Queens 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.

At our last assessment we rated this key question good. At this assessment, the rating stays as good.

Leaders had the necessary skills and were well regarded by staff. Staff felt respected and were listened to. The service had a management and governance structure that was effective, although opportunities to improve performance were limited.

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.

While we did not see and overall clear plan for the department, there was evidence of recent service redesign initiatives and leaders told us of their plans for further improvement. There was a positive culture within the department and staff supported one another to cope with pressure and workload and adhered to the trust values.

The ED shared the wider trust values which were to deliver “Compassion”, “Openness” and “Excellence” under the heading of “Exceptional Care Together”. There was an overall ambition to bring the EDs at Burton and Derby into a single operating framework. However, we did not see a plan for how this would be actioned.

Staff with clinical leadership responsibilities told us how they saw the department had developed, and where they saw that change going, but we did not see, nor were told of an overall departmental strategy. There was a focus on moving patients out of the ED into areas where they could be effectively and safely treated. Examples of this included the recent introduction of virtual ward beds under the management of the ED and an aspiration to move more patients through to an enhanced Same Day Emergency Care (SDEC). Staff were positive about recent and ongoing change, but they did not talk about longer term plans.

Staff told us they were listened too when they proposed changes or made suggestions and they would be given an opportunity to put these in place themselves by being given protected time to do so. We saw several genuine examples of this, including the redesign of the deep vein thrombosis (DVT) pathway and a system to better record contact details for new staff. When speaking to managers it was clear they were proud of what other members of staff had done. Senior managers told us they noted a positive, rather than a defeatist attitude pervaded the department and they were proud of that.

While many staff told us there was low morale in the department and expressed their frustrations, this was not directed at their immediate colleagues and rarely at other areas of the hospital. Rather their frustration was directed at the workload and pressure on the department, and we generally saw staff being supportive of one another. We did not see tensions between the different professions that worked in the department.

Staff frequently told us they felt valued and respected by their managers and their peers. We were also told of a happy and friendly department, and many of the interactions we saw between staff were, while professional and against the background of a busy and stressful department, reflective of people happy in their work. There was good staff retention in the department and both staff and leaders attributed this to a friendly and supportive culture.

Many staff spoke highly of their leaders and managers. One charge nurse said they “loved it here, the team are incredible, matron support is fab, they will always come and help and support”. However, while staff were complementary of their leaders in the department, they sometimes expressed the view they felt under pressure from the operations function of the hospital. However, when we observed the site level meetings it was clear that all relevant departments and wards were put under pressure as the managers tried to manage flow and balance capacity and risk across the whole hospital.

The trust had a disability equality network, a race equality network, and a Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and more (LGBTQ+) network. The role of the networks included visible representation and acceptance of difference within the workforce, and safe space where people could access advice and information.

We understood that, at trust level, feedback from staff with protected characteristics under the Equalities Act (2010) had shown they were more likely to have a less favourable experience at work than others. Senior leaders had invited leads from the equality diversity and inclusion networks to the divisional board meetings to help understand the reasons for their experiences and to develop meaningful strategies to redress these inequalities.

The service had leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty.

Organisationally the ED was part of the Burton Acute Medicine Business Unit (BAMBU). For the ED itself the senior leadership comprised a general manager, a clinical director and 2 matrons.

Managers and leaders had the skills to do their jobs effectively. When we spoke to staff, they expressed confidence in their leader’s abilities and were often complimentary of them. This was reflected in the most recent, albeit outdated, staff survey results.

Leaders worked well together, and we observed they were both professional and friendly. Leaders understood the pressures that the department was under and were continually looking for ways to solve problems, support their staff and provide safe and effective care for patients. Staff told us leaders with clinical qualifications would often work directly to support patient care. However, while supporting staff and relieving pressure it compromised the time they could spend on other parts of their roles and responsibilities, and we were told of senior staff working long hours.

Medical staff had a clear management structure with a lead, and other senior clinicians taking on specialist lead roles such as for trauma and paediatrics. On a shift basis there was leadership from an Emergency Physician In Charge (EPIC). Medical staff in training roles told us they had no concerns about leadership.

Similarly, there was a management structure within nursing with senior leadership roles at matron level. Senior nursing staff were visible during our inspections as were business managers, and staff told us this was typical. During interviews with these senior staff, they demonstrated a sound understanding of the department. They were almost always aware of issues we had noted, expanded on them explaining solutions and mitigation, and were forthright in bringing other problems as well as successes to our attention.

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

Staff were aware of who the freedom to speak up guardians were and how to access them.

