The Robert Jones & Agnes Hunt 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

During the assessment we found that policies and documents were in date. Staff were able to show us how they accessed documents and policies on the intranet.

Staff were aware of the Freedom to Speak Up (FTSU) service through posters and training.

Leaders completed various leadership courses. Staff we spoke with told us they were able to raise concerns to their managers, who they felt were visible and approachable.

Various critical care team meetings took place. Meetings reported on quality issues such as medicine management and standard operating procedures.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture.

The trust had a clear set of values, with quality and sustainability as the top priorities. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Staff demonstrated the trust values during our inspection, as all were friendly and caring to patients, relatives/carers and each other. Staff were observed to be carrying out their role to the best of their abilities; demonstrated professionalism and respect to others.

The clinical lead maintained an honorary contract to stay current in intensive care practice and was exploring a shared contract model to attract additional intensivists, ideally with ortho-geriatrics expertise. The unit addressed the rising complexity of patients by commissioning an external review and aligning with broader NHS changes, ensuring contractual requirements for complex orthopedic hip revisions, spinal services, and enhanced care were met.

The last staff survey dated 2024 identified that 74% recommended the trust as a place to work; 92% of staff said they were happy with the standard of care provided by the trust if a friend or relative needed treatment and 75% of staff said they felt valued by their team. However, only 68.4% of staff said they felt secure about raising concern about unsafe clinical practice, and 59.6% felt confident the trust would address concerns. Almost 30% of non-white staff responded to the survey they had experience harassment, bullying or abuse from patients, relatives or the public compared to 18% of white staff that responded. however, this was not critical care specific. Working groups and action plans had been implemented and improvements was a working progress.

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.

Leaders had the skills, knowledge and experience to perform their roles. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff told us they felt supported, respected, valued and proud to work in the high dependency unit.

Leaders were visible in the service and approachable for patients and staff. Morale within the high dependency unit was high. Staff felt they were being supported to provide care and treatment which was both safe and of high quality.

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

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Effective speaking up arrangements were in place to protect patients and improve the experience of the trust’s workers. Staff had access to Freedom to speak up guardians so staff could speak up about any issues of patient care, quality or safety.

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.

Equality and diversity were reported and monitored through the quality and safety committee. There were equality and diversity champions within the service. A multi-disciplinary equality and diversity steering committee considered equality, diversity and inclusion matters for patients and staff and reported to the quality and safety committee. The trust had actions in place to ensure they followed the workforce race equality standard (WRES), the 9 Indicators-actions required were against standards 6, 9, 4, 8 and 7.

There was an equality diversity and inclusion policy with the purpose of ensuring fairness for all in addition to an equality impact assessment policy whose purpose was to help to evidence and understand the differential impact that a decision may have on different groups of people covered under the Equality Act 2010.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

A trust-wide governance structure was in place with all individual services feeding into it. We saw information was documented in unit, divisional and board meeting minutes and was cascaded up and down.

Various critical care team meetings took place. Meetings reported on quality issues such as medicine management and standard operating procedures. The meeting looked at areas such as governance reports and performance reports, finances and IT systems. Band 7 meetings included areas such as complaints, compliments and incidents.

The critical care service sat within the Musculoskeletal unit and had a triumvirate in place. There was a critical care unit risk register. The risk register was red, amber, green rated and contained controls as well as a risk review date. The risks at the time of the assessment included risks around staffing, out of hours anaesthetist cover, risk around non-compliance with GPICS standards and limited number of staff in possession of critical care post registration qualifications.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

There were 29 full-time anesthetists (the highest workforce in the hospital), with 75% of the work done by anesthetists. However, anesthetics and critical care were embedded within a surgeon-led framework, staff told us that this was not fully appreciative of their contribution. The current model relied heavily on anesthetics intensivists, but there were plans for future towards a more practitioner-led unit, supported by both local and remote intensivist input. Senior staff told us that plans were being developed to create an opt-in location for developing critical care practitioners and to expand the HDU as a training ground and safety net for deteriorating patients.

Plans were in place to rotate nurses to other neighbouring trusts to improve experience and highlight their value, as well as to integrate acute care cases such as acute spinal admissions and establish a regional spinal injury weaning unit.

The clinical lead advocated for a structural reform, such as establishing a division of perioperative medicine to ensure proper investment and leadership in critical care, and to address the limitations of the current surgeon-led structure.

The clinical lead told us they were currently building a financial case for the investment required for a well-staffed critical care unit. Viability of the unit depends on maintaining and developing specialist services to provide the case mix and funding to support a well-resourced critical care unit.

ICNARC data demonstrated good performance, but broad standards hinder the identification of specific improvement areas. The clinical lead said there was a need for more specific standards for smaller critical care units, to drive progress and ambition, as the broad standards did not pinpoint areas for improvement and may lead to lack of ambition.

The senior leaders believed that current patient outcomes were satisfactory but emphasised the need for improvement and expansion to meet growing demands and future standards such as GPICS 3. The clinical lead expressed pride in the highly engaged team and the one-to-one patient care provided in a well-controlled environment. Some senior staff also expressed their concern about the risk of relying on a single intensivist’s innovation and the necessity for continuous innovation to meet growing critical care demands.

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.

Directorate leaders engaged with external stakeholders, such as commissioners and Healthwatch. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Many positive examples were shared with us during the inspection.

Improvements were noted since the previous 2018 inspection, which included commissioning an external review and comprehensive assessment against GPICS standards. Developing a structured critical care improvement plan and an interactive dashboard of standards. A regular submission and review of ICNARC data was discussed at patient safety and quality meetings, leading to enhanced clinical governance and regular board-level discussions.

Emphasis was placed on wanting to develop a strong network partnership, particularly with West Midlands critical care networks, to ensure patient safety, effective transfers, and recognition as a serious critical care unit. Senior leaders told us that they wanted to Improve collaboration with partnering trusts. The clinical lead stresses the need for the network to recognise and partner with the hospital as a serious critical care unit.

The service 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 and effective practice.

There was evidence of improved culture across the service and there was strong leadership. The divisional leaders and ward managers acted to make improvements in the running of the critical care services. They had regular meetings where learning was discussed in a variety of forums.

All staff we spoke with were passionate about the care and treatment delivered. Steps had been taken since last inspection, although at early stages the trust were now benchmarking themselves against other similar units. Staff participated in national audits and learned from them. Staff used quality improvement methods and knew how to apply them.

Senior staff had an interest in expanding the unit to become a national spine unit, which would require additional staffing and resources. The need for more intensivists was noted, given the increased complexity and frailty of patients. The unit leaders stated they may need to become more advanced to meet these challenges, also mentioned by clinical leads. Justification for further specialisation and resources allocation was necessary, especially in comparison to larger specialised units.

The unit aspired to expand its capability for longer-term ventilation and more advanced care as part of its development goals. During 2023/24 the trust went live with ‘enhanced recovery’. This had seen significant improvements in length of stay (LOS). Trust overall elective LOS was 3.24 days (February 2024.) Improvements sustainability was a significant part of focus for 2024/25 plans and HDU was a big part of this initiative to drive patient outcomes.