The Princess Royal 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 Requires Improvement. At this assessment the rating has improved and rated as Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 evidence showed a good standard. 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.

The trust had a clear vision and a set of values, with ‘Putting Patients First’, ‘To provide excellent care for the community we serve’, and values; Partnering; Ambitious; Caring; Trusted, was underpinned by an ambitious 5-year strategy. The trust was focusing on 6 strategic themes to deliver their vision, these were continually reassessed to check that the trust was continuing to respond to challenges in the local community, reducing health inequalities and improving population health and well-being. The trust engaged both externally and publicly around the trust vision and strategy.

The 2022-2027 trust strategy set out the trust’s ambitions, detailing the ways in which the trust would improve the delivery and quality of patient care, support and develop the workforce, address key challenges, and further develop a culture of improvement across the organisation. It also described the values and behaviours to which the trust was committed. Through their collaborative working with the Shropshire, Telford and Wrekin (STW) Integrated care system (ICS), the strategy was aligned to the ICS joint forward plan (2023-28). There was a robust strategy for achieving the priorities and delivering good quality sustainable care. However, there was a significant amount of work to be being done to fully realise the strategy with huge importance being placed on the Hospital Transformation Plan (HTP). Staff and the senior team we spoke with were extremely positive about the future and that they were on the right trajectory for future.

There had been a positive shift in culture since our last inspection. We had received overwhelmingly positive feedback about the senior leaders, and the direction of travel the trust was taking. Most staff we spoke with during our inspection knew and understood what the vision, values and strategy were and their role in achieving them. The vision, values and strategy had been developed in collaboration with staff and staff were able to keep up to date with progress through the trust intranet, regular bulletins and through visual displays across the trust.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff could explain how they were working to deliver high quality care. Staff understood equality and diversity and its importance in a strong culture. They talked with us about patients and staff being individuals and needing different inputs into their care and treatment or working life to meet their needs. Senior staff we spoke with understood the importance of supporting an open culture where patients, their families and staff could raise concerns without fear and the importance of appropriate learning and action being taken because of concerns raised.

The department was often overwhelmed with patients and at time not enough staff to carry out all the required tasks in a timely manner, some seniors told us that staff were ‘burned out’ that caused some shortages due to sickness, stress. Despite this, front line staff felt listened and supported by their seniors, and aware staffing was challenging but all worked well together through challenging time.

The evidence showed a good standard. 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.

The senior leadership team consisted of the matron, clinical lead and centre manager who was new in post. Leaders were generally visible and available to their staff and teams. They were clear on the issues they were facing and were alert to some pockets of some poor culture, and the impact this had on some of the staff. They met weekly, informally, and monthly formally to discuss the department and actions needed.

Leaders had the skills, knowledge and experience to perform their roles, with a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders were supportive of their staff and caring about the service. Leaders were aware of how the ED environment and pressures in the workplace affected the welfare of their staff. We were told they supported the staff who worked hard and tried to ease the pressures of working in such a busy environment. There were daily escalations on bed meetings, divisional matron meetings but staff did not always feel the impact of these meetings.

There was a team of band 7 nurses who managed and ran the department supported by the matron and group lead. Some staff told us matron and centre lead were approachable, whilst other staff told us they were not. There were usually 2 or 3 band 7s on each day and they were all assigned to work 60% of their time clinically and 40% in the office. Staff told us their immediate managers were “really supportive as they have worked in the department and understood the pressures, they were under”.

Leadership development opportunities were available, including opportunities for staff. There had been some significant progress in the service since our last inspection. Safety was no longer rated inadequate, and those areas where we found a breach of regulations had been mostly addressed. All band 7 nurses were completing a development programme.

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.

Staff felt able to raise concerns without fear of retribution. Staff raised concerns or issues with their managers and would also report through the FTSU process.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Staff were aware of the Freedom to Speak Up Guardian and knew who their guardian was at the trust. Resident doctors were also aware of their guardian for safe working and how to escalate concerns if they had any, staff we spoke with commented on how happy and supported they felt.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. Staff we asked said they knew about whistleblowing and how they might approach organisations beyond the trust, such as Care Quality Commission, if they felt this was needed.

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.

The evidence showed a good standard. 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. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Senior leaders explained that the executive board were well sighted on the challenges facing the ED and there were good lines of communication, that some of the board members listened and were sympathetic and would take immediate action to support the department, although they did not always have the means to provide a solution to the immense pressures ED was under. Although there had been improvements with the creation of additional services since our previous inspection, ED was not always able to provide services to meet the needs and rising demand of the local population. Services had evolved, patient numbers had increased, but the service was not always able to meet demand. This resulted in patients waiting for long periods of time to be seen in the department and to be moved out of the department into a hospital ward. The waiting area was often crowded along with all other areas of the department. Senior managers analysed capacity and demand daily and capacity concerns were high on the risk register, but mitigations were only making limited inroads to improve flow and waiting times for patients in the department. More was needed to be done to improve care for patients. The increased demand meant that the department was not being run as an emergency department and staff were not always able to ensure all patients were being seen promptly. Despite the pressures, staff cared for patients as best they could. Senior leaders were sighted on the corporate and clinical risk register. They told us about risks being allocated, reviewed and with mitigation being in place.

