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

We rated well-led as good. Staff at all levels were clear about their roles and understood their responsibilities and what they were accountable for. The service had suitable arrangements for identifying, recording and mitigating risks to the service. Leaders had a good understanding of these risks which they regularly discussed. Staff felt respected, supported and valued. Staff were committed to continually improving services.

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 told us they felt valued and expressed satisfaction with working in the surgical division. They told us they were well supported by their managers and confident they could raise concerns and have them addressed.

Staff took great pride in their teamwork, especially during periods of peak demand. There was a sense of cohesion within the surgical division, with different specialties collaborating effectively to provide a multidisciplinary approach to patient care.

Trust values were embedded and most of the staff we talked with could tell us about the 6 values of Compassion, Improve, Learn, Openness, Partnership, Pride and Respect.

Results from the staff survey 2024 showed a lower-than-expected response rate (60%) from staff[AG1][GW2]. The highest scoring area was staff engagement and the lowest reflected how staff felt about recognition, being rewarded and morale. A total of 75% of staff reported enjoying working with colleagues in their team and 68% said they felt they received the respect they deserved from colleagues. However, 51% of staff felt supported to develop their potential and 56% said there was sufficient opportunities to develop their career. We were provided with an appropriate action plan to address the issues raised by staff and there was evidence of the support offered to staff and improved.

The 2024 staff survey included 9 areas for staff to respond to which were: we are compassionate; we are recognised and rewarded; we each have a voice that counts; we are safe and healthy; we are always learning; we work flexibly; we are a team; staff engagement; morale. For the surgical services group, the number of responses across the 9 areas varied from 305 to 324. Surgical staff responses to each area were rated out of 10. Scores varied from 5.45 to 6.97 across the 9 areas. ‘We are recognised and rewarded’ was the lowest scoring, followed by ‘morale’. ‘We are compassionate and inclusive’ was highest scoring, followed by ‘staff engagement’. The results for surgical staff were very similar to those given by the organisation as a whole. The trust had an action plan to address areas of concern from the survey.

During our March 2025 assessment staff told us they felt the culture in the surgical division had improved and they were happier at work as a result.

Processes

The trust developed their strategy ‘More than a hospital’ 2022-2030 with consultation from staff, the public and wider stakeholders. The key elements of the strategy included transformation of facilities, elective surgical hub, integration, and of advanced technology. Key elements were underpinned by the trust’s desire to deliver exceptional surgical care, enhancing patient experiences, and addressing the evolving healthcare needs of its community.

A wellbeing delivery plan was in development in alignment with the trust’s people strategy. It focused on valuing and supporting staff. The plan outlined specific actions to create a valued and empowered workforce within a healthy and fulfilling environment, with a particular emphasis on psychological wellbeing.

Feedback from staff and leaders

Surgical Services at UHCW, included three clinical groups Trauma and Neurosciences, Surgical Services (with 12 surgical subspecialties) and Clinical Support Services (comprising of theatres and anaesthetics). Each clinical group was led by a triumvirate led by a Clinical Director, supported by a Group Director of Nursing and AHP's and Group Director of Operations. Reporting into the Directors for each group were specialty/department teams consisting of a clinical service lead, a senior nurse and a group manager. This model was replicated throughout the three clinical groups. These teams met weekly and also held a separate weekly meeting with the chief operating officer.

The surgical group operational structure included 5 operational and performance managers, overseen by a group manager and 3 associate group managers, all accountable to the group director and deputy group director of operations.

The nursing leadership structure included 9 ward managers. The lead nurse and modern matrons reported to the group director of nursing, while advanced clinical practitioners (ACPs) were led by a nurse consultant lead ACP, who also reported to the group director of nursing.

The chief executive officer held meetings with administrative staff, and board members conducted monthly rounds of the service to engage with staff.

Staff reported having access to a support scheme designed to provide individualised assistance for those with physical or mental health conditions or disabilities, ensuring they could continue working. The trust also had an inclusion delivery plan, which aimed for all staff to have passports outlining their reasonable adjustments, working arrangements, communication preferences, and other relevant needs.

The leaders were visible, approachable and set a positive example. They understood the challenges in the department and worked to make improvements when needed. They focused on staff wellbeing and encouraged a culture of safe, high-quality care. Staff received monthly newsletters with updates on safety issues, reported incidents, and new team members.

Processes

The trust developed a wellbeing delivery plan linked to their people strategy of valuing and enabling their people. The plan was to identify actions that would create a valued and enabled workforce working in a healthy and fulfilling environment by focusing on psychological health.

The trust held a psychological wellbeing away day in 2023, where it consulted staff from a range of different departments and roles on matters such as their lived experiences of psychological support and designed a post incident support pathway and support process for managers supporting staff as well as an online wellbeing guide.

