Winfield 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

We reviewed freedom to speak up; and governance, management and sustainability for the well led key question. There were clear systems for reporting and monitoring risk. Managers monitored performance and identified actions to support a sustainable service. Staff knew how to raise concerns.

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.

Policies provided guidance for staff on how to raise concerns regardless of their role in the department. Posters clearly displayed the process and included details of how to use a range of methods to raise concerns. Staff were expected to attend 'speaking up for safety' modules as a mandatory part of their training. Staff who held freedom to speak up roles had attended additional training to support their role.

Concerns had been raised about culture within the service and staff feeling unable to speak up. Managers told us a focus on supporting staff in theatres had improved culture in the department. Staff spoke of a supportive structure. Staff felt comfortable to raise concerns in a variety of ways and gave examples of the Speak up for Safety process, raising concerns with managers, and how they would contact the freedom to speak up guardian. The freedom to speak up guardian had received no concerns from theatre staff in the last 3 months.

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 described actions they took to maintain patient safety. A range of audits were undertaken and staff received feedback from managers of where improvements could be made. An environmental audit had prompted refurbishment plans for a utility area of the department and quotes were being requested from contractors. Staff practice was monitored using national audit tools to promote patient safety. For example, the World Health Organisation's 5 steps to safer surgery. We saw all staff taking an active part in this process. Staff told us of ongoing plans to improve an endoscopy sterilising unit. Options were being considered by managers and executive leaders in order to provide a sustainable service with least disruption.

Policies we reviewed were clear and identified responsibilities for directors and staff across the hospital. A range of committees reviewed specific areas such as infection prevention and control, incident reporting and investigation and lessons learnt. Risks were identified and escalated to governance meetings for senior review. We saw action plans were reviewed and shared with staff. Further oversight was provided by Ramsay Health Care UK executive leaders.

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.