Buckshaw 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 of an inclusive and positive culture that promoted continuous learning and improvement. We assessed whether leaders focused on meeting the needs of patients and supported staff to deliver safe, person-centred and sustainable care. We also considered how the service worked collaboratively with partners and used learning to improve outcomes.

At this inspection, we found that leaders promoted an improving and supportive culture within the service. Staff told us they felt able to raise concerns and that these were responded to appropriately. Leaders were visible, approachable and understood the priorities and challenges within the department. Systems were in place to support governance, risk management and oversight of performance.

There was evidence of continuous learning and improvement. Leaders used learning from incidents, audits and feedback to drive changes within the service, and staff at all levels were encouraged to contribute to improvements. The service worked collaboratively with partners to support coordinated care and ensure continuity for patients.

At our previous inspection, this area was rated good. At this inspection, the rating has remained good. This meant the service was well organised, and leaders supported the delivery of safe, effective and 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.

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 provider had a clear vision and set of values, which were aligned to the wider organisational strategy. These were communicated to staff through organisational events, including a vision and strategy day, and through supporting materials displayed across the service. Departments had defined objectives linked to the organisational strategy, helping staff understand how their roles contributed to service delivery.

Staff were focused on meeting the needs of patients and described working in ways that supported organisational priorities, including commitments to quality, sustainability and patient experience.

Staff described a culture that had improved over time. Some staff told us there had been previous challenges; however, they reported that changes in staffing and leadership had contributed to a more positive and stable working environment. Most staff told us they felt satisfied working within the service.

Relationships between staff were generally positive, and staff described supportive team working. Staff said they felt able to raise concerns and contribute to improvements within the service.

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 understood the impact their behaviours and leadership had on patient outcomes and staff experience. The leadership team had the appropriate skills, experience and knowledge to run the service and demonstrated an understanding of the priorities and challenges within the department.

The service formed part of a wider independent healthcare provider, with leadership structures in place at both local and organisational levels. The hospital director, who was also the CQC registered manager, was supported by senior leaders, including the head of clinical services and departmental leads. Staff told us leaders were visible, approachable and supportive, and promoted a positive culture within the service.

Leaders engaged with staff through a range of communication channels, including staff forums and regular updates. Staff told us they felt able to raise concerns and that leaders responded appropriately. Leaders also maintained a visible presence within clinical areas, which supported their understanding of day-to-day service delivery and enabled them to respond to emerging issues.

We identified some challenges in maintaining consistent leadership within the radiology service, which staff told us had impacted team cohesion during a period of management absence. Senior leaders were aware of this and had taken steps to address it, including providing additional leadership support and strengthening day-to-day management arrangements.

Leaders demonstrated a commitment to staff development, and staff told us they were supported to develop their skills and take on additional responsibilities. However, personal development review (PDR) completion rates within the department were lower than expected. Leaders were aware of this and had plans in place to address the backlog.

Leaders promoted a culture where concerns were taken seriously and used as opportunities for learning and improvement. Staff described a supportive working environment where they felt respected and valued.

Staff engagement was monitored through organisational surveys, which showed improvements in engagement, wellbeing and inclusion scores compared to the previous year, indicating a positive and improving staff experience.

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 systems in place to support staff to speak up and raise concerns safely. Staff had access to a “Speak Up for Safety” hub, which provided up-to-date information, guidance and tools. Policies to support this, including speaking up for safety and whistleblowing, were in date and accessible to staff.

Staff told us they felt able to raise concerns through established routes. Data reviewed during the inspection showed that concerns had been raised by staff working within diagnostic imaging, including themes relating to staff attitudes and behaviours.

Leaders were aware of the concerns raised and told us they were taken seriously and used to inform improvements. There were processes in place to review and respond to themes identified through staff feedback.

These arrangements supported a culture where staff had access to mechanisms to raise concerns and where issues could be identified and addressed.

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.

The service promoted equality, diversity and inclusion within the workforce. Leaders used workforce data, including findings from the Workforce Race Equality Standard (WRES), to understand staff experience and identify areas for improvement.

