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

Staff understood the service’s vision and values; most managers were supportive in terms of development and there were opportunities for innovation.

Although there was a good culture in parts of the service, not all staff felt there was healthy morale. However, there was a lack of effective partnership working when a child in crisis was placed with the service and out of hours support from the neighbouring trust was problematic out of hours.

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

Senior leaders were sometimes not visible, supportive, or accessible to some staff. This was a particular concern for the staff on ward 14. This ward had low levels of staff, delivered complex care to children in crisis, had a high level of reported incidents and low staff morale. These concerns had been identified and were formally recorded on the risk register. However, despite the recognition of the ward risks staff felt they were not receiving appropriate support to manage and mitigate these. During the inspection we saw staff on this ward struggling to provide safe care and treatment to a child in crisis and found a lack of senior oversight and support for this ward.

However, most staff in other clinical areas told us they experienced a positive culture in the service and described feeling well supported by their immediate line managers. They told us they felt able to raise concerns without fear and were confident their concerns would be addressed appropriately. Most staff knew who their services leads were and how to escalate concerns.

The service was included in the trust’s overall vision and strategy dated 2020 to 2025. Staff were aware of the service strategy, participated in its creation and aligned with the delivery.

The trust also ran a leadership programme which was open to all staff in leadership positions. This programme equipped leaders with the technical improvement tools as well as human behaviours tools to support and develop a learning culture. All the senior leadership team and a number of senior ward managers had completed this training.

Processes

The service provided a national staff survey action plan for 2023 to 2024, which the service asked for feedback for 5 actions. The service identified 6 actions to take forward from the staff survey.

The service had response rate of 60% (547 responses) across the group to the staff survey. The service compared scores from 2023 to 2024, and all 5 actions had increased the percentages.

The service was implementing the perinatal culture and leadership national programme which focused on the safety culture, operational risks, reliability, burnout, and engagement. An action plan had been created. The plan was risk assessed and on track to be completed by the end of 2025. The service had a dedicated survey owner who was responsible for taking the lead on the action plan implementation. This had 15 actions identified which included who was responsible for ensuring the action was completed and the date for completion. There were still a number of actions to be completed. The service saw a rise in the number of cultural conversations from 39% to 42% in 2024. We also noted an improvement in relation to the question regarding the service focus on staff health and wellbeing which had increased from 40% to 42%.

Feedback from staff and leaders

When speaking with staff, we received mixed feedback regarding the visibility, supportiveness, and compassion of senior leaders within the service. While ward managers and matrons were consistently described as supportive, not all staff felt the same level of support from more senior leaders.

Staff particularly highlighted the efforts of ward nurse managers, who were described as approachable and hands-on. In times of nursing staff shortages, they often stepped in to work clinical shifts, helping to ease pressure on the team. This approach to supporting staff when there was a shortage of nurses was especially noted on Ward 14, where the ward manager would step in during challenging periods.

The 2023 staff survey data for children’s services found not all staff felt their ideas were heard when making decisions about their work. Around half (52%) of staff felt they could make improvements in their job area. Another important point was staff felt their health and happiness needed more help from the organisation as fewer than 40% felt the organisation took positive action for their wellbeing. While 73% of staff reported they had chances to learn new things and improve their skills, supporting them to grow their potential. A total of 36% of staff felt their work was not valued by the organisation, and 45% felt they got recognition for doing good work. Also 62% of staff felt colleagues showed appreciation to one another. As a result of the findings the service had developed an action plan which hoped to make improvements in all areas in the 2024 survey.

Processes

Recruitment was underway to ensure the leadership structure was supported by a Group Director of Operations.

The service provided people support cafés, which the data showed there had been 7 support cafes organised and with approximately 15 staff in each group, which was a good staff attendance. However, wards 14, 15 and 16, had only had one support café in total held in August 2023.

The service was in the process of employing a dedicated people support manager who would focus exclusively on staff wellbeing. There was an aim to develop a wellbeing delivery plan in collaboration with stakeholders across the organisation to improve staff wellbeing.

Feedback from staff and leaders

Staff told us they knew and understood the role of the Freedom to Speak up Guardian. They knew how to access the guardian for support. However, most told us they would usually raise any issues with their direct line manager.

