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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

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 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 provider’s core principles and values were to provide patient-centred care people can trust. This encompassed five values and behaviours underpinning each. Their vision was to be the most innovative and best quality provider of niche health and social care services.

Staff understood and shared the hospital’s clear vision and values. They did not have a separate vision or strategy. The manager understood their strategic priorities and how they related to wider hospital services. For example, the provider trust’s charitable mission and purpose. The team leader told us the service’s focus was on service development in their urology-gynaecology and menopause clinics for staff and patients. Work was ongoing to improve their pre-assessment patient experience.

The HoD worked collaboratively with internal colleagues and across their provider trust. They explained the main benefits of working for the provider were a strong collaborative culture, a receptive and approachable leadership as well as a strong focus on quality and safety.

Managers told us they had learnt new and more effective methods of communicating with their team. They felt encouraging open communication, and supporting staff development had helped improve staff morale. Senior nurses felt the OPD culture had improved in the six months before our assessment. They were planning to implement training on improving working relations.

However, some staff felt managers were not open, supportive or receptive to feedback. Some nursing and support staff said they were not well treated or supported during the endoscopy service closure. Their morale had been negatively impacted by management and senior leadership decisions in the year before our assessment. They found managerial communications were not always respectful or sufficient to help them support some patient cohorts, such as cosmetic or orthopaedic. This meant they had to ask consultants, administrative staff and request learning sessions.

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.

The Head of OPD demonstrated good oversight, dedication and focus of all clinical and non-clinical governance processes, arrangements and issues within their department. They were well supported and maintained good cross-site relations with the head of clinical services (HCS) and senior leadership team (SLT).

The Head of Department had the necessary skills, experience and competencies. There had been a Head of Department in place since January 2024. Prior to this, it had been overseen by the pre-operative assessment team lead for two years. We heard that pre‑operative assessment and OPD staff had been working more separately during this period. The Head of Department was now based in the department full time, which improved leadership and coordination for staff.

Leaders gave examples of improvements they had made to patient care. For example, the department introduced a nurse‑led uro‑gynaecology service, which was valued by patients and freed doctors to see new cases.

A review of audit results led to a new informed decision‑making audit. This resulted in safety‑focused projects relating to appointment cancellations: medical optimisation and informed consent. Leaders also reorganised the department layout, making staff more visible and accessible to people in waiting areas.

However, not all staff told us leaders and managers were responsive. Leaders would not always make themselves available when required. Their queries were not always addressed, engaged with or responded to. For example, relating to pay reviews or service closures.

The service and managers aimed to foster a positive culture. However, not all staff felt they could speak up and their voice would be heard.

Most staff told us the service had a positive, friendly and inclusive culture. All Staff we spoke to enjoyed working for the hospital and felt respected and appreciated. Staff had mechanisms to raise feedback, suggestions or concerns. However, they did not always feel well supported by managers, leads and teams to do so.

OPD had a freedom to speak up (FTSU) champion who was a specialist nurse. All champions undertook FTSU training. They were contactable and could access their intranet site for related resources. Hospital staff could contact other champions out of hours or on night shifts at the provider’s care homes.

The provider and hospital had a FTSUG lead who was the nominated individual (NI). The lead collated and summarised wider feedback and suggestions into quarterly reports to the executive team. The hospital held stalls and events during FTSU week in October 2025. This included a day where staff fed back the need for consistent training.

The provider also had a trustee lead for FTSU. The provider’s FTSU lead held a bi-monthly call with all the champions to feedback and share any issues.

However, the FTSU champions told us they did not always have protected time outside their usual roles to carry out their speak‑up duties, making it difficult for them to meet the expectations of the role.

All staff and trustees completed three different levels of speak up, listen up or follow up training appropriate to their managerial role. Hospital staff compliance in all FTSU training was above 90%. Staff could access a communications platform which shared feedback.

Leads told us staff could speak up in confidence. They used an online anonymous reporting form on their intranet. We saw the guardian and champions were advertised in staff rooms and areas.

Staff could access support from occupational health and an external counselling service if needed. Posters signposted staff to wellbeing organisations and resources.

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.

Senior leads and managers ensured staff completed the yearly staff survey. However, not all staff groups had done so, as they felt any issues they raised would not be addressed by managers. Some support staff were made to feel their feedback was not important to managers, and so they no longer raised issues.

Staff were given the opportunity to have a voice. For example, they could submit ideas and nominate colleagues for different awards. The hospital celebrated its nominees.

Patients could feedback through ‘you said, we did’. We saw examples displayed on walls in OPD areas. For example, patients reported patches of the car park were not gritted so they nearly fell. In response hospital staff had purchased a small salt spreader.

