Northampton General 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 patients’ care, treatment, and support achieved good outcomes and promoted a good quality of life, based on the best available evidence. We assessed 6 quality statements.

At our last inspection we rated this key question good. At this inspection we changed the rating to requires improvement. This meant leaders did not always have effective oversight or response to risks and concerns in the department to make changes or make improvements to support care for people.

The provider was in breach of legal regulations in Good Governance in relation to lack of audit activity to identify and improve care and treatment for people

Leaders did not always understand how best to meet the needs of the people using their service, however they understood the challenges in the department and embodied the culture of the workforce. They had the skills, knowledge and experience to lead well. Governance and risk structures had not been effective to ensure the delivery of safe and good quality care and treatment. There was limited meaningful improvement based on concerns found through audit and quality improvement. The department was prepared for emergencies.

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 did not have a clear shared vision, strategy and culture which was based on equity, equality and human rights, diversity and inclusion, and engagement. They understood some the challenges in the department but not how this affected the needs of people or their community.

There was a ‘Group Clinical Strategy’ (2022) that set out the aims to work with a neighbouring NHS hospital to provide ‘safe, compassionate, and clinically excellent care for patients in Northamptonshire’. The vision was also to offer a supportive culture that empowered staff to learn, develop, and innovate in partnership with the wider system.

Within the department, leaders and staff had shared values centred around patient care. At the time of the assessment, the department did not provide us with a shared vision or strategy. Following the assessment, we were sent evidence that an urgent emergency care (UEC) vision, values and strategy had been created in 2025. The values were to be: Collaborative, Inclusive, Responsive, Contemporary Prepared. Time would be needed for these to embed. It was unclear how the vision, values and strategy had been developed, if it had been implemented and how it would be monitored for success. It was not clear how this vision and values met their population and departmental needs.

We were told that the leadership in the department understood the departmental direction of travel, but that overall vision was lacking. However, some leaders felt the senior management team did not understand the nature of the pressures staff faced within the department and the solutions involved. The lack of support was felt by leaders within the department to take forward challenges affecting the hospital but primarily impacting the emergency department. Staff felt a lack of understanding from trust wide leaders to address issues affecting the hospital which directly impact on the emergency department, for example where operational delivery was seen as more important than providing safe and appropriate care to patients.

Post inspection, we were provided with evidence of how Northampton General Hospital UEC performed compared to other hospitals within the Midlands. It was unclear how leaders used this data to take remedial action or improve their performance. For example, where the hospital was within the top 10 worst performing ED for the area and above the average for the area handover time.

Strategic ambitions led by the trust from 2022 in the group clinical strategy included a proposal to improve emergency pathways with indicators such as, no patients waiting over 12 hours in the emergency department and develop pathways in partnerships with other services in out of hours and community setting to support right team, first time. Long waits as detailed in “how staff and teams work together” indicated that these ambitions are not being met. We were not provided with evidence of what improvements were being made against the strategy.

The service had inclusive leaders at divisional level who understood the context in which they delivered care, treatment and support. Leaders embodied the culture and values of their workforce.

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There was a clear leadership structure with a triumvirate leadership team which consisted of a divisional director, an associate director of nursing, and a divisional general manager who came together to provide leadership at the divisional level.

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Divisional leaders had an understanding of their challenges, staff and patients. Department leaders managed challenges presented by staff including developing functions to support the department and escalate outside of the department where required. However, they were not always able to manage risk effectively and the disconnect between the department leaders and hospital executives had caused strain between the emergency department and other specialties. For example, patient safety risks around pressure areas and patient flow out of the department.

Leaders had recognised that there was a lack of response from using Operational pressure escalation levels (OPEL). OPEL is the system used to monitor and manage level of pressure in NHS services. To improve safety and reflect pressures in the department, leaders were developing an emergency department escalation level (EDEL), which was an escalation plan to reflect departmental pressures and demand to create action.

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Leaders in the department were visible and lead by example, modelling inclusive behaviours. Staff told us leaders in the department were visible, they felt able to escalate concerns and were held in high regard.

