George Eliot NHS 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 shared direction and culture, capable, compassionate and inclusive, freedom to speak up, workforce equality, diversity and inclusivity, governance, management and sustainability, and learning, improvement and innovation. Shared direction and culture: The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff knew and understood what the vision, values and strategy were, and their role in achieving them. Capable, compassionate and inclusive: Leaders had the skills and abilities to run the service. They were visible and approachable. They supported staff to develop their skills and take on more senior roles. Freedom to speak up: All of the staff we spoke to knew how to contact the freedom to speak up team. The service had an open culture where patients, their families and staff could raise concerns without fear. Workforce equality, diversity and inclusivity: The service promoted equality and diversity to make sure it was fair and accessible to everyone. Governance, management and sustainability: There were effective structures, processes and systems of accountability to support the delivery of the service. There were arrangements for identifying, recording and managing risks, and mitigating actions. Learning, improvement and innovation: All staff were committed to continually learning and improving services. We saw evidence of initiatives introduced to modify the service to improve patient access.

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.

Leaders told us that they consult staff on proposed changes to service delivery and take a team approach to implementing change. All the staff we spoke to told us they enjoy working in the hospital within their teams. Without exception they said they are part of a learning, not blame, culture.

The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and providing excellent patient care.

Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. Modality leads had radiology backgrounds and were offered the opportunity to attend leadership courses. As part of the departments succession planning Band 7 radiologists had been invited to complete a leadership course. It was anticipated this course would give them an understanding of the difference between management and leadership and equip them with the confidence and skills to become managers/leaders of the future as well as improve their ability to communicate with others. Staff told us managers had an open-door policy and they felt able to go to their managers with any questions or concerns about the service.

There were clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and a leadership strategy and development programme, which included succession planning. There were processes to support new leaders joining the service, this included guidance on supporting them to develop supportive relationships with staff. Governance meeting minutes showed leaders understood the challenges to quality and sustainability and could identify the actions needed to address them.

Leaders and staff understood the importance of staff being able to raise concerns without fear of retribution, and appropriate learning and was action taken because of concerns raised. The culture encouraged openness and honesty at all levels within the organisation, including people who used services, in response to incidents Staff said they did not have a fear of speaking out. Staff were aware of the freedom to speak up service, but they told us they had not used this service as they felt problems were resolved within the department through honest and frank discussions of problems as they arose.

The trust had a Freedom to Speak Up Guardian which the service was engaged with and promoted. Although the evidence collected from staff demonstrated they were aware of the service, the information held by the service showed no staff members had accessed the freedom to speak up service in the 3 months prior to our assessment.

Leaders recognised diversity is a strength that can enhance the patient journey. They said they understood their priorities from the results of the staff survey and listening to team. In response they told us they took deliberate measures to empower staff by connecting them to equality and diversity networks within trust. The departments diversity and equality lead attended the patient’s forum and fed back important messages to the team. The trust held events throughout the year to celebrate equality, diversity and inclusivity. For example, they held a race equality week, a LGBTQ+ month, an equality, diversity and human rights week, and an overseas NHS worker day.

There were policies and processes to ensure the service was inclusive and fair. These included directions to ensure all staff and patients were treated equally regardless of age, gender, ethnicity, sexuality and religious beliefs. They also contained information on how to promote inclusivity within the service. For example, asking patients their preferred name and using this throughout their appointment ensured transgender people, and others, had their human rights respected and their personal choices accepted.

Staff at all levels told us they were clear about their roles and understood what they were accountable for, and to whom. They told us they had regular opportunities to meet, discuss and learn from the performance of the service. Leaders said they felt supported by the governance process, which they described as robust.

There were effective structures, processes, and systems of accountability to support the delivery of the strategy and good quality, sustainable services. These were regularly reviewed and improved. All levels of governance and management functioned effectively and interacted with each other. We saw meeting minutes that demonstrated staff in each modality meet regularly to share information and learn from incidents, complaints and other feedback. We saw the risks on the risk register matched what staff told us were the risks facing the radiology department. We saw the monthly Radiology report for the Urgent and Emergency Care Directorate Management and Governance meeting and the meeting minutes. The report contained information about incidents, risk and risk management, up to date information on compliance with mandatory training and appraisals, delays in reporting (with explanations), DNA rates, staffing, and complaints.

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 were aware of what incidents to report and knew how to report them on the trust’s electronic reporting system. Staff told us they received feedback from leaders after the incident they reported had been investigated. The radiation protection supervisor understood what incidents they were required to report to external agencies they followed guidance provided in line with the Royal College of Radiologists and the Society of Radiographers. Findings from incidents were shared within the department, they also shared learning from near misses, these were seen as learning opportunities. Leaders told us they were introducing the use of a software application that runs automated tasks to assist with pulling information from 1 system to another to cut down on the amount of time admin staff spent completing this task. The service had invested in technology that allowed for accurate measurement of fatty content in patients liver to reduce the need for liver biopsies to be performed and to stop patients needing to travel to more than 200 miles (round trip) for this intervention. The service was investing in training radiography staff to enable them to provide more radiography led services to reduce waiting times for treatment. For example, staff in interventional radiology were being trained in techniques normally carried out by doctors or nurses so that patients did not have to wait or travel to other hospitals for these procedures.

There were systems to support improvement and innovation work including service improvement workstreams and a service improvement meeting that fed into governance meetings.