Staff to whom we spoke did not express any reservations about speaking up and several said they readily expressed their concerns to managers. We observed this during a huddle where there was a disagreement about the safe staffing of an escalation space. The member of staff raising concerns was listened to and a compromise reached.

One recently recruited staff nurse told us they knew about the whistleblowing policy and how to contact freedom to speak up guardian. However, they also said they had the confidence to challenge outside of that protection and gave an example where they had queried a wrong prescription by a senior member of staff.

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.

Governance and management arrangements generally supported the delivery of safe and responsive treatment and support. The service had clear responsibilities, roles, systems of accountability and governance. They acted on information about risk, performance, and outcomes, and shared this securely with others when appropriate. However, there was limited audit of compliance with national standards.

The service had clear responsibilities, roles, and systems of accountability. Leaders, including local, divisional and trust level engaged with a range of governance groups and meetings. This enabled leaders to monitor quality and safety. However, this did not result in the consistent delivery of safe and responsive treatment and support.

Divisional and business unit meetings were well structured and ran to a “business cycle”. This ensured topics were regularly discussed, but that they were only discussed as often as they needed to be.

There were twice weekly senior staff meetings where current issues and all incidents were discussed. Attendees shared outcome or actions with staff through briefing and noticeboards. It was expected that all senior nursing staff would attend but this was not usually possible because of pressures on their time to support care in the department. These meetings had action logs to ensure tasks that had been agreed were allocated to individuals or groups and progress monitored.

As part of the trust’s governance arrangements there was a risk register that identified the key risks affecting the ED and any plans or mitigation to reduce those risks. When asked for the 3 top risks in the department senior and middle managers cited overcrowding, paediatric provision and difficulties in transferring patients to other hospitals. This aligned well with the divisional risk register we obtained from the trust through our data request. We saw through the notes of divisional and business unit meetings that the risk register was on all agendas, and time was put aside regularly in meetings to review specific elements of it.

All staff and managers had access to a “live ED dashboard”. This gave detailed, current information as to the occupancy of the different areas of the department and key performance indicators such as time to assessment, time in the ED and breaches of those standards. However, there was no system to readily identify the acuity of patients in the department which is a key component of the pressure a department is under.

Within the department there was a clinical governance noticeboard that included information about risks, incidents, friends and family scores, and a “how are we doing board”.

There was good emergency and major incident planning which involved rehearsals and exercises. Major incident (MAJAX) equipment and documentation was readily available including in the operations room from where a MAJAX would be managed.

Senior staff told us they were aware of the Royal College of Paediatrics and Child Health (RCPCH) standards, known as “Facing the Future: Standards for children and young people in emergency care”. It was recognised that several of the standards were not met but we saw the provider had carried out a formal gap analysis and was working on plans to either mitigate or achieve the standard.

The service experienced some difficulties in working across several agencies that resulted from the hospitals location. However, managers and staff understood their duty to collaborate and work in partnership, so services work well for people. They shared information and learning with partners and collaborated for improvement.

The service worked with the two NHS ambulance trusts who conveyed patients to the department and their staff to ensure joined-up care. However, managers told us there were differing levels of engagement by the ambulance trusts. One trust engaged through weekly discussions and the other provided a Hospital Ambulance Liaison Officer (HALO) funded by the local ICB.

The hospital was at a location where around 40% of patients came from the ICB patch in which the hospital was located, another 20% from an adjacent county, another 20% from a second adjacent county and the rest of the patients from other areas. As a result, managers dealing with flow and capacity had good engagement with their host ICB but received much less input from other ICBs. This affected their ability to discharge patients to those areas affecting flow in the ED.

Similarly, the hospital was where 3 police force areas met, and this introduced complexity and extra work as the forces had different approaches and expectations as to how they dealt with patients, particularly those with mental health needs, that they brought to the department.

Staff in the ED worked to a set of internal professional standards (IPS) which explained how they should work with other areas of the hospital. We saw they worked hard to implement these standards, but this was not always effective because of pressures on other parts of the hospital.

When the department carried out surveys they recorded and analysed attributes of the studied population including diversity and protected characteristics. When managers developed action plans, they took account of this data to ensure that people where not being disadvantaged and that services took account of the needs of different groups.

The service understood their duty to collaborate and work in partnership, so services work well for people and they shared information. However, while there were initiatives to respond to risk and make improvements there was sometimes not the capacity to focus on innovation.

When the department was presented with challenges, we saw clinical staff and managers responded with plans to improve, through elimination and mitigation of risks. This was done within project management frameworks that measured the efficacy of changes.

One example we saw was the introduction of a rapid falls assessment tool, specifically designed for emergency departments to carry out a basic assessment in the department prior to a more comprehensive assessment should the patient be admitted.