St James's 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At this inspection we rated well led as requires improvement.

This service scored 57 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Leaders did not understand the challenges and the needs of people and their communities.

Leaders ensured there was a shared vision and strategy for the service. The trust had a plan in place to build a new hospital allowing for centralisation of the children’s services on one site along with maternity services. We saw that there was a structured planning process in place allowing for people who used the service, staff and external partners to contribute to the plans. However, we found that the direction was over-reliant on the development of a new hospital site. The timeframe of which was not wholly within the control of the service at the time of inspection. There was no clear direction that supported current ways of working beyond the new hospital being built.

A consultation regarding the proposed new hospital had been carried out including targeted work to reach families from Black African and Pakistani communities. There was also easily accessible information made available for those with for example, hearing impairments or learning difficulties.

Staff at all levels had an understanding of equality, diversity and human rights. Staff were clear about the changing complexities of families care needs both locally and the nationally changing picture.

The service worked in partnership with the regional neonatal networks to support understanding of local challenges and share learning that supported inclusion and engagement of people and communities using the service.

Staff were praised for their dedication to teamwork through regular monthly staff award processes.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service had a triumvirate team made up of senior and experienced staff with responsibility for the neonate service alongside all other children’s services. However, they did not always demonstrate a clear understanding of the context in which they delivered care. We found that babies were transferred between St James hospital and Leeds General infirmary according to pressures for cot spaces. This did not always support babies needs as some babies were transferred to St James when they had a higher level of care need that should have been provided for. Staff we spoke to were not always clear about the level of care provided for on the unit at St James.

Leaders at this level were aware of challenges around ensuring their visibility for all staff within the unit at St James site as they recognised there was a larger proportion of children’s services at the Leeds General Infirmary site. They mitigated this to some extent as they recognised that a lot of the neonatal staff team rotated across both sites.

Unit leaders and team leads were visible at St James and were knowledgeable about the issues and priorities for the service.

Practice Nurse Advocates were in post to support development of leadership skills within the teams.

Nurses were supported to progress through advanced neonatal nurse practitioner training.

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

Staff were encouraged to speak up within the neonatal service as part of an open and supportive learning culture.

The trust had an established Freedom to Speak up process where staff could raise concerns if not addressed through the line management route. Staff were aware of this service. There were three freedom to speak up champions within the children’s hospital service. Staff had not raised any recent concerns with the freedom to speak up guardians.

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.

The trust supported work based learner programmes and international nurse and medical staff recruitment to support diversity within the workforce. There was an equality, diversity and inclusion policy in place. Staff completed equality, diversity and human rights training.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The neonatal services were part of the trusts children’s clinical service unit (CSU). There was a clear governance structure in place for the neonatal teams to feed into the children’s CSU. There was a monthly specialist quality governance and risk meeting attended by the multi-professional neonatal team. This meeting fed into the quarterly Children’s Hospital quality assurance group which then fed into the wider trust quality structure. There was a consultant and nurse lead for governance. We reviewed minutes and saw that learning from incidents was shared at this level.

There was a risk register in place for the neonatal services on both hospital sites. We reviewed this and saw that controls were put in place to manage risk areas and mitigate risks. We saw risk scores reduced with mitigations and ongoing review took place where scores continued to indicate risk concerns.

During inspection we found differences in staff understanding of the level of need the unit provided care for. The unit was identified as a special care baby unit. There was admission criteria in place in line with national guidance for a special care baby unit (level 1 care). However, staff frequently told us during inspection that they understood the unit to provide care at level 1 and 2. Level 2 care is for high dependency babies. During inspection we reviewed recent admissions and found examples of babies admitted who did not meet the criteria for admission on the unit. They required admission to a unit dedicated to providing a higher level of care.

We identified concerns during inspection that the infrastructure and premises were insufficient to adequately care for the babies admitted that required a higher level of care than that of a special care baby unit. We raised this with the trust following the onsite inspection. Leaders told us that a review of premises and the service footprint would be completed to identify works required to improve the environment. We also raised concerns regarding our observations of insufficient equipment to be able to provide intensive and high dependency care and treatment safely. Leaders told us that procurement of necessary equipment would be expedited following concerns raised following the inspection.

We found areas of the environment in need of repair, for example door locks required fixing. We highlighted a number of concerns to staff during the inspection. We saw repairs were carried out promptly following this, however these were not new concerns and leaders recognised that there needed to be stronger oversight and escalation processes where jobs were not completed in a timely way to ensure safety. We also saw that equipment was aged and there was a risk of failure. This was recorded on the trusts risk register and there was a five-year replacement programme in place.

The neonatal team were represented at the local Neonatal death overview panel. Learning and risks were shared through the governance structure. There was a multi-disciplinary, multi-agency child death overview panel in place to review all deaths within Leeds. The service was also represented at this panel.

Perfect ward meetings were held monthly. These meetings were attended by ward managers and matrons. The meetings supported sharing of information relating to key themes regarding everyday practice, for example, safeguarding, IPC, staffing, health and safety concerns reported. Actions were recorded where improvements were needed. Evidence of improvements was also recorded.

Lead nurse meetings had been started in October 2024 and were to provide an opportunity for lead nurses to discuss risk, share learning and service changes and discuss patient safety issues. The terms of reference were in development at the time of inspection.

There was a clearly established process for reporting and investigating patient safety incidents. There were clear structures in place to ensure oversight at all levels of the organisation and to ensure significant information was shared within the relevant committees and forums.

There was a clear process in place for reporting and escalating concerns through the governance structure to the CSU leadership team, Executive Directors and Trust Board.

During inspection we observed three electronic systems for recording information in use. We observed one meeting where staff had two systems open to cross check information against each system. We heard that discharge information required input onto three systems to ensure follow on care. This posed a potential risk of error in information getting missed or incorrectly duplicated. This was a recognised risk and was recorded on the risk register. This was a duplication of data and information.

Records were stored securely.

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 told us about partnership working with other agencies across the community to support families in their ongoing journeys.

There were recognised partnership working arrangements in place with other regional services. The team were active participants in the regional networks for sharing of best practice and learning from other neonatal services within the region. We saw examples of learning shared across the region through this network. The team had active involvement in cardiac network meetings and palliative care services across the region.

The team participated in a regional neonatal voice co-production group meeting with representatives from a range of other organisations and parent representatives.

We also heard that neonatal services worked effectively in partnership with other teams within the trust.

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, effective practice and research.

Members of the neonatal teams across the trust had been involved in research and innovation projects to support development of services locally and nationally. For example, members of the team had been involved in working groups for development of national frameworks and guidance related to British Association of Perinatal Medicine (BAPM) standards.

We saw recently published research papers and articles by members of the medical teams along with contributions to key textbooks available nationally. The service were active participants in research studies. The service also planned to begin working in conjunction with the local university regarding child health outcomes.

We also heard that members of the neonatal service were involved in collaborative work with the local ambulance service to enhance newborn life support in out of hospital settings.

Staff were not always knowledgeable about quality improvement projects taking place. However, following inspection we were provided with details of a number of quality improvement projects that had been shared during December 2024 and June 2024. The projects were identified as areas for improvement through patient feedback, incident reviews, NNAP audit data and waste reduction schemes. Details of progress and evidence of improvement following the projects was not always evidenced with clear time scales and further action plans.

We saw leaders would liaise with other external agencies and peers in other neighbouring hospitals to support improvements where there had been variations in practice or an increase in incidents identified.