St Hugh's 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 looked for evidence 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 as inadequate. At this assessment the rating has improved to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service had an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of patients and wider communities.

Leaders had effective governance systems and processes in place. They monitored outcomes and patient safety, and disseminated lessons learned with staff teams.

The service had capable and compassionate inclusive leaders. Teams had a daily hospital huddle where all departments were represented. Heads of department escalated any concerns at the start of each day.

Staff we spoke to were positive about the leadership culture across the organisation. They said senior leaders were visible and accessible. They had support from all levels of management.

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.

Staff understood and shared the provider’s vision and values. They knew how they were applied in the work of their team. This was embedded within the appraisal framework.

The provider’s senior leadership team had successfully communicated their vision and values to the frontline staff in this service.

The hospital had a vision and strategy aligned with the health priorities of the local area. It was focused on meeting demand, expanding capacity and incorporated risk-based decision making.

Service managers and leaders recognised any limitations of the hospital. They had a site development plan which had incorporated the needs of patients, staff and external partners. The plan included options to utilise the space available after the endoscopy service closure.

Staff told us improvements had been made since their last staff survey. They felt supported and valued by senior leaders and colleagues. Staff we asked had a good understanding of the provider’s objectives, values and behaviours. Managers told us progress against the business objectives was reviewed as part of routine meetings.

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.

Managers and leaders had the relevant skills and abilities to manage the services effectively. They had clear oversight on safety, governance and performance issues through daily involvement and quality monitoring. This meant they understood all risks to the services.

Several senior leaders had undertaken HMT’s own leadership programme. The Head of Clinical Services onsite had also undertaken a Shadow Board Leadership Development Programme through the Inspiring Leaders Network. This was arranged through the local health board. At the time of our assessment this was no longer available. However, they were developing programmes for each level of leader to attend.

The hospital director was the registered manager. Staff we asked were consistently positive about the senior leadership team. They said they listened to concerns and updated staff through the daily huddle on any action and updates on issues that had been raised.

All staff spoke positively about the support they had received from their managers and senior leaders. They told us all leaders were visible, approachable and provided them with good support and guidance.

The ward and theatre managers were responsible for the day-to-day management of these areas. They could always access senior leaders.

Both clinical and non-clinical staff had clear reporting lines. The consultant surgeons and anaesthetists had clinical responsibility for the patients they treated. The medical staff were overseen by the medical advisory committee (MAC) chair.

We saw good multi-disciplinary working throughout the hospital. Staff held regular meetings to gain colleague feedback towards any potential improvements. Staff said they felt listened to. They were comfortable raising issues either within MDT meetings, or directly with one of the senior leadership team.

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 provider and hospital had a Freedom to Speak Up Guardian (FTSU) 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.

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. Leaders explained their expectations of role hours to the champions.

However, no FTSU champions had protected time outside their working roles to fulfil speak up commitments.

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 (Viva engage) which shared feedback.

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

Staff we asked felt confident raising issues with their manager. Managers responded positively when staff shared any concerns.

Staff followed the provider’s whistleblower policy and FTSU policies guidance around raising any concerns. They were also given information on how to raise concerns through the provider’s intranet and on information boards throughout the hospital.

Staff knew and were positive about their FTSU guardian. They said they felt comfortable using the FTSU service if they had to. Staff understood how to contact the FTSU guardian if needed.

Patients and carers had opportunities to give feedback on the service. Staff could tailor feedback formats to reflect their individual needs. The ward manager was visible and talked to patients during their daily rounds. They identified any concerns from both patients and staff.

Managers and staff could access the feedback from patients, carers and staff. They used it to make improvements, such as improving signage in the hospital and changes to the patient menu.

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 evidence showed a good standard. 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.

Staff told us the service had an inclusive working culture, and they were treated with respect and equity. Staff told us managers engaged with them regularly. They felt confident their concerns were listened to. Staff we asked were proud of and positive about working for the service.

Equality, diversity and inclusion was incorporated in the provider’s recruitment policies and processes. These had support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers and senior leaders engaged with staff to monitor work culture and identify any bias or discrimination. The service carried out annual staff surveys to gain feedback from various staff groups about their experiences.

Managers had undertaken appropriate actions following their last staff survey, which focused on staff wellbeing. The hospital had since implemented a variety of wellness provisions in collaboration with staff.