The WRES findings showed progress in areas such as improved access to training, reduced harassment from colleagues and strengthened organisational culture. However, some disparities remained, including in disciplinary processes and representation at senior levels. Leaders were aware of these and had plans in place to address them and support longer-term improvement.

The service took steps to prevent and address inappropriate behaviour. Staff told us that concerns relating to staff attitudes and behaviours had been raised and were taken seriously by leaders. These were used to inform ongoing cultural improvement work within the service.

Staff told us the culture had improved over time, with previous concerns being addressed. Most staff reported that they were happy working within the service. Staff also gave examples of reasonable adjustments being made to support their individual needs, including changes to working patterns and duties to accommodate health conditions or personal circumstances.

Policies to support equality, diversity and inclusion were in date, and staff had access to established routes to raise concerns, including speaking up and whistleblowing processes.

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 operated effective governance processes to support the management of risk, performance and sustainability. Risks were clearly identified, recorded and monitored through structured systems aligned to organisational processes. A radiology governance system and risk register were in place, with risks categorised and tracked, supporting clear oversight across the department and wider organisation.

Leaders reviewed risks regularly and implemented appropriate mitigations. Specific risks, including those relating to MRI, were informed by national guidance and reviewed annually to ensure they remained current. Lower-level risks were retained within the register to maintain staff awareness and reduce complacency. Risk documentation was accessible in both digital and paper formats.

There were effective processes for monitoring performance. Key performance indicators, including referral-to-scan times and reporting timelines, were reviewed to ensure service delivery remained responsive. Performance information was shared through governance processes, including regular contract reporting and clinical quality meetings.

Staff at all levels were aware of their roles and responsibilities and contributed to governance processes. Risks, incidents and operational pressures were discussed through team meetings and daily safety huddles, ensuring information was shared in a timely way.

Audit processes were used to monitor quality and drive improvement. Audit results, patient feedback and external assessments were reviewed, and learning was used to inform service development. The service followed structured processes for learning from incidents, including the Patient Safety Incident Response Framework, to identify themes and embed improvements.

Leaders maintained oversight of workforce and sustainability through workforce planning and succession arrangements. Recruitment and workforce strategies had reduced reliance on bank staff and supported service stability. Leaders were aware of challenges in appraisal completion and had plans in place to address this.

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 service worked collaboratively with partners and external organisations to support coordinated and integrated care. There were established processes in place to share information across organisational boundaries, ensuring continuity of care when patients moved between services.

Leaders engaged with external stakeholders, including the Integrated Care Board (ICB), through regular reporting and meetings. The ICB received assurance through monthly and quarterly contract reporting, alongside bi‑monthly contracting meetings and regular clinical and quality touchpoints. These processes provided oversight of performance, safety and service delivery.

Staff, teams and services worked effectively together, sharing information to support continuity of care and reduce duplication. This helped ensure patients did not need to repeat their history when moving between services and supported a coordinated patient experience.

Information and learning were shared across services and with partners to support consistent practice. Learning from incidents was managed through the Patient Safety Incident Response Framework, enabling themes to be identified and improvements embedded across services.

The service gathered patient feedback through a range of mechanisms and used this to inform improvements. Feedback was also triangulated with partner organisations to support a coordinated approach to service development.

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 described a positive and proactive culture of learning and continuous improvement. They told us they felt confident to raise concerns and share learning, and that leaders encouraged openness and reflection to support service development.

Learning from incidents, feedback and service pressures was discussed through team meetings and daily safety huddles. These forums were used to identify themes, share learning and support timely improvements to practice. Staff told us this helped ensure learning was embedded and led to changes within the service.

Leaders used learning to drive improvement and shared this across the department and wider diagnostic services, supporting consistency and the spread of good practice. Staff gave examples of how improvements were identified and taken forward through governance processes.

Staff at all levels were encouraged to contribute to improvement and innovation. This included both clinical and administrative teams. Staff described how non-clinical staff contributed to identifying themes in booking and utilisation, supporting improvements in capacity management and patient flow. These were escalated and reviewed through regular meetings to support responsive changes to service delivery.

Leaders supported staff development through structured induction and ongoing training. Staff told us they felt supported to develop their skills and contribute to improvements within the service