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

Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills, knowledge, and experience to lead well. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management. However, senior leaders did not always have the opportunity or resources to make changes to improve safe and good quality care and treatment. This was not helped by the severe pressure on the department from demand and capacity. The department was prepared for emergencies and major incidents and worked with others as part of a multiagency response.

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 equality and diversity were actively promoted, and they felt they were treated equitably regardless of any protected characteristics.

A shared decision-making council had been established to give staff a way of implementing quality improvements with support from senior department leaders. The council met 8 times in the 12 months before our inspection. Staff understood their role in the council as being able to improve the things in the department that reflected their biggest concerns about patient safety. For example, to reduce long waits and overcrowding in waiting rooms. Staff said their main priorities for improvement had not received backing from the leadership team and they had not received feedback about why not. Some staff said as a result they lacked motivation to fully engage in the shared decision-making council, because what they saw as important stood in stark contrast to what the leadership team saw as important. Senior leaders told us the council had made improvements to the variety of food that could be offered to patients in the department.

Most staff told us they enjoyed working in the department and especially valued the strong sense of team work. They told us the culture was patient focused, and they had the opportunity to develop and progress in their career.

Processes

There was 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 wider communities to meet these.

Senior leaders had a clear vision for the service and a strategy that included working with other divisions across the trust and with external providers, such local ambulance services and the wider system to improve access and flow.

Feedback from staff and leaders

Leaders had the skills, knowledge, and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.

Leaders understood the challenges to quality and sustainability and could identify the actions needed to address them.

All of the staff we spoke to told us leaders were visible and approachable.

Staff said they felt supported to develop their skills and were given opportunities to take on more senior roles. One member of staff told us they had received support to complete their master’s degree. We heard from staff that health care assistants had been developed to nursing associate roles. Nursing associate training is the step between working as a healthcare assistant and becoming a registered nurse.

Processes

Leaders received support and opportunities to develop and maintain their credibility, skills, and knowledge. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning for the future.

Feedback from staff and leaders

The trust had a freedom to speak up guardian and freedom to speak up ambassadors. Staff told us they knew how to contact the freedom to speak up team. Staff said they felt able to raise their concerns without fear of retribution.

Leaders and staff apologised and responded quickly with sensitivity and confidentiality when things went wrong. People were meaningfully involved in implementing actions to prevent reoccurrence.

The staff we spoke to said they had viewed the shared decision-making council as a way of speaking up about their direct concerns about patient safety. Because the role of the council was to drive improvements, they had seen it as a way staff could come together to openly discuss their concerns and then work to make positive change. Because the changes they wanted to implement were not the ones backed by the leadership team, this staff group had become apathetic about their role within the council, and about what they viewed as their ability to speak up.

Processes

There was a process for staff to follow if they wanted to use the freedom to speak up service, information about this was available on the trust intranet. The trust had introduced an app to support staff in raising their concerns to the freedom to speak up team. There was eLearning available for staff who wanted to find out more about speaking up.

A bi-annual freedom to speak up report was presented to the trust board. The report contained details on the number of people who had raised concerns on the types of concerns that had been raised. Concerns could be raised anonymously when people did not want to disclose their personal details. Eight members of staff from the emergency medicine directorate had used the freedom to speak up service between January and December 2023. The themes raised were poor staff behaviours or attitudes (4), bullying (2), and staff safety (2).

When the new electronic patient record (EPR) system was introduced, senior leaders used a feedback box so staff could give their anonymous opinion on the new system and suggest improvements. Senior leaders then completed a ‘you said, we did’ poster so staff could see that their feedback had been listened to and what managers had done to improve the EPR.

Feedback from staff and leaders

Supported by the trust, leaders championed diversity and understood it was integral to a positive, inclusive, and high performing workforce.

Staff told us they did not experience bullying or harassment including those with protected characteristics under the Equality Act.

Staff told us they were regularly asked for feedback about the service, which they could provide anonymously, and the department held a number of events where staff could share their thoughts and ideas.

Processes

Staff received training in equality and diversity as part of their mandatory training.

