University 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

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.

This is the first time we have inspected this service. At this inspection we rated the service as good. This meant leaders were inclusive and capable and embodied the culture and values of the service. Staff were passionate about driving improvements, innovation and research in the service. Staff worked collaboratively with key external agencies and partners. However, governance processes were not always effective.

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.

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.

Leaders ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision. The service was part of the Women and Children’s directorate and had a combined vision and strategy. The current strategic plan was due to come to an end, at the end of December 2025, with the new strategy for 2025 to 2030 was awaiting board sign off. Information shared by the service indicated both the current strategy and the new strategy were in line with the trust’s wider organisational strategy which covered the time period of 2022 to 2030. All items on the Women and Children’s strategy which were due to come to an end at the end of December related to gynaecology were recorded as completed.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding. All staff told us there was a positive culture at the service and they enjoyed working there, with a number of staff having worked within the service for a number of years. Staff felt valued and respected and believed their concerns and views were listened to and felt they were able to raise their concerns freely without any fear of reprisal. The staff survey from 2024 showed 76.2% of staff from the service were enthusiastic about their job and 95.2% felt they were trusted to do their job. Both of these elements from the survey demonstrate a positive culture where staff feel trusted. However, there was no comparison to how the service previously performed in relation to the culture and how staff feel trusted.

Staff at all levels had a well-developed understanding of equality, diversity and human rights and they prioritised safe, high quality and compassionate care. There were no concerns raised within the service about any types of bullying, harassment, or discriminative behaviours. The most recent staff survey from 2024 showed 7% of staff indicated they had been personally exposed to discrimination at work from a manager, team leader or other colleague. However, there was no comparison to how the service previously performed in relation to discrimination. Staff we spoke with did not believe there were any issues around discrimination.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered and risks were managed well. The service had a triumvirate in place which included a group director of operations, group clinical director and group director of nursing and allied health professionals. All staff we spoke with were complimentary about their immediate leaders. They believed they led by example and modelled inclusive behaviours. Staff told us leaders, including the senior executive team, were visible and approachable and they demonstrated behaviours they looked up to.

Leaders were knowledgeable about issues and priorities for the quality of the service provided, and could access appropriate support and development to their role.

Leaders were alert to examples of poor culture which had the potential to impact the quality of care patients received and the culture within the service. Staff told us the human resources team were extremely supportive and where any action was required, this was done with their support and completed in a sensitive but effective manner.

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

Staff and leaders acted with openness, honesty and transparency. All staff we spoke with told us their leaders acted in ways which they believed was honest and transparent and this empowered them to behave in the same way.

Staff we spoke with were aware of the Freedom to Speak Up Guardian and their team. Staff approached the team for support when staff were unable to speak directly with their line manager and felt comfortable in doing so. However, staff told us they were confident speaking directly to their line managers so did not feel the need to contact them.

When something went wrong, patients received a sincere and timely apology and were informed of any actions being taken to prevent the same happening again. Staff were open and honest with patients in their care and gave them and their families an apology and a full explanation if things went wrong.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Leaders took steps to remove bias from practices to ensure equality of opportunity. All staff were required to complete equality, diversity and inclusion training tailored to their roles. At the time of our inspection, all staff except the medical staff were 100% compliant with this training requirement. Medical staff recorded a compliance rate of 89.7%.

Despite staff saying they felt valued by their colleagues and leaders, the staff survey did identify some areas of concerns about staff experiencing harassment, bullying and discrimination, although no additional information about whether this had worsened or improved since the previous survey was provided. However, the survey results indicated staff were confident any concerns around poor behaviour in terms of discrimination or bullying would be managed appropriately.

Leaders made reasonable adjustments to support staff to carry out their roles well. Staff told us if they required reasonable adjustments to be made, they were confident this would be accommodated.

The service did not always demonstrate effective systems and good governance, and this impacted staff ability to manage and deliver good quality, sustainable care, treatment and support.

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Staff regularly attended the Quality Improvement and Patient Safety (QIPS) meetings. Information from these specialty meetings reported into more broader assurance meetings and patient safety meetings. Meetings had standardised agendas to ensure a consistent approach. We requested examples of the minutes from these meetings and found thorough review of pertinent governance and performance issues.

