Fitzwilliam 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

Leaders ran services well and supported staff. Staff 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 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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 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. Staff and leaders, we spoke with knew the service had an up-to-date risk register and were aware of the risks relevant to their area of work. Risks were rated based on their severity, had a review date, and named individual responsible for oversight and mitigation of the risk.

Leaders operated effective governance processes throughout the service and with other organisations. Leaders and staff used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. The service had an up-to-date business continuity plan, and this clearly defined how to continue to manage the service if there were any unplanned disruptions, as well as roles and responsibilities in an emergency.

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 were committed to continually learning and improving services. Staff reported an open, non-judgemental culture for learning from incidents. Leaders encouraged innovation and participation in research and designed the service’s strategy with a focus on commitment to learning and improvement. Staff and leaders sought feedback from patients and the community to make improvements to their service. For example, in pre-operative assessment staff introduced an online virtual pre-operative assessment tool for patients undergoing hip, knee and spinal surgery. This initiative was created to empower patients, reduce length of appointments, and ensure any chronic diseases were optimised. We were also provided with multiple other initiatives from staff and leaders to learn and improve the service. Leaders were dedicated to pursuing higher levels of accreditation for aseptic non-touch technique (ANNT).

The service had a strong focus on sustainability, as well as recycling and looked for renewables where possible. They were in the process of replacing lighting with low energy bulbs, installed electric vehicle charging points and new power and plant management systems to reduce energy usage and their carbon footprint. The service engaged in research programmes in order to improve patient outcomes and shared research outcomes with other providers to have wider impact on the health economy. The service had received recognition for commitment to patient safety through the National Joint Registry (NJR). The service received bronze accreditation in aseptic non-touch technique (ANNT) from The Association for Safe Aseptic Practice.