There was a process to include patients’ and carers experience of care in learning and development activities for staff. This included hearing stories of poor care and how care could have been improved from patients so staff could learn from peoples lived experience and help them develop meaningful strategies to improve care. This included stories from patients with a learning disability and patients from minority ethnic groups.

Staff views and experiences were gathered and acted on to shape and improve the service and culture. This included people with a protected characteristic, so their views were reflected in the planning and delivery of services and in shaping the culture.

Feedback from staff and leaders

Leaders had time and resources to undertake effective governance and identify risk. There was a good range of accurate and timely data and information available to understand performance and quality.

Governance systems were effective in identifying risk and areas for improvement, although pressures from demand and capacity were continuous.

Information held about patients was secure and protected.

Processes

Leaders operated effective governance processes throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss, and learn from the performance of the service.

There were good structures, processes and systems of accountability to support the delivery of the service. The service had a meeting structure for senior leaders and managers to take regular opportunities to discuss operational issues. Leaders were clear on the links to trust wide groups and committees to escalate risks and issues.

There were regular and effective meetings. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were usually taken to learn and improve.

The highest rated risk for the department was overcapacity and patient flow. The trust’s executive team were well aware of this risk, and they ensured it was not held exclusively by the department but was shared across the whole organisation. For example, to support flow in the department each ward hosted an escalation bed. This could be said to increase the risk held by all specialities, but mitigated some of the risk facing the ED, in order to share the pressure. There was strong intradepartmental working to reduce the overall risk.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from staff and leaders

The department was focused on continuous learning, innovation and improvement, although this was hampered by the pressures the service faced from demand and capacity. Staff and leaders had a good understanding of how to make improvement happen. Their approach was consistent and included measuring outcomes and impact. For example, frailty champions measured the outcome and impact of their project to reduce deconditioning of frail elderly adults. They shared details of their research with the wider staff team to demonstrate how encouraging patients to use their ability to sit out of bed and meet their own care needs, whenever possible, prevented deconditioning. This project was able to demonstrate a reduction in pressure ulcers, and improved patient confidence and a sense of wellbeing.

Staff told us they had developed resources to help patients presenting in mental distress reduce their likelihood of psychological deterioration. The resources included eye masks to help patients sleep, information on how to improve sleep, and puzzles to help patients focus on an activity that reduced anxiety

All staff told us they had opportunities to learn and develop their role. They described a learning rather than blame culture when things went wrong.

The department had recently won a prize for sustainability efforts. Staff had introduced a policy that blood tests were only carried out on people that needed them rather than having a standard set of blood tests completed for all patients. This was saving the department £9,000 a year.

The amount of plastic used in the department had been reduced and had been replaced with recyclable materials. For example, plastic cups had been replaced with paper cups.

A local school had been contacted to get schoolchildren’s thoughts on what type of artwork might like to see in a hospital setting if they were unwell. The seaside theme fedback by the school was incorporated into the art used in the children’s ED.

Processes

Leaders ensured the service actively contributed to safe, effective practice and research. For example, ED staff took part in the Royal College of Emergency Medicine (RCEM), and other national and local audits to ensure they were effectively driving improvements and demonstrating good patient outcomes. The RCEM audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care given against 3 treatment criteria each year.

We saw evidence that managers and staff carried out a programme of repeated local audits to check improvement over time, for example, sepsis, and falls audits. Managers used information from the audits to improve care and treatment by sharing outcomes with staff and introducing training and making other changes to improve performance. However, some things were not regularly audited, for example, the National Early Warning Score version 2 (NEWS2).

Some audits were conducted over the emergency medicine group rather than specific to each department such as the fluid balance chart audit. Granular level detail that might have helped improve patient care was therefore not visible.

There was a shared understanding of the negative impacts the organisation’s activities had on the environment. Staff and leaders ensured that sustainable healthcare was seen as everybody’s business. Staff were encouraged to identify areas for improvement.

The department had won an RCEM bronze ‘Green ED’ award for their reduction in CO2 emissions. This had been achieved through, by example, the introduction of electronic information leaflets that could be accessed through a QR code reducing the need for paper information, a reduction in the use of single use items like torniquets and suture packs, and a switch from plastic cups to paper.