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We reviewed data on how doctors on the emergency medicine teaching programme felt their training support had been in the emergency department and found whilst overall satisfaction has improved since 2021, there has been a deterioration in scores for workload and feedback.

Staff survey results for 2024 were similar to the national median. For example, for the question \u201cwe are always learning\u201d the national median and the trust result was 5.6 out of 10. The trust did not provide evidence of a staff survey which reflected the thoughts of staff in the emergency department alone.

Leaders fostered a positive culture where staff felt they could speak up and be heard up to divisional level. People did not always feel confident that freedom to speak up concerns would be responded to and acted upon where concerns were raised beyond the department.

There was freedom to speak up mechanisms in place and staff felt able to raise concerns to departmental leads. There was a \u2018Freedom to Speak Up: Raising Concerns at Work\u2019 policy (2022), which provided guidance for staff to raise concerns without fear of detriment.

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Where concerns escalated outside of the department, we heard mixed feedback on raising concerns through freedom to speak up, with fear of reprisal and handling of information. For example, we heard that where a concern had been raised about a staff member, that staff member had been included in correspondence removing the anonymity of the person raising the concerns.

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It was discussed in the February 2025 board meeting, that some individual staff members had mistrust in the organisational FTSU due to delay in responses from senior staff.

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There had been a review of freedom to speak up concerns. Quarter 3 of 2024-25 saw an increase across the Northampton General Hospital including urgent care. Although we were unable to see the specific concerns raised in the department, themes included; behaviours, bullying and harassment, patient safety, worker safety and detriment.

There was a team of Freedom to Speak Up Guardians (FTSU) who worked across the hospital, listening to staff who wanted to raise concerns. Information about the FTSU was displayed around the hospital.

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.

Although the service had clear responsibilities, roles and systems of accountability there was a lack of response to concerns to ensure good governance. They did not always act on information about risk, performance and outcomes.

There was not a clear system to responding to operational pressures in the department. The department was at OPEL4 status during our assessment. Operational pressure escalation levels (OPEL) is the system used to monitor and manage level of pressure in NHS services. We heard that staff did not feel there was a change in action by executive leaders during OPEL 4, as compared to lower levels of escalation. Staff told us they had previously seen action and presence of leaders during periods of increased pressure, however at the time of assessment, we saw this only occurred when critical incident level was reached.

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During our assessment, a series of deteriorating patients prompted trust wide leaders to come to support the department. However, there did not appear to be routine action taken as a result of the department being at capacity to avoid further difficulties. In response the department leaders were developing an emergency department escalation levels (EDEL) criteria, with plans for it to be approved at the next leaders meeting on 7 March 2024. The aim was to use data to evidence the capacity challenges the department faced. Long delays for patients with a decision to admit had resulted in care being provided in areas not designed for ongoing assessment and treatment of people (ambulances, pod, clinical observation area, waiting rooms, corridors). However existing systems to promote accessible timely care, and support in line with best practices, quality standards, and legal requirements were not always effective.

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We heard from staff in the department that executive leaders did not always support the department to manage patient safety concerns. Staff reported a lack of presence from executive leaders during time of pressure, an emerging fear of repercussion and that issues raised by the department were seen as an emergency department fault or issue. We heard that at times decisions impacting the department were made without full consultation with department leaders. Although there was an appropriate governance reporting structure, there was a risk that without appropriate action from the executive leader\u2019s staff may not feel able to escalate concerns.

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There were monthly divisional governance meetings that followed a set agenda, which included the number of incidents, incident investigations carried out and overdue, and recommendations for closed investigations. The agenda also included learning from morbidity and mortality (M&M) meetings, risks, patient satisfaction and experience data, and an overview of extreme and corporate-level risks within the division. Although areas of improvement were discussed, action was not always taken during these meetings, to respond to complaints and incidents.