Processes

Staff had multiple ways to raise concerns or provide feedback. These included speaking with their line managers, sharing concerns in staff meetings, participating in staff surveys, or contacting the Freedom to Speak Up Guardian or trade union representatives.

All contacts with the Guardian were kept confidential, but trends and themes were monitored and reported to the board. The trust also had a whistleblowing policy, which staff were aware of. The Guardian collected trend and theme data and reported directly to the trust board.

The service had a freedom to speak up policy which staff could access to understand the role of the guardian and how to make contact.

Feedback from staff and leaders

The service had a diverse staff team, and when speaking to staff we had a mixed response in relation to the culture of the department.

The trust used the national workforce reporting framework (WRES – the workforce race equality standards) to monitor and address race equality and had created an action plan to make improvements. Data from 2024 showed the trust experienced a growth of over 4% in the employment of ethnic minority staff. The data also identified a decrease in reported incidents of harassment and bullying. However, it highlighted ongoing areas for improvement, including ensuring equal opportunities for career progression.

The service was working on a WRES development plan which included 10 key actions due to be completed at the end of 2025. Examples of these actions included: signing up to the rainbow badge and to ensure the trust were creating an inclusive environment for staff from the LGBTQ+ community. To develop and implement an anti-racism toolkit to support staff to report any racial discrimination.

The data showed the service was considering staff well-being and implementing support. However, a small number of staff told us after an incident had occurred a “hot de-brief” did not always take place, and staff did not always have the time after the incident to discuss what had happened, what went well and what they could have done better.

Processes

There were 3 staff networks which supported the trust to address and solve problems for underrepresented groups and individuals working at the trust. This included the Pride network, Supporting People of Colour (SPOC) network and Disability and Wellbeing network (DAWN).

Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data for both reports in 2023 did not highlight any areas of significant concern. However, there was an ongoing commitment to improve the service position by developing an action plan in collaboration with the staff networks to address improvements in recruitment and retention processes, reducing the experience of violence and aggression and increasing belonging for those from minority backgrounds.

Feedback from staff and leaders

Staff had a clear understanding of their roles and responsibilities and most felt supported in their role. The service operated under a clearly defined leadership structure.

The paediatric and neonatal services sat in the Womens and Childrens group structure. The service was overseen by 4 directors which were a group director of operations, a clinical group director, director of nursing and AHP’s and a director of midwifery. Each service had 2 clinical leads who were supported by an operations and performance manager. However, at the time of our assessment the operations and performance manager role was vacant. There were also 2 group managers for each speciality.

Staff told us they attended all-staff meetings. However, data from the trust indicated these meetings were not held regularly with the last occurring in February 2024.

Service leaders told us they held daily clinical and operational discussions. Weekly ‘grand huddles’ took place in which incidents and patient harm were discussed. There were monthly ward-based meetings where the risk register was discussed. The neonatal service discussed key safety and quality indicators, risks and dashboard metrics at the perinatal safety champions production board with representation from Trust board perinatal safety champions.

The service held paediatric and neonatal quality improvement and patient safety meetings (QIP) meetings to discuss any improvements could be made to the service. These meetings discussed key learning and trends and themes from safety alerts, service risks, shared learning, morbidity and mortality reviews, and service user feedback.

The service provided a selection of minutes, agendas, and key learning points from the most recent incident reporting system safety huddle. Minutes showed the service discussed risks, incidents and learning, clinical audits, and quality improvements.

Processes

There were systems and processes in operation to assess, monitor and improve the quality of the service. The service operated a red, amber, green (RAG) risk rating process, and each risk was assigned an impact and score. Every risk had a responsible officer, an action plan, and a set review date.

The risk register was reviewed regularly in different meetings, including the risk committee, the weekly leadership meeting, and quarterly reviews with the chief executive officer.

The group board shared updates with the trust board through various channels, including accountability meetings, quarterly performance reviews, and the quality governance committee (QGC). The QGC also received updates from the risk committee and the patient experience and engagement committee.

The service held a number of meetings on a regular basis to discuss quality and concerns. For example, there was a trust mortality meeting which the service presented at every 6 months. If learning was identified from incidents, then teams would present to the Quality Improvement and Patient Safety (QIPS) meetings in other departments, so the learning was shared outside of the service.

