University Hospital North Durham

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

We rated well-led as good. We assessed 3 quality statements. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management based upon delivering safe and good quality care and treatment. The department was prepared for emergencies and major incidents and worked with others as part of a multiagency response.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Medical and nursing staff understood the key risks to the department. They were aware of the challenges they faced and were able to explain the improvement actions being undertaken to improve capacity and patient flow in the department. Staff we spoke with told us the departmental leads and senior managers were approachable, visible, and provided them with good support. Staff understood the reporting structures and leaders understood their key roles and responsibilities. The senior leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they worked with external stakeholders, such as the local and regional commissioners, integrated care boards and local NHS ambulance and mental health trusts. Stakeholders such as NHS England and local NHS ambulance and mental health trusts told us they worked collaboratively with the urgent and emergency services. They said they worked well together and there was regular engagement to review performance and identify improvements to services.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate care group leadership structure at departmental and divisional level with medical, nursing and operational leads in place. There were clear reporting structures and key roles were supported by deputies or associate roles to support succession planning. Leaders held routine monthly governance meetings to discuss governance, risk and performance. Risk registers were reviewed during these meetings. The governance and reporting processes enabled leaders to understand the key risks and challenges to the service and to identify improvement actions to address key risks, such as capacity and flow issues. Daily safety huddles and bed management meetings enabled sharing of information and escalation of patient risks, such as capacity and resource issues. Leaders understood but did not always have resources and space to manage the priorities and issues the service faced. Capacity constraints within the services and across other parts of the hospital impacted on patient flow in the emergency department. Leaders engaged and worked in collaboration with external partners to monitor performance, identify key risks and to develop improvement plans to address key risks, such as patient flow and capacity constraints within the service and across the hospital. This included measures to improve admission avoidance and patient discharge processes. Task and finish groups and working groups were in place to monitor and implement improvements. Leaders were able to demonstrate the improvement actions they had undertaken or planned to address key risks, such as capacity and flow issues.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff had time and resources to undertake effective governance and manage risk. There was a good range of accurate and timely data and information available to understand performance and quality and improvements were made as needed. Governance was used to learn, improve and innovate. Information held about patients was secure and protected. Staff were part of the emergency preparedness network, and they had the strategies and guidance to respond to major incidents.

There were regular and effective meetings led by a consultant and nurse who were leads for safety, audit, quality and governance. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Changes had been made when needed to improve the service. Good practice was recognised and celebrated. There was effective workforce planning including for managing major incidents or emergencies.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff and leaders demonstrated commitment to improving patient safety and experience through continuous learning and collaboration. Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff. Staff were supported to prioritise time to develop their skills around improvement and innovation. There was a clear strategy for how to develop these capabilities and staff were consistently encouraged to contribute to improvement initiatives. Staff and leaders described improvements made since our last inspection. These included refreshed approaches to leadership, better ambulance handover processes, ‘see and treat’ service improvements and more effective escalation processes. Leaders we met with spoke with enthusiasm about innovative and collaborative work to develop virtual prison wards, and care home support outside core hours.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation. The service had introduced virtual prison wards to improve the pathways for category A and B prisoners. In addition, in collaboration with the local care home forum, General Practitioners (GPs) working within the urgent and emergency care group’s urgent treatment centres agreed to take calls from the single point of access team, to provide advice to care homes, when their own GP service was closed. The aim of this initiative was to reduce unnecessary visits to UEC and avoid hospital admissions. The community nursing teams reported they found this initiative extremely supportive.