New Royal Liverpool University

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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

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers collaborated with the local community to deliver the best possible care and were receptive to latest ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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 scored the service as 3. 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.

Leaders had a shared vision, strategy, and culture. This was based on transparency, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and the local communities.

Leaders had produced a new vision for improvement for the department which linked to the trust’s vision and culture. They were able to explain the improvement measures that had been undertaken and were able to describe future improvement plans to improve capacity and flow issues within the department.

The trust vision and values were ‘’we work together to support our communities to live healthier, happier, fairer lives” and leaders described how this impacted the department. The vision statement for the emergency department was more than 2 years old and in the process of being updated. The focus at the time of assessment was to simplify complexities of the local health care system so that people received the right care, in the right place, at the right time. Reconfiguration of the department was key to this as part of the improvement programme.

Staff described a positive culture of transparency and openness.

We scored the service as 3. 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.

Nursing and medical staff across the emergency department understood the key risks to patients within the department. They could describe the challenges faced and were able to explain the improvement actions being undertaken to improve capacity and patient flow. Staff 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. Leaders also fully understood the key risks and challenges faced by the department. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as local NHS ambulance and mental health trusts. They told us 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 leadership structure at departmental and divisional level with medical, nursing, and operational leads. There were clear reporting structures and key roles were supported by deputies or associate roles to support succession planning.

Monthly governance meetings were held 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. Processes were in place to escalate issues to the hospital leadership team.

Daily safety huddles and bed management meetings enabled sharing of information and escalation of patient risks and capacity and resource issues. Risks were discussed at safety huddles, board rounds and bed management meetings and staff and leaders were proactively managing and escalating any concerns.

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.

Risks were captured on a divisional risk register and were rated in terms of likelihood and consequence. The trust had risk management processes which meant that risks were escalated appropriately from the department up to board level when required.

Risk management was included in the trust improvement plan to ensure that processes were in place so that ‘risks and issues could be transparently escalated and managed from ward to board.’

Staff and leaders at all levels demonstrated a good understanding of the risks within the department and the action being taken to mitigate or remove risks. We discussed the top risks for the service with the leadership team and reviewed the department risk register. We saw the top 3 risks were, risk that patients experience long waits in ED, ability to respond safely and timely to patients attending Emergency Department (ED) and Acute Medical Unit (AMU) with urgent and acute mental health needs, and Lack of safe storage for patient's own medications in the Emergency Department.

We saw that there was a strong focus on risk management within the department. Department, division, and hospital leaders had access to live data which meant they could be proactive in managing performance in real time. In addition, a programme of audits was in place to support this. We saw staff and leaders using systems to support them to keep patients safe and they collaborated with teams in other divisions to balance risk across the hospital and trust rather than working in silo.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning for the future. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

We scored the service as 3. 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.

The department had 1 Freedom to Speak Up champion who was known to all staff. Staff were aware of the policy and how to use it. A poster was on display in the staff room to alert staff of ‘freedom to speak up’ and how they could act on concerns.

Leaders fostered a positive culture where people felt that they could speak up and that their voice would be heard and were able to describe how staff reported concerns and how these were investigated, then feedback given to staff, via various forums. Leaders described an open-door policy and had an eagerness to want to help and support staff.

The trust Freedom to Speak Up (FTSU) Guardian was an appointed individual who worked independently and had a key role in helping to enable a positive speaking up culture in the organisation. They provided confidential advice and support service to staff in relation to concerns they had about patient safety and/or the way their concern has been managed.

The service promoted equality and diversity in daily work and provided opportunities for all staff to develop. For example, ability to self-roster to observe religious festivals. A prayer room was available in the department.

Policies and processes in place to ensure the service were inclusive and fair in the way they operated. Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work.

We scored the service as 3. 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.

