George Eliot NHS 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 reviewed shared direction and culture, capable, compassionate and inclusive leaders, freedom to speak up, workforce equality, diversity and inclusion, governance, management and sustainability and learning, improvement and innovation as part of the well-led key question. We found well-led improved to good. Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

This service scored 79 (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 had a vision for what it wanted to achieve and a strategy to turn it into action. Staff and leaders shared the same vision for the service which was putting patients first. The strategy focussed on working with partners and embracing new ways of working to improve patient care and access to treatment. Staff told us that managers were supportive, approachable, and compassionate. All staff had a good understanding of equality, diversity, in relation to meeting both patients and staff's individual needs. The service had a risk register in place and the managers had a good understanding of the risks identified on this and were working with the team to manage the risk identified.

There were processes in place which identified the vision and strategy for the service, and this was supported by strategic objectives for how they intended to achieve their ambition. The service shared their staff survey results after the onsite assessment activity as part of the data request. This showed the service scored 7.2 for compassionate and inclusive which was about the same as the trust overall. This demonstrated staff believed the culture was one which was fairly compassionate towards patients and between staff and that it was fairly inclusive. In addition to this, the service scored 6.64 for ‘we are a team’ which again was about the same as the trust overall score. This identified the service was generally working as a team. There was no additional context provided in relation to the survey results and no scores to compare against from the previous year to see if this had improved or not. Based on the result of the survey alone, there appeared to be some sense of shared direction and positive culture.

All staff spoke positively about their line managers who they said were approachable, supportive, and helped them develop their skills. Staff described their senior leaders as having an ‘open door.’ They gave examples of training opportunities that were available to them including nurse training courses for health care assistants. Department leaders all had a history of working their way up to their position and so had firsthand experience and knowledge of the challenges facing staff and patients. All the managers we spoke to provided us with plans they had to improve the working lives of staff and the patient journey. Leaders recognised that some staff were still deeply affected by their experience of nursing throughout the pandemic and so they maintained a focus on staff wellbeing. Some staff told us the trust’s executive team sometimes visited the OPD and that she was friendly and approachable. Staff said her presence made a positive difference to staff morale.

There was a leadership structure in place for the service. The service had processes in place to ensure staff were recruited fairly and for roles they were competent in. Where new leaders were recruited, there were processes in place to ensure they were supported. The minutes from the governance meetings showed leaders were knowledgeable about their issues and priorities for the quality of the services. There were processes in place to manage poor culture or behaviours which may impact the quality-of-care patients receive.

Staff said they did not have a fear of speaking out. Staff were aware of the freedom to speak up service, but they told us they had not used this service as they felt problems were resolved within the department through honest and frank discussions of problems as they arose. The freedom to speak up team confirmed they had not had any issues raised with them by staff in OPD. Staff told us that there was a positive culture within the service and that staff felt supported by managers, also there was a good staff moral within the team.

The trust had a Freedom to Speak Up Guardian which the service was engaged with and promoted. Although the evidence collected from staff demonstrated they were aware of the service, the information held by the service showed no staff members had accessed the freedom to speak up service in Quarter 4 2023/24.

The management team and senior staff were aware of the issues on the risk register and agreed they were representative of the risks they identified in the service. The unit’s risk register was RAG rated and identified the following key risks: airway emergencies, intensive therapy unit essential maintenance, ITU consultant cover, lack of portable EEG service, lack of real time and electronic monitoring, pressure area care and staffing risks in ITU. The risk register showed that controls were in place to mitigate these risks. Staff told us A service level agreement was in place for acute heart attack and other acute conditions. However, transfers remained a historical concern. Clinicians raised concerns about time critical transfers to a neighbouring NHS trust with potential impact on patient outcome. For example, clinicians had to go through the switch board due to the lack of speed dial which often proved to be challenging. Doctors gave an example of challenges faced whilst attempting to transfer a urology patient who required an urgent nephrotomy. We raised this with leaders who said there was work in progress to improve communication. Staff told us the service held monthly clinical governance, mortality and morbidity meetings, we reviewed 3 sets of the meeting minutes from December 2023 to February 2024 and noted brief documentation of discussions around governance, quality, training and performance.

There were policies and processes in place to ensure the service were inclusive and fair in the way they operated. Where concerns were raised or identified, leaders acted swiftly and appropriately to address the concerns. The processes in place demonstrated they were aware of the needs of the local population and acted to address any groups who were marginalised. All processes and policies in place had an equality impact assessment. The most recent staff survey completed a heat map of the issues raised, which leaders used to inform any improvements required within the service. The heat map unfortunately did not include specific information relating to diversity/equality/inclusivity for the department. Where individual risk assessment for staff had been completed, there were processes in place to make reasonable adjustments to enable them to complete their roles.