The organization had reviewed their workforce practices over the year before our assessment. These aligned to the workforce race equality standard (WRES) principles. Leads could track and record diversity data using the new human resources information system. Staff were asked to provide their equality monitoring data during their onboarding process. The hospital had diversity, equality and inclusion champions across the organization.

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 provider trust’s policies were first approved at clinical governance and medical advisory committee (MAC) meetings. These were then adapted and amended as per National Institute Clinical Excellence (NICE), Royal College, British Association and Anaesthetic Services guidelines. We saw the provider policy for National Institute for Health and Care Excellence (NICE) guidance implementation was amended as needed.

Team meetings included a clear framework of what must be discussed at a ward, team or directorate level. This ensured essential information, such as learning from incidents and complaints, was shared and discussed.

Staff undertook or participated in local clinical audits. Audits were sufficient to provide assurance and staff acted on the results when needed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

The service had a business continuity plan in place.

The hospital had undergone some cost improvement. For example, the endoscopy service has ceased in June 2025. The service had worked with their local acute trust and Integrated Care Board (ICB) to ensure patients were followed up.

Information governance systems included confidentiality of patient records.

Team managers could access information to support them with their management role. This included information on service performance, staffing and patient care.

Information was in accessible formats, timely, accurate and identified areas for improvement. The service had clear governance structures in place. These provided assurance of oversight and performance against safety measures. Leads held monthly patient safety and patient governance committee meetings. In addition, they had committees for risk and audit, infection control, workforce and health and safety, which all fed into the MAC.

Staff told us information on performance, risks and governance was discussed during daily huddles and routine team meetings. Meeting minutes showed key discussions routinely took place around performance, risk, governance, audits, and incidents.

Managers were aware of their responsibility to report notifiable incidents and any incidents related to the General Data Protection Regulation (GDPR). The hospital reported no data breaches reportable to the Information Commissioner’s Office (ICO) in the past 12 months.

The ward and theatre managers logged identified risks on the risk registers. They identified key risks and put control measures in place to mitigate them. Individual risks had a review date and an accountable staff member assigned to them. A risk scoring system was used to identify and escalate key risks to the leadership team.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives. Staff told us they participated in the audit processes. They received feedback following audits to aid learning and improvement.

The service had several policies to manage risks such as venous thromboembolism (VTE), caring for deteriorating patients, mental capacity, deprivation of liberty and restrictive practice. Staff told us they were alerted when policies were updated and the system allowed governance leads to see when staff had read the policy. All policies we reviewed were in date, comprehensive and in line with evidence-based practice and national guidance.

Board meetings had oversight of all clinical and financial risks across all provider sites. Hospital data was clearly reported, and risks and actions monitored.

The service understand our 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.

Patients told us the service coordinated their care and treatment well with their GP and the partnering NHS trust. They felt services communicated promptly and shared information about their care and treatment appropriately.

Patients spoke positively about being able to access treatment within their local area. They told us this was convenient and reduced their travel times.

Managers had an effective working relationship with system partners such as the ICB, the local health board, and local authority safeguarding board. The director of clinical services for hospitals and head of clinical services worked closely with the local NHS trust to address long waiting times and ensure timely treatment for NHS patients.

Leaders engaged with external stakeholders including the Integrated Care Board. They identified where they could provide services to impact on local waiting list initiatives.

The senior leadership team actively sought opportunities to provide services to the local health community.

The safeguarding lead participated in the local authority safeguarding forum.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

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.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery.

The hospital education lead had a held a joint sepsis conference with the local NHS Trust. They had won an educational award and been nominated for a national award.

Incidents and complaints were investigated, and learning was shared across the HMT group with staff to improve the services. The service provided evidence of shared learning with their local NHS hospital and other external partners.

We heard examples of service and quality improvement projects. Leaders had successfully implemented a patient optimisation initiative in outpatients. This supported the early identification of patients who may be unsuitable for surgery at the planned time. This had led to the optimisation of theatre slots and improved post-operative outcomes.

The service was proactive in identifying where they could offer services to the local health economy to provide services closer to home for the local community.

Staff on the ward had reviewed patient feedback, patients had expressed an interest in staff roles and their experience. The service had introduced a ward Tree of Career Progression which was displayed on the ward wall. This displayed positive feedback from staff, patients, relatives and visitors. The wall had been shared on the provider trust’s intranet site and social media channels.