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 for safety, audit, quality, and governance. These discussed and addressed key areas of performance, risk, audit, culture, and workforce. Minutes recorded areas of concern were identified and actions were taken to learn and improve. There were monthly core meetings chaired by clinical governance leads. These meetings had a set agenda that included: incidents, complaints, CQC action plans and the matron’s safety reports. Quality and safety reports were produced from these meetings and fed into trust divisional meetings, then to the hospital leadership board. There was a monthly performance meeting with the emergency department team and fortnightly finance meetings. The assistant directors of nursing led other meetings to review key concerns such as falls and pressure ulcers.

Information on governance was shared via a newsletter emailed to all staff, a poster was also displayed and there was a matron’s blog that disseminated information to staff. Staff received feedback from incident reporting and risks during nursing huddles.

Assurance reports were completed daily by the nurse in charge. These reports were used to check that daily tasks were completed, and a safe environment was maintained.

The emergency department has a dashboard with the area labelled as ‘the corridor’ with a tracker for overdue investigations and treatment plans. The tools used within the dashboard were able to manage capacity and demand. Heat maps helped to plan and change staffing according to pressures highlighted by this system.

Leaders had a ‘change group’ that scrutinised continual change needed to support demands on the service. The key issues highlighted were triage times, developing an urgent treatment centre, improving time taken for a patient to see a clinician and bettering the 4-hour emergency care standard.

There was effective workforce planning including for managing major incidents or emergencies. Good practice was recognised and celebrated.

We scored the service as 3. 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.

People’s views and experiences were gathered and acted on to shape and improve the services and culture. This included people in a range of equality groups. People who used services, those close to them and their relatives were actively engaged and involved in decision-making to shape services and culture. Leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The leadership team understood how their staff felt about delivering care that met both the physical and mental health needs of patients.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. Partners we spoke with advised there were no concerns in relation to staff working together, inclusivity and partnership working. It was highlighted that communication on both sides could be challenging to overcome at times, but there were no performance issues of concern.

The trust’s strategy aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population. The was ongoing collaboration with Healthwatch to use the experiences of patients and families to support the improvement programme in the emergency department. Healthwatch offered support to patients who regularly attended the department or required support to make a complaint.

The emergency department implemented the ‘Royal Liverpool Hospital UEC Improvement Project ED Processes’ and engaged with the local ambulance service and other stakeholders as part of their improvement programme regarding Right Patient, Right Team, Right Time. This improvement programme looked at how to improve and sustain the emergency department performance metrics in line with national standards.

The A-tED (Alternatives to ED/Alternatives to Admission) process was an NHS England report regarding missed opportunities, which the emergency department had fully engaged with, and used findings and feedback to support shaping their improvement plan in relation to alternatives to attending the emergency department and admission.

The emergency department had a monthly meeting in place with the local community and mental health trust to improve shared learning, oversight of clinical issues and performance and to enable joint service development and provision to progress in collaboration.

We scored the service as 3. 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.

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

Leaders and staff participated in research projects and recognised accreditation schemes. There standardised improvement tools and methods in use, and staff had the skills to use them.

Leaders had undertaken learning from complaints. There were ‘You Said, We Did’ notices on display in the department and performance metrics displayed in waiting areas. There were notices with QR codes in staff only areas with 10 questions to answer for suggested improvements in the department. Leaders told us of improvements already made following suggestions made. For example, availability of an extra GP in the department to improve the timeliness and effectiveness of streaming people presenting with symptoms that would usually be treated in primary care.

Staff from the trust had visited other emergency departments in other parts of the country to examine their access and flow models. They were keen to develop and improve by engaging with other specialists nationally.

The introduction of the rapid assessment nurse was deemed to have improved performance metrics to have people assessed within 15 minutes. These nurses collaborated with clinical navigators and observation guardians to ensure that people were seen within a timely manner.

Staff used a patient safety checklist to ensure the fundamentals of care were monitored for patients in the department. The checklist was developed to provide assurance that risk assessments were completed in a timely way and to monitor compliance with intentional rounding.