns. The service leaders demonstrated they were aware of the needs of the local population and acted to address any groups who were marginalised.

Feedback from staff and leaders

Staff understood their roles and responsibilities. Managers could account for the actions, behaviours, and performance of staff. There were effective systems to manage current and future performance. Risks to the quality of the service were reviewed, and the service took action to manage risks using new and innovative ideas.

The service had a meeting structure for senior leaders and managers to have regular opportunities to discuss operational issues. Leaders were clear on the links to trust-wide groups and committees to escalate risks and issues. A performance report was sent to the board each quarter.

There were effective arrangements for the availability, integrity and confidentiality of data, records, and data management systems. Information was used effectively to monitor and improve the quality of care.

The service had a clear governance structure with various committees that met regularly. There were monthly governance meetings which had a set agenda. Minutes we reviewed were detailed and covered important aspects of the way services provided safe and effective care. Risks were regularly reviewed, and new risks were discussed prior to being entered on to the risk register. Regular updates on audits were provided during each meeting and there was also an agenda item dedicated to learning from deaths.

Processes

There were clear and effective governance processes. Data or notifications were consistently submitted to external organisations as required.

Senior leaders attended weekly team meetings, departmental meetings for specific specialties, group governance meetings, group board meetings. Senior leaders held daily safety huddles meetings with ward staff and handover meetings at the start and end of each shift.

People's experience

Staff and leaders engaged with people, communities, and partners to share learning with each other, which resulted in continuous improvements to the service. They used these networks to identify new or innovative ideas that could lead to better outcomes for people.

Feedback from staff and leaders

Leaders collaborated with partners and other organisations to share information and learning and drive improvement.

Feedback from partners

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. However, this was not always effective with regard to discharge pathways for patients.

Staff and leaders collaborated with all relevant external stakeholders and agencies.

Processes

The service had service level agreements with the trusts and other organisations that it worked alongside with. For example, patient transport services and local independent health organisations.

Feedback from staff and leaders

Staff and leaders had a good understanding of how to make improvements happen. The approach was consistent and included measuring outcomes and impact.

Staff and leaders ensured that people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives.

The service had strong external relationships to support improvement and innovation. Staff and leaders engaged in external work, including research, and embedded evidence-based practice in the organisation.

Processes

There were processes to ensure that learning happened when things went wrong, and there was shared learning from examples of good practice. Leaders encouraged reflection and collective problem-solving.

Within all minutes of meetings reviewed, there was evidence provided to show the service participated in learning. The learning came from incidents, deaths, and complaints.

The service engaged with the improving lives work which aimed at improving outcomes for patients and keeping them healthier in their own homes and reducing hospital readmissions.