St Hugh's Hospital

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• 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

At our last assessment we rated this key question inadequate . At this assessment the rating has improved to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Since our last inspection the leadership team had changed and there had been a focus on governance across the organisation. We were assured by what we had seen and heard on site and the subsequent data provided that the diagnostics department was well led. Staff told us that the culture had improved and the team worked well together.

They had addressed the areas of concern we had identified at our previous inspection and provided assurance that governance and the standards for I(RM)ER were being met

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities

The diagnostic manager understood their strategic priorities and how they related to wider hospital services. They were using the getting it right first time (GIRFT) model to improve their service.

Staff understood and shared the provider’s vision and values. They knew how they were relevant and applied to their teamwork. Staff worked together to provide high quality care.

Staff could share and progress ideas to improve the service. Leads had introduced the arthroplasty meeting to review images and discuss treatment plans

The service have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced.

The diagnostics manager was visible across the service to both staff and patients. The team were very positive about their leadership at all levels. They said the culture had improved.

Staff told us the senior leadership team were visible, approachable and open to their suggestions and new ideas.

The diagnostics manager and team understood how their service contributed to the patient experience across all departments. Staff participated in service audit and quality improvement.

The service create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a clear framework embedded within the organisation for staff to raise any concerns.

Staff told us they knew how to speak up and would be comfortable doing so. Department staff approached the freedom to speak up guardian to raise concerns.

Please see the surgery report for further information on freedom to speak up.

The service value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service valued diversity in their workforce. Staff completed equality and diversity mandatory training. Leads worked towards an inclusive and fair culture by improving equality and equity for their employees.

The provider undertook equality monitoring of staff within the service. This aligned to the workforce race equality standards (WRES).

The leadership team encouraged staff to participate in the staff survey.

Staff told us the organisation was flexible. For example, they could alter their shifts to maintain a work life balance.

The service have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had clear governance structures in place. These provided assurance of oversight and performance against safety measures. The radiology manager contributed to monthly patient safety and patient governance committee meetings.

The department was compliant in the IR(ME)R regulations, the radiation Protection Advisor (RPA) carried out audits to mitigate risk and ensure that the department continued to meet the regulations. Diagnostic team members along with ward and theatre outpatients staff attended the Radiation Protection Committee which had oversight of risks, the meetings were minuted with actions in place

Staff undertook or participated in local clinical audits. The audits provided sufficient assurance and staff acted on the results when needed.

Staff understood working arrangements with other teams. This applied both within the provider and externally, to meet patient needs.

The service had a business continuity plan which would be put into operation in the event of an unexpected disruption .

Staff had access to equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records.

The service understand their duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement

The diagnostic lead worked with the senior leadership team to deliver the commissioning requirements from the Integrated Care Board (ICB).

The hospital leadership team worked with the local NHS trust to support their waiting lists.

The department worked with local universities to provide placements for student radiographers and received positive feedback on their placements.

The service focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service had moved to paperless e-referrals where requests were now made digitally. This had improved patient’s access to appointments.

Radiology had introduced “Radiology revealed”. This was a leaflet developed by a radiographer in response to patient questions. It gave succinct information on a range of information such as osteoarthritis and what they would be able to see on the x-ray.

The radiology department had student radiographers from two universities. They had developed a comprehensive induction book for knowledge of the department and hospital. The service received very positive feedback on the learning opportunities they provided for the students at St Hughs Hospital.

The department had started an interesting cases file. This shared learning for both the radiographers and students.