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 OPD and wider hospital’s governance and reporting structures were well embedded and understood by staff.

Leads proactively reviewed governance arrangements which reflected best practice. OPD managers and clinical staff promptly reported clinical governance issues. The Head of OPD reported directly to the Head of Clinical Services with a clear professional and operational line. Together they discussed incidents, themes, staffing gaps and skill mix risk, staff sickness and turnover. They also discussed clinic utilisation and overbooking risks as well as departmental risks. The HoD provided a monthly OPD assurance report aligned to trust governance frameworks.

The Head of OPD attended clinical services leadership meetings. They contributed to SLT papers where OPD risks or performance required escalation. OPD staff, both registered and non-registered had also recently attended so that governance processes were more transparent. This helped ensure staff had the chance to observe discussions and understand what they entailed and why.

The HoD received close support from the hospital director, head of patient safety and improvement, along with executive leads. OPD managers met with other leads regularly, including at their other hospital site to share knowledge.

OPD had clinical representation at the hospital’s medical advisory committee (MAC) through the patient safety lead. The Head of OPD was also invited to discuss any issues pertinent to the department. They would communicate any MAC updates to the team through the departmental huddle, meeting, individually and by email.

The hospital had monthly quality governance meetings with standard agenda items. High level governance matters were escalated to provider-level quarterly governance meetings. The quality group also reviewed any patient safety events which occurred in OPD. Meetings were as long as needed to address all the patient safety issues.

We reviewed minutes from the department’s last three staff meetings in May, September and November 2025. Attendees discussed any matters arising and reviewed the action log and department’s main risks.

OPD staff had to read and acknowledge all policies and standard operating procedures affecting them. They could also search for policies to review on the provider trust’s website.

ODP leads and managers were aware of key risks which affected their services, and what was being done about them. They and other hospital leads maintained a risk register. The HoD outlined all their open risks categorised as moderate or low risk.

Service-specific risks were frequently reviewed and escalated appropriately. Attendees reviewed any risks categorised as moderate or above at quality group. The highest scored risk related to ODP was the transfer of patients due to the endoscopy service’s closure in June 2025. Mitigating actions were in place for this and other OPD risks. For example, relevant leads held meetings with their integrated care board (ICB) to seek and agree a solution.

All clinical risks were escalated through the quality group which discussed any clinical governance issues. All non-clinical risks such as IT, estates, housekeeping were fed up to governance committee level. Both clinical and non-clinical risks then fed up to the executive board. These were in the form of quarterly quality reports outlining all higher-level risks (scored 15 and above). Risks scored 8-10 were discussed at the quality group.

However, one ODP staff group and nursing leads were impacted by lack of timely or responsive remote IT support. Some OPD staff including the team leader could not always access online meetings such as the ‘ten at 10’ due to IT issues. Support staff told us IT issues, including for consultants accessing systems were not quickly resolved onsite. Leads confirmed the provider trust had appointed a new head of IT to help them address issues more promptly.

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.

ODP worked with their local NHS trust, other trusts and the integrated care board to frequently review clinical governance. For example, leads attended long wait meetings and quarterly ICB meetings with ICB quality leads and the local trust. They also held patient safety meetings with ICB quality team involvement.

The department displayed single point of access (SPA) information in waiting areas. This gathered all professional health and wellbeing advice and guidance across the region in one place. The SPA was contactable all hours for outpatients and relatives

The OPD had a close relationship with a local community centre which housed a social prescribing project. Staff frequently signposted patients who were more isolated or vulnerable there.

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 department was nominated for Best Provider of Outpatient Services for their patient optimisation initiative, reducing cancellations and health inequalities at the HSJ Awards. The initiative arose in response to a complaint resulting in safer care and improved patient outcomes.

The Head of OPD introduced a menopause clinic for staff and patients, supported by a GP, which had a small number of attendees across its first two sessions. Nursing staff added menopause‑related prompts to pre‑operative assessments, using a NICE‑affiliated GP’s 28‑day metabolic health plan to guide care. Patients responded positively. The Head reported this clinic had a clear, positive impact. It improved staff and outpatient confidence, reduced stigma, and encouraged greater openness. Increased self‑referrals and earlier presentation of menopause symptoms were already evident.

The department had examples of staff-led quality improvement projects (QIPs). These related to patient optimisation and reducing cancellations. Leads shared these improvements in governance papers. The hospital planned to embed and scale up these improvements, with next steps in place. One QIP made the provider trust and hospital an independent healthcare provider awards (IHPA) finalist at the Health Service Journal Independent Healthcare Providers Awards 2026.