Peterborough City Hospital

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

Leadership for medical care included a multi-disciplinary triumvirate consisting of a trust-wide divisional nursing director, clinical lead (divisional director), and operations director.



Leaders had the experience, capability and integrity to ensure the services’ vision could be delivered. They were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. Leaders told us they visited clinical areas every 1-2 weeks to provide staff with the opportunity to discuss concerns.



There were clear governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours and performance of staff.

There were systems in place to manage current and future performance and risks to the quality of the service. There were arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care.

Leaders implemented relevant quality frameworks, recognised standards and best practices to improve equity in experience and outcomes for people using services and tackle known inequalities.

Staff and leaders had a good understanding of how to make improvement happen. There were processes in place to ensure that learning happened when things went wrong. The service had strong external relationships to support improvement and innovation. Staff and leaders engaged with external work, including research, to embed evidence-based practice.

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.

International staff told us they liked the working culture at the hospital, we heard comments such as, “Other staff are very supportive”, “Very happy on ward” and “Staff are friendly.” A comment made by the winner of one ward’s ‘Star of the Month’ was, “Staff are really valued and recognised” and they provided an explanation of the values given to achieve the award. Other staff told us, “Love working in the team”.

The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. They had developed the vision and strategy to cover a 3-year period from 2022 to 2025. The vision and strategy were focused on 5 goals; delivering outstanding care and experience, recruiting, developing and retaining the workforce, being an anchor for the community, working with health and social care providers and delivering long term sustainability. These were aligned to local plans within the wider health economy. Leaders had considered their role within the ICS and the North Integrated Care Place Partnership (ICPP), and included this throughout their strategy.



The service had also developed an improvement plan to complement these 5 goals, which monitored actions implemented.

The trust had an established leadership structure within the division of medicine. This included a divisional director, divisional operations director, and a divisional nursing director, who made up the divisional triumvirate. They were supported by the divisional leadership team comprising of the associate divisional director, deputy divisional operations director and the head of nursing. They were supported by divisional operational managers, clinical leads, matrons and lead nurses and ward managers.

Staff told us they felt respected, supported and valued, particularly by senior leaders. They said senior staff, such as matrons were visible and approachable.



Leaders of the service were able to describe the challenges that the service faced. They told us they had the experience and capability to ensure the service’s vision could be delivered.

Senior managers told us they visited clinical areas as often as possible and completed walkabouts every 1 to 2 weeks to engage with staff. This gave staff the opportunity to make suggestions about what would work better for them. Staff told us senior managers were approachable, they felt listened to and senior staff supported them.

The trust’s staff survey showed improvement in all areas asked about. In all but one of these areas medical care scored equal to or higher than the trust average. The service completed an action plan to address issues identified in the staff survey in June 2023, however only 8 of the 24 actions had been completed over a year after the survey and 3 were still RAG rated as red.

All staff that we spoke with during the assessment felt confident to raise concerns and knew of the Freedom to Speak Up guardians. However, they did not all feel listened to. Staff escalated concerns regarding patients cared for in corridors that did not meet the criteria, but despite reporting, this continued to occur. Staff, therefore, did not feel confident that their concerns were always listened to.

The service had systems in place to engage with staff and guidance was provided on how to do this in the trust policy. There were staff and student information boards in clinical areas that provided contact details for Freedom to Speak Up Guardians and others where staff could get support.

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 service had a clearly defined governance structure that supported the flow of information from frontline staff to senior managers and the trust board. Specialty governance meetings reported to the Clinical Business Unit meetings, which reported to the Joint Division Quality Governance & Management Board Meeting, which ultimately had oversight from the Hospital Management Committee.

Monthly Medicine Joint Quality Governance Board meetings were held. We reviewed the last 2 governance meeting minutes and saw that discussion areas included performance data, audits, training, risks, guidelines and complaints.



Leaders monitored key safety and performance metrics. They identified and escalated relevant risks and issues and identified actions to reduce their impact. An audit programme was in place to provide assurance of the quality and safety of the service. Local audits, such as clinical and compliance audits were undertaken.

The divisional triumvirate regularly attended meetings to look at risk and governance, incidents, training compliance, complaints, and guidelines. They confirmed oversight of all complaints and responses before these went to trust governance review. They also met with complainants to fully understand the concerns.

There were systems in place to manage current and future performance and risks to the quality of the service. Leaders monitored key safety and performance metrics. They identified and escalated relevant risks and issues, and identified actions to reduce their impact. Information was used to monitor and improve the quality of care.



The service had a risk register which reflected current risks within the service. All risks had dedicated owners, risk and effect, risk ratings from red to green, and control measures. The risk register was reviewed and updated at regular intervals. Issues relating to corridor care was documented as a high risk on the register.

Specialty and divisional governance meetings were held monthly, although not always well attended by the multi-disciplinary team and not all the meetings had enough members present to make decisions. Attendance for April and May 2024 showed only 2 people attended both meetings and only one of these was from the divisional leadership team. Discussion areas included, but were not limited to, performance data, audits, incidents, guidance, complaints, and risk.

A Risk Management Policy was in place which described the Trust’s approach to the management of risk at all levels within the organisation.



Various policies and procedures were in place to cope with unexpected events. An Emergency Preparedness, Resilience & Response Strategic Framework was in place, which detailed the strategic arrangements and the activities undertaken within the Trust to support the emergency preparedness and business continuity agendas. Specific business continuity plans were in place for specific areas such as the renal and respiratory areas.

There were arrangements for the availability, integrity and confidentiality of data, records and data management systems.

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.

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