We reviewed a sample of minutes from the QIPS meeting and found there was consistent oversight and scrutiny of a range of quality markers covering serious incidents and morbidity and mortality reviews. There were discussions around clinical audits and quality improvement, mandatory training, sepsis screening, patient information and feedback.

All medical records were kept secure and confidential.

The service still had actions to ensure they were meeting the needs of children/young people who came into the service with additional needs. The service reviewed learning disability improvement standards 2022/23, and in June 2024 they completed an action plan. This covered the 3 standards: Standard 1. respecting and protecting rights, this had been RAG (Red, Amber, Green) rated red, with a completion date of January 2025. Standard 2 inclusion and engagement, this had been RAG rated as amber with the completion date as March 2025. For Standard 3 workforce had been RAG rated as amber with the completion data as March 2025.

Morbidity and mortality reviews were held and these linked with the local child death oversight review panel. Home visits and rapid response meetings were provided by the trust. They are held within 24 hours of a child death or on the next working day if the child dies over a weekend. The trust has 3 doctors who contribute to the child death review process and provide home visits on the day of an unexpected death. Information is provided to the regional child death overview panel. Review findings were shared and discussed in relevant governance meetings and directly with clinical staff.

Peoples experience

We did not collect enough information from children and young people about their experience of partnership and communities to express their views in this report.

Feedback from staff and leaders

Staff told us they worked in partnership with external agencies. For example, staff supporting children and young people with mental health needs worked alongside child and adolescent mental health services, local GPs, the local authority safeguarding teams and the multi-agency safeguarding hub.

Feedback from Partners

We did not collect enough information from partner agencies about partnerships and communities to express their views in this report.

Processes

Staff did not always have access to current information about young people’s needs, which could impact their care. We identified some communication systems between the service and external agencies were not always effective. This was largely due to electronic recording systems not being accessible to external agencies. Trust staff were also unable to access partner systems. However, once the service had received the documentation from the external agencies, staff would ensure this was scanned to the electronic recording system.

There were systems in place for the service to engage with children and young people and their families, including the diabetes and epilepsy support networks.

Feedback from staff and leaders

The service supported research and development projects. At the time of our inspection there was 40 active projects.

Staff were actively encouraged to get involved with innovation and development in the organisation. For example, 2 nurses developed a device called hydro bubble to administer cystic fibrosis treatment to children. The technique involved patients blowing bubbles into water to clear secretions, such as phlegm and sputum, from their lungs.

The ‘Jack’s Room’ project was set up to support bereaved families. The room had been set up following the death of a child in the service. Staff had spent time with family members who felt it would improve families experience if an identified but separate room were available, rather than being directly on the wards. This enabled families to spend time in an appropriate, private environment where they could begin to process the loss of their child.

Ward staff had access to skilled support during busy periods, outside of normal hours, and when caring for complex patients. The service had nursing staff acting as supernumerary bleep holders which had been appointed after staff identified a need in the service. A supernumerary staff member was extra to the normal staffing numbers and not counted in the rota. The supernumerary nurse worked across the units, identifying staffing pressures, patient acuity, patient flow across the department and attended resus. They predominantly worked out of hours and on late shifts when there was less support around on the unit. The bleep holders were Band 6 nurses, who had completed their European Paediatric Advanced Life Support course and had experience in the paediatric bed management role.

The epilepsy team had set up a media platform to enable parents to send videos of seizures safely and confidentially. This made improvements to the timeliness of diagnosis and seizure management.

The service had implemented a virtual reality app, which allows patients and families to familiarise themselves with the department prior to their admission.

The service leads told us they looked at trend and themes from a range of data points to identify where improvements could be made. These included themes from incidents, complaints, service user feedback, current risks, and compliance with sepsis pathways. Sepsis compliance was monitored every 2 weeks. The service reported consistently delivering antibiotics within 60 minutes within the decision to treat.

Processes

The trust was building a continuous culture of learning using the UHCWi methodology to support a patient centred approach to improvement. This was developed in collaboration with a well-recognised institute championing quality leaders and improving quality and safety, training and development and innovation.

A number of improvement projects were underway in the service. This included improved information boards, reducing delays on the day of surgery, a parent room project as well as a number of staff health and wellbeing initiatives.

The service were working towards meeting all of the British Association of Perinatal Medicine standards.