The Trust urgent and emergency care (UEC) improvement programme for 2023/2024 had an objective to deliver continuous improvements in patient flow in a sustainable manner. The ED transformation project was launched in October 2022 with a work stream focused on initial assessment and flow. There were various workstreams, that included, therapies, discharge and flow, virtual ward direct access pathways, escalation, and Frailty. An ED matron led the task and finish group to allow focused work and leadership. Actions and trajectories continued to be monitored through the emergency transformation group and the work stream task and finish groups. We looked at minutes of the trust improvement group chaired by the deputy chief operating officer which revealed that workstreams had progressed immensely since our last inspection.

Leaders took a proportionate approach to managing risk that allowed them to assess new and innovative ideas. The service used effective governance processes to monitor risks and outcomes, and to drive improvement. The risk register for the ED had set of key risks as well as actions, mitigations, and environments, workforce and financial strategies. Key reports kept leaders informed of challenges faced with short, medium and long-term plans identified. All risks were rated as Red, Amber, Green (RAG) with individual staff members allocated to each action associated with risk.

There was a good range of accurate and timely data and information available to understand performance and quality, there were structures, processes, and systems of accountability to support the delivery of the service. The service had a meeting structure which gave senior leaders and managers regular opportunities to discuss operational issues. Leaders were clear on the links to trust-wide groups and committees to escalate risks and issues.

We saw that systems were in place to monitor the quality of the care. The governance system monitored the quality of care provided, patient feedback, staff performance and changes to best practice guidance. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Leaders undertook a range of reviews and audits to monitor performance. Leaders and managers discussed the results of audits at governance meetings, which they also shared with the board and appropriate staff for learning.

Staff undertook and participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. The service had plans for emergencies for example, adverse weather or a flu outbreak, winter pressure.

Where cost improvements were taking place, they did not compromise patient care. This was evident by the ongoing positive changes such as hospital transformation programme, and the trust coming out of financial special measures, which is part of the NHS oversight framework (SOF) segment 4, where NHS trust enters a Recovery Support Programme (RSP), trust was now out of RSP.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service understood the duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement. Key organisations included the local NHS ambulance service and the local NHS mental health trust. They also included the integrated care system for the region and other system partners who had links with other health and social care services.

There were several pathways to support patients who would otherwise be in hospital to receive the acute care, monitoring and treatment they need in their own home. The team were continuing to work with external partners on initiatives to help some patients avoid admission to hospital when they could be treated at home, as part of a virtual ward, or other community-based services.

We spoke with some of the local NHS ambulance service staff, that said they had a good working relationship with the emergency department leadership team, staff and the trust in general. There had been close working over some of the most challenging times for urgent and emergency care over particularly the winter months.

The partnership working with the mental health trust required far more cooperation and responsiveness than was happening in practice, but we were told it was improving. It was in this clinical specialty where many patients were being held in the department for unacceptable lengths of time. However, the 2 organisations met monthly to discuss performance. There were also daily calls which included the integrated care system team and mental health trust to review the needs of patients.

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

There was a plan for the service to focus on continuous learning, innovation and improvement.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. The service had a passionate and committed team of clinical educators across various grades and clinical specialities. Their role was to support with education for staff, including development and advancement, and to help through this with staff retention. The team were supportive to each other and looked out particularly for the new or newly qualified staff. Members of staff were given training programmes which were both mandatory and role-specific depending on their role and experience. The work of the clinical education team also included supporting the international nurses. Staff told us during the winter period, due to high demands and pressure on services, the clinical educators worked 100% clinically until end of March 2026 to provide support in areas that needed additional staff.

Leaders gave evidence of changes resulting from our last inspection, such as moving patients to a corridor that had more visibility, along with corridor nurses and Health care support workers. They had developed a frailty assessment area within the ED to reduce the length of stay for the older population, extended discharge lounge hours from 7am to 10pm from January 2026. The trust completed interventions to benefit UEC pathway throughout December 2025 and January 2026, by creating more than 10% in general and acute capacity across the trust, such as 40 new acute assessment spaces, extended urgent community response until midnight 7 days a week and the introduction of rapid access bridging domiciliary care from December 2025.

The trust was continuing to embark on the “getting to good” improvement journey and worked with health and care partners on implementing a system-wide urgent and emergency care improvement programme. The aim of the programme was to ensure optimum flow into and out of hospitals so that patients were not facing long waits to access a hospital bed or long delays leaving the hospital when care was no longer required. Alongside some pre-hospital workstreams led by system partners, the trust carried out many work streams, that focussed on improving discharge, flow pathways and ward processes.

Innovations were taking place in the service. The trust was improving coordination of single point of referral through NHS 111 and 999, aiming to deliver a timely and appropriate discharges and improve same day emergency care and acute frailty services across the trust, with ongoing goals to improve patient flow, accelerate recovery of elective and diagnostic waiting list.

As of March 2025, the emergency department were trialing a waiting room nurse and health care support worker to carry out clinical observations, providing regular pain relief and oversight of the area. They were also trained in triage and were able to support the triage nurse when the department became busy. The service also had a streaming nurse and a navigator role to support and carry out that initial assessment of patients attending the department. There was also front door consultant that was able to see patient and carry out assessment to alleviate the pressure on the service and support those that did not require to be admitted.