The Droitwich Spa 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

Managers and leaders were caring and compassionate and had the skills and abilities to run the service. Managers were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. The service had a vision and strategy for what it wanted to achieve and appropriate plans to achieve it. The managers monitored action plans to deliver the strategy. The manager promoted a positive culture that supported and valued staff. Staff felt respected, supported and valued and were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. The Imaging service operated effective governance processes. 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. There were appropriate systems to manage performance effectively. Risks were identified and escalated and actions were in place to reduce their impact.

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.

Staff and leaders had a shared vision, strategy and culture based on transparency, equity, and equality. The manager had developed a team culture which had a positive impact on improvements for the service. The direction for the service was shared with staff and included developments which both impacted on staff and gave additional opportunities. The business plan included the extension of opening hours for the MRI service and development of new services including an echo cardiogram service. The service had strategies to develop and support its staff. Staff spoke positively about the apprenticeship scheme which enabled them to develop and become radiographers with the support of a mentor within the service. A succession planning policy was available to support staff to progress within the service and supported a diverse workforce.

The service had a shared vision, strategy and culture which was cascaded to staff. Processes ensured that staff were aware of diversity and inclusion, engagement, and understanding the needs of people who used the service. The imaging service business plan captured aims for developing the service and was shared widely both within the team and the hospital.

The service had inclusive leaders at all levels who understand the context in which practice and support was delivered. Managers had the skills, knowledge, experience and credibility to lead effectively. The manager had identified improvements since they had been in post. Staff said they felt valued by managers and leaders and that both the service managers and hospital managers were approachable and supportive.

The service recruited managers and leaders with the skills, knowledge and experience to lead effectively. There were systems to review the performance of the manager and leaders to continually develop their skills and improve the service.

Information provided by staff and leaders identified the organisation had a positive culture where people felt they could speak up and that their voice would be heard. Staff told us managers were supportive and approachable. All staff said they would be confident to raise concerns about practice and any concerns would be listed to and acted upon.

The service had systems and process to support people to raise concerns and for their concerns to be acted upon. The hospital had a Freedom to Speak up Guardian who provided support for people to raise concerns. Policies which supported "Speaking up" also included a complaints procedure, incident reporting, sharing the investigation of incidents, and duty of candour.

Staff and leaders we spoke with told us the service valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for its staff. Staff gave us examples of how the service had supported equal development opportunities rights for staff with protected characteristics under the Equality Act. The service had a new diversity and inclusion lead for mental health. The hospital had a multicultural hospital prayer room which was available for both staff and patients.

Information provided demonstrated processes supported equal opportunities for an inclusive and diverse workforce. The equality and diversity policy was the framework for the organisation to support a diverse workforce underpinning other human resources policies such as recruitment.

Staff and managers told us they had clearly defined roles and responsibilities. Staff and managers were aware of the risks to the service. There were 3 risks on the risk register with actions identified to address these risks. Staff were clear about how to escalate concerns. The manager of each department in which radiation was used was responsible for radiation safety in that department and ensuring safety and protection measures were conducted. They were assisted in this task by the appointment of suitable leads and radiation protection supervisors. There was a hospital wide communications huddle meeting held daily which involved a member of the senior leadership team and representatives from each department. The imaging team also had a daily safety huddle to share concerns from both the hospital safety huddle and department. This meant important and urgent information could be shared across all services to keep staff fully informed of any risks or safety concerns.

The service provided information around the radiation governance arrangements. Within the hospital there were meetings of the Hospital Radiation Protection Committee (RPC). The meeting included the hospital senior management team, imaging clinical services manager. Radiation Protection Supervisor (RPS), Lead Radiologist and Radiation Protection Advisor (RPA’s ). The appointment of RPS was a legal requirement where there were controlled areas and 'local rules'. The RPS role ensured the local rules were enforced to keep patients and staff safe. The RPS completed an annual assessment and subsequent report which confirmed their findings. In addition to governance arrangements for radiation there was a clear governance structure for all hospital services with various committees. For example, quality and infection prevention control fed into the integrated governance committee. The director of clinical services held meetings with the heads of each department monthly and departmental meetings were held. All meetings were structured, and minutes were available.

Patients told us they had been referred to the service by their consultant or GP. They had received information from the service with a date for the planned procedure. They confirmed they had been asked to confirm information about themselves, the procedure and their health prior to their diagnostic test. Patients said following the diagnostic test they had a further appointment booked with their consultant who would discuss their results and if required any further treatment.

Staff and managers told us the service worked in collaboration with the community and other organisations. The service offered free consultant led "mini" consultations with the imaging manager and a physiotherapist in respect of treatment options. The service had worked with the local NHS trust to reduce the backlog of 2 week waits for colon cancer computer tomography (CT) screening. It had provided additional MRI sessions and a service for pelvic floor assessment. The service continued to offer ongoing additional services for MRI and CT scans.

GPs could refer direct to the service rather than through an indirect NHS pathway in certain circumstances. The service was working with the local Integrated Care Board (ICB) to provide direct patient referrals. There were clear processes to accept referrals, assess urgency and a timeframe in which an diagnostics appointment should be offered. Information provided identified the effectiveness of these processes. Processes had been developed between several organisations to improve patient access to diagnostic testing.

At the time of the previous inspection of the service in February 2019 there was no permanent manager in post within the service with diagnostics experience. Since the appointment of the current manager, all requirements made at the previous inspection had been addressed. Information had been provided to show that audit frequency and performance had also improved with actions identified for any improvement to be undertaken. The manager shared improvements made to the service which included the reduced number of rejection X-ray films. The rejection rate had been discussed during team sessions in addition to the clinical governance meetings. The standard for the service was reject analysis results were to remain below 4%. Furthermore, all audits were to be completed on time and with action plans if necessary. Staff told us they were actively asked for their views on improvements to the service. One example was the introduction of a new CT intravenous policy to ensure evidence-based practice was followed. Staff were also positive about the apprenticeship scheme which enabled staff to develop.

The service effectively investigated incidents with actions identified and shared with the team to help drive improvement and contributing to safe and effective care. There were systems and processes to benchmark the service against other diagnostic services within Circle Health Group Limited (the provider organisation). The service, as part of the Circle Operating System, held regular 'Quality Quartet' sessions which identified quality performance measures for the service to ensure development and improved patient outcomes.