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There was a weekly senior ED leader meeting. Whilst it did not appear to follow a set structure, there was discussion of key issues. The structure did not allow for clear actions to be recorded. There were monthly clinical governance meetings that did follow a set structure and discussed relevant information. However, risks and concerns raised during these meeting were not always managed or mitigated. For example, where it was discussed that staff training and appraisals were not in line with trust policy and incidents were not always being reviewed in a timely way, it was not clear action was being taken to address this and mitigate any risks surrounding this.

We found policies were not always reviewed regularly and although this had been identified by leaders, no action had been taken. We could not be assured policies were up to date.

We heard there were multiple platforms of data which presented a challenge. KPI's and data including discharge, time to be seen, and length of stay in hospital were available and reviewed. A report was developed and the reporting structure was in place to deliver to the executive team. We were told that sometimes the differing platforms provided conflicting data which had left leaders unable to determine their performance. As a result, the data was now requested from the business intelligence team for continuity.

The last Getting in right first time (GIRFT) report was received in February 2024 and contained 2 key actions for immediate implementation in emergency medicine, which had not been addressed:

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• Share the risk of long waits for admission across the urgent and emergency care (UEC) pathway.
• Reduce unacceptably long waits for patients in chairs and in areas with no facilities for privacy or dignity.

Risks were known and recorded for ease of access and knowledge for leaders. There was an open risk register for urgent and emergency care which identified the risks to patient safety, including those we found during our assessment. Leaders were aware of the top risks and remedial actions in place. Temporary escalation areas and auditing minimum care standards were some of the controls being used to reduce the risk. However, it was unclear how these controls were monitored to ensure they were effective where risks added in 2020 remained high. All actions on the risk register had a review date and were scored with a risk lead assigned.

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Operational audits were completed, however we were not assured that outcomes of audits were being used to make improvements. We saw evidence of various operational audits including, daily safety quality, Treatment escalation space (TES) quality and safety, Hand hygiene and personal protective equipment (PPE), infection prevention and control (IPC) and venous thromboembolism (VTE) audits. Where quality had fallen below expected standards it was not always clear what action was taken. We reviewed trust clinical audit and effectiveness meeting minutes. Whilst the meetings were in place, there was little evidence of how this group monitored audits across urgent and emergency care. There was no audit of consent within the service and oversight of the process and how it conformed with legislation was not in place.

The department was undergoing a transition from paper to electronic patient records and systems to manage this were not effective at the time of assessment. We found examples where patient notes were not available, complete or were missing time stamps, which could impact care when a patient leaves the ED. Staff and audits identified that systems didn\u2019t support safe keeping and recording on paper patient records, however we did find good record keeping when using the electronic system. Due to using 2 different documentation sources, following a patient journey was difficult. The department were due to be on the electronic patient record system during Spring 2025.

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We requested evidence of an emergency department (ED) performance action plan, which the trust did not provide. We could not be assured there was adequate oversight of performance in the ED or action taken to address performance concerns.

In October 2024, a UEC winter plan was discussed at trust board with known issues around flow and capacity understanding there needed to be a system approach to admission. Plans to improve patient experience were developed through the UEC steering group to ensure shared governance arrangements to improve flow and discharge. This plan covered 2 sites under this provider and it was unclear from the information we reviewed how each UEC department would need different support, goals and interventions to support their population, demand and risks.

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The service understood their duty to collaborate and work in partnership, so services work seamlessly for people, however this work was limited.

Leaders had done some work to collaborate with external stakeholders. There had been a combined piece of work involving police and representatives from places of safety, which included other local providers, to collaborate on care plans for 'high intensity users' with a mental health illness, who frequently present at other local emergency departments, are discharged and then attend Northampton General Hospital.

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The \u2018High intensity user program\u2019 was implemented using external funding which had later ceased. Departmental leaders continued this programme without additional funding, or executive leadership support, because the care plans were extremely effective for patients, and the meetings between teams were productive. At the time of assessment, we found that the department were meeting with some stakeholders about high intensity users to develop care plans.