Leaders operated effective governance processes throughout the service and with partner organisations. There were structures, processes, and systems of accountability to support the delivery of the service. The service had a meeting structure which meant senior leaders and managers had regular opportunities to discuss operational issues. Leaders understood links to trust wide groups and committees to escalate risks and issues. A performance report was sent to the board each quarter. Staff told us they introduced new systems to improve access to treatment for patients. This included improved room management so more clinics could be run, and a room cancellation policy to give increased oversight. Leaders told us they understood the problems they faced around staff vacancies and retention. They had plans to improve working conditions to address this including introducing flexible working. In addition, they had devised a competency framework to enable staff to work across a greater number of specialities making their workload more interesting and enhancing their ability to apply for promotion. A monthly training session had been scheduled to increase confidence through experiential learning. Leaders told us they regularly thanked people for the work they did and gave awards for excellence as part of creating a culture of appreciation and improvement. Staff told us the trust had implemented a ‘shared decision-making council, this was a system of meetings open to all staff to allow them to meet up with colleagues from other parts of the trust to problem solve together. Staff gave examples of how this had worked to solve problems. Staff told us there was only 1 risk for OPD listed on the trust’s risk register and that concerned a potential for a breach of General Data Protection Regulations. Other risks included RTTs, but these were held by the different specialities rather than the OPD itself.

There were monthly governance meetings which had a set agenda. We reviewed 3 sets of minutes and found these were details and reviewed important aspects of the way services provided safe and effective care. Risks were regularly reviewed, and new risks were discussed prior to being entered on to the risk register. Regular updates on audits were provided during each meeting, and there was an agenda item dedicated to learning from deaths. There were weekly improvement meetings to discuss performance and how local improvements could be driven. The outcome of these meetings was fed into the trust’s overall quarterly improvement board. The service had 1 risk on their register. However, during the onsite assessment, the team identified an additional risk in relation to staffing. We also saw a document which was provided after the assessment which showed staffing was raised as a moderate risk. This risk had not been formally included within the risk registered and no additional information was provided to identify why it had not been included. The service had a dashboard which showed key performance indicators including did not attend rates, cancellations, and waiting lists. All staff had access to this system which meant there was good oversight of these issues. An area previously raised as a concern was in relation to patients who were ‘lost to follow up’. This was where patients had been reviewed in a clinic and identified as requiring further appointments, but a follow up appointment had not been made. The dashboard ensured patients were no longer at risk of not receiving a follow up appointment. The service had systems and processes to manage additional external services which were required to ensure the smooth running of the service. The team had systems to ensure key information was disseminated to staff. Daily safety huddles were held within the department and the issues raised were recorded to ensure there was an auditable trail of information shared with staff.

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.

Volunteer tele hub was ran by a coordinator the tele hub provided a number of services that helped maintain the wellbeing of patients while they were waiting for an appointment and helped to reduce the number of failed appointments. Text validation. The service had a room booking system and policy in place. Patient initiated follow up (PIFU) is when a patient initiates an appointment when they need one, based on their symptoms and individual circumstances. If patients do not need to initiate and appointment within a set time period, for example, 3, 4, or 5 years they are discharged from the service. In some cases, the consultant will offer a review appointment prior to discharge. This meant patients who needed to be reviewed would be, but other patients who did not experience a change or deterioration in their symptoms and who did not feel it necessary to see their specialist again were not offered additional follow up appointments. This created more capacity for doctors and other clinicians to see people who had been waiting a long time for their first appointment.

The service had processes in place to continuously learn, drive improvement and look for innovation on how to improve the service which patients receive. As part of the Clinical Support Services Governance and Safety Report, all members who attended the meeting were requested to update on aspects within their department which was going well. Evidence reviewed identified the service were regularly proud to demonstrate the improvements made to the waiting list with no patients waiting over 52 weeks recorded in December 2023. Additional evidence provided by the service demonstrated the improvements they had made since the last inspection in 2017. The action plan produced after the inspection had been completed and evidence provided to demonstrate the impact this had on the quality-of-service patients now received. Within all minutes of meetings reviewed, there was evidence provided to show the service was a service who participated in learning. The learning came from incidents, deaths and complaints. The service had also implemented some innovative ways to improve the service. Evidence on provided a list of different projects which the service had implemented or been involved in which demonstrated an improvement to the service. Within the list of projects, the Back to Health initiative and the DNA reduction programme appear to be many of the successful innovations of the service presented. The introduction of the outpatient improvement programme has been both an innovation and improvement to the service, which oversees the various projects in place, reporting quarterly to the trust improvement board.