Staff told us there were regular opportunities for important information to be shared with staff. There were daily ward huddles which staff would receive any key information including any learning which needed to be shared. Formal ward meetings were also completed; however senior leaders highlighted the variance between the minutes as the meetings were at various stages of maturity. Senior leaders identified the need to develop and support ward level governance processes and support those in charge to ensure this was developed. Examples of ward meeting minutes shared did not follow any set agenda, however it was clear key important information was shared during these meetings. However, it was not evident from the minutes that any areas of concern identified during these meetings were escalated upwards and no actions for staff were recorded.

In addition to the daily huddles and more formal ward meetings, there were additional opportunities for the sharing of key information and actions which included but was not limited to monthly accountability meetings between ward managers and the group director for nursing and allied health professionals, group board attendance and the weekly huddle board safety message book. The ward also had a focus board which concentrated on 5 specific issues. During our inspection we observed the 5 key areas for focus related to the introduction of Martha’s Rule, malnutrition screening compliance, concerns raised about noise at night, staff experience around the incorrect acuity levels being reported and the overflow of waste medications.

Staff used a system to manage current and future performance and risks to the quality of the service and took a proportionate approach to managing risk. The risk register mostly reflected the risks which staff discussed with us during the inspection. During the senior leadership interview, we were told that medical staffing was considered to be one of the main risks to the service, especially due to there being only 1 member of the medical staff who could provide sub-specialties of endometriosis and urogynaecology care and treatment. On the risk register, the issues which identified where medical staff was an issue was not in line with the concerns shared during the interview. All other areas of concern and risk which staff had identified during the inspection were noted on the risk register. The highest risk after mitigation was delays in treating gynaecological patients in a timely way, resulting in poor patient experience and inability to cover the emergency gynaecology unit within the current consultant establishment. Both of these were given a risk score of 12 and red, amber, green ‘RAG’ rating of amber.

The delay to providing timely gynaecology treatment to patients was identified as a risk. Following the COVID-19 pandemic, the waiting lists for all specialties including gynaecology escalated and the service have worked hard to reduce the waiting lists. However, within the group of patients waiting for treatment, it was acknowledged there was an element of risk to their health. The service therefore implemented a system for reviewing patients who were waiting for treatment to establish if treatment was still required and to also establish if their health had worsened (harm review). Staff told us if they identified a patients' condition had deteriorated, this would be escalated and further prioritisation would be completed.

The service maintained a dashboard which recorded performance metrics, information and statistics. This information was discussed at relevant governance meetings. On the focus board, we also observed ward level key performance indicators which included but was not limited to catheter care, falls, number of pressure ulcers and mandatory training compliance.

The service had a programme of clinical and internal audit to monitor quality and operational processes. Audits identified fairly positive outcomes for patients, however the audits based on processes, identified areas of where improvements were required, but sustained improvement waivered. Examples of this included NEWS2 and VTE assessments. We identified areas during our onsite inspection where staff had not complied with local policy, and the services own audit data had identified challenges to improvements.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders engaged with people, communities and partners to share learning with each other which resulted in continuous improvements to the service. Staff discussed examples where effective engagement with partners and the local community had informed projects which were in progress as well as helping to put forward future projects which will benefit the women using the service. An example of this had been in relation to the Health in the High Street model where staff told us the engagement from those in the community and patient forums had been instrumental to the project.

The service mostly focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

Staff and leaders had a good understanding of how to make improvements happen. There were processes to ensure learning happened when things went wrong. The approach was consistent and included measuring outcomes and impact on women using the service. Staff discussed examples of where learning had occurred as a result of serious and significant incidents. One example which was discussed was around the mislabelling of specimens and the learning which resulted from this.

The service did not hold their own regular mortality and morbidity meetings due to deaths within the service being low in numbers. However, the service had other opportunities where any learning relating to the morbidity of gynaecology patients could be identified and shared. Despite mortality being rare within the service, this was a standard agenda item on the QIPS meetings.

Leaders encouraged staff to speak up with ideas for improvement and innovation. Staff told us they were encouraged to raise any ideas they had around improvements for the service. Most staff we spoke with told us the service had outgrown the current area where they were located and had started to share ideas with leaders around how they believed improvements could be made.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work which included research. Research was one of the 5 main priorities on the trust’s operational strategy for 2022 to 2030. All specialties including gynaecology had a research strategy which aligned with the overall operational strategy. The service had several ongoing research projects which were all entered on to the research inclusivity dashboard.

The service was involved in many innovative projects which would help to improve women’s health within Coventry and Warwickshire. As part of some of the innovation projects, the service had applied to become an endometriosis centre. The service also provided robotic surgery for benign gynaecology surgeries which included surgery for endometriosis and fibroids.