The department was working towards improving cross speciality awareness. There was a review into community responsiveness and monitoring the number of patients in care homes who had advanced care plans but have difficulty accessing other pathways, so are conveyed to the emergency department (ED). The ED were aiming to recruit a GP into the department, but were finding it a challenge at the time of assessment. We were told there was an open invite from hospital specialties to work supporting flow in the hospital.

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We found limited examples of stakeholder engagement. There was trust led a programme to improve haemoglobinopathy for patients attending the hospital. We saw evidence that patients feedback and questions from patients were being responded to. Hemoglobinopathy is a clinical term used to describe a genetic blood disorder. Although peoples\u2019 views were collated, the department did not always act on these.

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Post inspection, we were sent evidence that there were future plans to engage with patients and the public about the use of restraint in the emergency department. It was unclear from the evidence we reviewed, what the timeframes for this to be put in place. The group terms of reference had a review date of May 2023.

There were multi-stakeholder meetings including the integrated care board (ICB) to share intelligence and particular patients. There are discussions around shared risk management and investigations that impact the system.

The service had some focus of continuous learning, innovation and improvement across the organisation and system. However, learning opportunities were not always identified to deliver equality of experience, outcome and quality of life for people. Staff contributed to research.

Changes and action to address areas of improvement had not always been successful. There had been a ‘Getting It Right First Time’ (GIRFT) review and report completed in February 2024 and a report in October 2024 identifying areas of improvement including reducing input to ED, optimising flow and improving discharge. Updates and actions were identified in November 2024 and February 2025, however it was unclear what progress had been made.

The last GIRFT report contained 2 key actions for immediate implementation in emergency medicine, which were similar to our findings: Share the risk of long waits for admission across the urgent and emergency care (UEC) pathway and reduce unacceptably long waits for patients in chairs and in areas with no facilities for privacy or dignity. Finding in the report were also similar to those from an earlier report. Therefore, we are not assured that the department was responding to recommendations in a timely way.

Following the assessment, we were provided evidence of a GIRFT action plan, which had been updated on 24 February 2025. Although the action plan had aligned the actions to workstreams, it is unclear what progress has been made, estimated timescales and how any actions will be audited for efficacy.

There was evidence that innovative processes were put in place by staff within the department, for example the ‘EDEL’ devised by a department leader in response to inaction in the emergency department when hospital escalation levels were at OPEL 3 and 4.

Consultants did not have protected continuing professional development (CPD) time or a dedicated consultant-only meeting.

The department held monthly mortality review meetings, where deaths should be reviewed in line with national guidance. However, leaders we spoke with were not confident this process was in line with recommendations from the Royal College of Emergency Medicine (February 2025), which recommends mortality reviews include quality measures such as length of stay in the department and any delays in patient assessment including initial assessment, time to clinician and corridor waits. We did not see evidence that there were governance processes in place to monitor the correlation in long waits in the department, which was a known issue, so we were not assured learning was in line with best practice recommendations.

We found limited research took place in the ED. At the time of assessment, the department was due to be involved in a new research project named “UnCorKED” which aimed to understand escalation area and corridor care in the UK emergency department. The research was identified in November 2024 and due to begin in March 2025.

We saw examples of QI, however these were not yet complete, require a reaudit or further information before meaningful change can be implemented into the department. For example, During the assessment, we were provided evidence of quality improvement project from January 2025 aiming to improve the culture of delivering 1:1 care for patients by health care assistants (HCAs). Following additional training, confidence had improved amongst HCAs, however we were unable to see the impact of this work for patients. One of the challenges fed back had been that 1:1 care for a whole shift was too long and that 4-6 hours was better. This wasn't addressed during the project and there was no clear plan to review if patients and HCAs felt the benefit of the additional training in the long term.

Further examples included, pain assessment and satisfaction in line with RCEM standard, improvement of the neck of femur (hip) fracture pathway and the prevention of unnecessary cannulation. At the time of assessment, the service, we were unable to see the impact of the QI projects and how QI was being used to improve the service provided for patients.