The trust had an equality diversity and inclusive policy. Compliance with equality, diversity and human rights training was 98% for surgical services.

Feedback from staff and leaders

Staff told us their managers were visible and approachable. Staff also reported feeling confident in raising concerns with their line managers, trusting that their issues would be taken seriously and addressed appropriately. The culture of the service was described as positive, supportive and inclusive.

Staff were aware of the Freedom to Speak Up Guardian and their responsibility to support them to raise concerns.

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.

In the 2024 NHS Staff Survey results for surgery, trauma neurosurgery and theatres, 324 staff responded. There was a plan to achieve 60% responses across the group, which would be 509 staff for the 2024 survey.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from staff and leaders

Staff actively took part in the governance and risk management processes within the surgical division. Each area maintained its own risk register, and leaders were able to identify their top risks and explain the measures in place to manage them.

The highest risks were assessed against the clearly defined risk threshold, and if necessary were escalated to the divisional risk register. The leadership team worked closely with different specialty groups and held monthly meetings to review quality, performance, and efficiency plans. They used these meetings to learn from past experiences and make improvements.

Staff were part of an emergency response team and had clear plans to follow in case of major incidents.

Key messages from governance and risk management meetings were shared with staff through safety huddles, team meetings, displayed on communication boards and newsletters.

Processes

There was 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. Some risks had been on the register for a long time. There were 14 major risks, including staff vacancies, skill mix issues, theatre infrastructure concerns, limited vascular capacity, such as interventional radiology and hybrid theatres - and challenges with ward and outpatient space.

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.

There were 11 mortality leads across surgical specialties. Their role was to contribute to quality reviews and present findings to the group board. Mortality and morbidity meetings were a routine part of the process, ensuring learning and improvement in patient care.

Information from the specialty leadership meetings was reported into broader assurance and patient safety meetings. Information from these meetings was then discussed at the surgical risk meeting before being passed to the group board. 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.

Theatre teams held a weekly safety and governance meeting across both sites to review reported incidents and risks.

A surgical nursing and allied health professionals (AHP) production board was in use, feeding into wider nursing, midwifery, and AHP leadership meetings, as well as the chief executive officer’s forum.

All medical records were kept secure and remained confidential.

People’s experience

We did not gather any evidence for this quality statement about people’s experience during our assessment

Feedback from staff and leaders

The public, staff and wider stakeholders participated in the development of the trust-wide strategy. Clinicians actively participated in shaping the new strategy, and staff were heavily involved in key projects, including the design of new theatres, the outpatient department, and the main entrance. A business case was in progress for a urology investigations unit, aiming to provide patients with same-day assessments and care.

Leaders also highlighted regular collaboration with general practice through primary and secondary care liaison meetings, as well as partnerships with neighbouring hospitals, particularly for patient transfers.

The trust planned to align its strategy with broader NHS priorities, including the national Getting It Right First Time program. For example, a business case was being developed for robotic surgery, which could lead to shorter hospital stays and improved patient outcomes. Additionally, the trust was involved in national initiatives such as the ‘Health on the High Street’ program to enhance healthcare accessibility.

The trust was also working closely with partner organisations in the Coventry area to transform services for older people.

Feedback from partners

The service had a good working relationship with other stakeholders in the wider health care system and voluntary groups.

Feedback from staff and leaders

Patients were involved through providing informal feedback which helped to inform the delivery of services. Matrons and ward managers gathered patient feedback during ward visits.

The Patient Advice and Liaison Service team looked at complaints, which had led to a faster response rate and reduced the number of complaints received.

Processes

There were well-established processes to ensure risk was identified, managed and learned from to prevent recurrence. Trends and theme data from incidents, complaints and comments from patients and staff was collected and used to improve the service.

There was board oversight of all key risks because these were escalated through the various governance committees.

The service actively participated in a range of research programmes.

The trust was recently shortlisted for a national ‘Digital organisation of the year’ award.

Outcomes

In response to public requests for expanded services at the Hospital of St Cross in Rugby, the trust introduced the 8-year ‘More Than a Hospital’ strategy in 2022. As part of this plan, an elective hub was established at Hospital of St Cross to enhance elective care pathways. The trust aimed to transfer a substantial portion of elective procedures from the University Hospital, Coventry to the Hospital of St Cross, improving patient experience, increasing capacity for specialist tertiary and cancer services, and helping to reduce the elective backlog across the healthcare system.

The trust operated a sepsis support group for patients and their families to help them manage their recovery and emotional well-being following sepsis.

The trust website was available in multiple languages and provided a large library of patient information and health promotion material.