Alexandra Private 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

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 inspection, the service was in breach of regulation as whilst there were audit tools in place for staff these were not being used effectively. Since then, the service has taken effective action to address the concerns identified.

Managers had introduced new audit tools which were being used regularly to monitor consumable stock and medicines were in date and as a result, the service was no longer in breach of this regulation and at this inspection, the rating for this key question has changed to Good.

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

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture.

The service had a clear vision and set of values with a strategy for how to achieve this which was shared with staff. These values were communicated through bi-monthly team meetings, induction processes, and ongoing staff engagement. Staff consistently demonstrated a shared commitment to delivering high-quality, patient-centred care in line with the service’s vision by sharing ideas to improve patient experience and ensure safe care.

There was a strong patient-centred culture embedded across the service. Leaders and staff consistently prioritised patient safety, with a measured approach to increasing patient numbers to maintain safe standards of care.

There was a strong sense of teamwork and mutual respect, with staff working collaboratively.

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 demonstrated compassion and had a supportive approach, with a clear understanding of their roles and responsibilities within the service. Leadership visibility was evident throughout the service. Leaders were visible to patients, presenting a caring approach to running the service.

Leaders were responsive and had taken appropriate action in response to concerns identified during the previous inspection.

Staff felt supported by the leadership team and feedback from the most recent staff survey indicated that staff viewed the leadership team as approachable and felt respected in their roles.

We scored the service as 2. The evidence showed some shortfalls.

Leaders fostered an open and inclusive culture where staff felt able to raise concerns.. The service had an anonymous feedback box for staff to use should they wish to raise feedback in this way and staff meeting minutes showed that freedom to speak up was a priority and the importance of this was regularly discussed. Staff did not have access to a third party freedom to speak up representative which limited their ability to raise any concerns that they did not feel comfortable speaking to management about.

There was a clear commitment to listening and learning from patient experiences. Patients were actively encouraged to provide feedback through various channels, and those who expressed dissatisfaction were offered face-to-face meetings with leaders to discuss their concerns.

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.

Leaders promoted a culture of respect and inclusivity, creating a workplace environment where staff felt valued and encouraged to contribute meaningfully. This was reflected in the service’s mission and values which demonstrated a clear commitment to promoting diversity and inclusion.

The service had procedures in place to ensure fairness and inclusivity during recruitment, supporting equal opportunities for all applicants. All staff had completed mandatory training in equality and diversity, reinforcing the service’s dedication to maintaining an inclusive working environment.

The structure of the working day was aligned with the scheduling of surgical procedures, reflecting the operational needs of the service, however feedback from the most recent staff survey indicated that some team members would welcome greater flexibility in start and finish times to support work-life balance.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders held regular governance meetings held to review performance, discuss risks, and examine incidents. As part of this inspection, we reviewed the minutes of governance meetings which had taken place since our previous inspection. The meetings were well-structured and documented, ensuring that actions were clearly defined and followed up. Leaders used these meetings to promote continuous improvement, with clear plans in place to address identified risks and learning from incidents. The service had an up-to-date risk register which was discussed at these meetings.

Following our previous inspection, the provider was found to be in breach of Regulation 17 (Good Governance) due to the absence of a robust incident reporting process. Since then, the service has implemented a revised system, which was regularly reviewed by management to ensure that all incidents were investigated and addressed.

During the last inspection, we identified out-of-date medication and missing equipment on the ward resuscitation trolley, despite audit records indicating that checks had been completed. At this inspection, we reviewed updated audit documentation which confirmed that appropriate checks were now being carried out consistently, and all equipment and medication was present and in date reflecting 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.

We did not speak with partners as part of this assessment.

The service had a formal agreement in place with the local acute hospital trust to support continuity of care and maintain patient safety. They also actively engaged with the local Integrated Care Board and acute hospital trusts.

Clear operational processes were established with the acute hospital trust, including protocols for the decontamination of surgical equipment, the disposal of controlled drugs, and the management of deteriorating patients.

We scored the service as 3. The evidence showed a good standard. Leaders recognised the value of staff expertise and actively encouraged the sharing of ideas to aid with service improvement. This collaborative approach supported a culture of continuous learning and development across the organisation.

Leaders recognised the value of staff input and all staff were encouraged to share good practice and make suggestions for service improvements. One example was a tool developed by a staff member to track all consumable items in the hospital. It ensured stock was rotated regularly and highlighted items nearing expiry, ensuring staff removed them when necessary. We saw evidence that the tool was actively used and embedded in the routine operation of the service.

There was a clear commitment to learning from patient experience. Leaders welcomed feedback and were directly involved in addressing concerns raised by patients. In cases where patients reported dissatisfaction, leaders took proactive steps to resolve issues and used the insights gained to drive continuous improvement.