Nuffield Health Hereford 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 that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patient who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. This key question has remained good. This meant patient’s needs were met through good organisation and delivery.

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 patient and their communities.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff spoken with had awareness of how their work contributed to achieving targets.

The hospital’s strategy included playing a vital role in the Herefordshire health community and its surrounding areas.

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

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Consultant staff we spoke with said they felt there was sufficient clinical leadership especially through the medical advisory committee (MAC). Consultants we spoke with said they felt they were a part of the hospital and had a good relationship with staff.

Staff could explain how they were working to deliver high quality care. We observed patient centered culture across the theatre and ward areas. Most of the staff we spoke with had been at the hospital over two years and were happy working there. Morale was positive and staff said one of the best things about the job was having the time to get to know patients and care for them.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear. Team and Individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

The service had leaders 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.

There was a clear management structure with clear lines of responsibility and accountability. The senior leadership team consisted of the hospital director, director of clinical services and a director of operations.

The senior management team were visible in the service and approachable for patients and staff. Each head of department reported to 1 of the senior managers and there was a monthly head of department meeting. Staff told us leaders were well respected, visible, approachable, and supportive. Departmental managers worked clinically and provided cover for sickness when required. Ward and theatre staff worked together effectively. We were told managers were approachable at all levels and were helpful and always ready to listen to concerns or to raise any new ideas.

The consultants we spoke with felt the hospital was well run and efficient, and the managers were responsive.

Leadership development opportunities were available, including opportunities for staff. The service had processes in place to ensure staff were recruited fairly and for roles they were competent in. Where new leaders were recruited, there were processes in place to ensure they were supported.

There was a process in place for leaders to meet and discuss issues and cascade information back down to the staff in the service. The minutes from the governance meetings showed leaders were knowledgeable about their issues and priorities in their services.

Monthly newsletters were introduced for staff with articles sharing local information such as welcoming of new staff, celebrating long service, promotion of flu vaccinations, highlighting workshops with local GP’s and seasonal festivities.

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. Leaders were visible and approachable in the service for patients and staff. Staff felt the leaders supported them to develop their skills and take on more senior roles.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

Staff told us when they had raised valid concerns, they felt they were or would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially. The local senior leadership and corporate team were made aware when whistle blowers had raised serious concerns.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. There was a patient experience forum which met three times a year.

There was a provider freedom to speak up (FTSU) policy and a national FTSU guardian. There were 2 FTSU guardians for the service and staff knew who they were and how to contact them. FTSU guardians were supported by senior leaders for the organisation. FTSU information was displayed on information boards for staff.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

Managers put reasonable adjustments in place for staff members to help them carry out their role if needed. This could be in the form of shorter or longer shift patterns depending on the concern. Staff with disabilities were offered reasonable adjustments to support them to carry out their roles well. For example, flexible working agreements were taken into account for personal circumstances such as caring responsibilities and health issues.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

There were policies and processes in place to ensure the service was inclusive and fair in the way they operate. Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work. Equity, diversity and inclusion’ training was part of staff’s mandatory training programme; 98% of theatre and ward staff had completed this.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on information about risk, performance and outcomes, and shared this with others when appropriate.

The service operated effective governance processes through various committees and on-site activities. For example, there was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the provider. Performance data was analysed and compared within the provider organisation and where improvements were needed at the location level, action plans were developed to make this happen.

There was a medical advisory committee (MAC) led by a chair and supported by the service leadership, which included approval of practicing privileges and review of clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

The MAC were responsible for providing assurance and advice to the senior management team on medical and operational matters. It was attended by a consultant representative from each specialty. We reviewed 1 set of minutes and saw actions were taken to make improvements. Set agenda items included discussions of incidents, outcomes, recruitment and their future job plans.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them. This was important because it showed a greater accountability amongst the staff and there were consistent standards across the service.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly. Data or notifications were consistently submitted to external organisations as required.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared through email, meetings and communication folders. The service held departmental meetings for staff bi-monthly at a minimum. Risks such as staffing would be discussed and training, appraisals, reminders regarding processes and actions to take to improve audit results. Patient feedback was shared and, any notable improvements or successes were celebrated.

Risks were clearly identified and a formal log of these were used to keep oversight and manage mitigations and/or bring to resolution. Staff contributed to decision-making to help improve sustainability and improve quality of care.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to positive changes. The clinical audit and effectiveness committee discussed the local audit plan, complaints, outcomes and risks.

The service had a business continuity plan which could be put into operation in the event of unexpected disruption to the service, this included a short-term disruption plan and major incident plan.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

There were weekly senior leadership meetings. These included a standardised agenda with updates from the hospital director, finance, director of clinical services as well as any departmental escalations. The clinical governance committee for the service met monthly with attendances from leaders across the hospital departments. There was a standardised agenda template and reporting deck for the provider, that included review of top risks on the risk register and any regulatory updates. Incidents were reviewed including summaries where any emerging theme could be highlighted, cancelled operations, any pressure ulcers, medicines and infection incidents. Information submitted for patient reported outcome measures (PROMS) and the National Joint Registry (NJR) was discussed. The service had achieved gold status for NJR. Patient experience and feedback was reviewed including summaries of complaints. Actions were produced based on this information. There was an opportunity for individual department escalations as well as raising any other business.

There was a committee for infection, prevention and control that included core members and departmental links. This committee met quarterly and discussed set agenda items such as audits, risks and training compliance.

There were also other committees and forums that met quarterly; information governance, resuscitation and critical care, medicines management, medical advisory committee (MAC), infection prevention and quality and safety. All were formally minuted, which we saw evidence of.

The hospital patient experience forum meetings were planned biannually, although this year they would be increasing this to three times. There were representatives from each department where feedback was discussed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. The senior leadership team would visit other Nuffield hospitals, and discuss risks, incidents and complaints to share learning and new ideas. We were told that there was positive communication and support from the regional leadership team. They had weekly calls and monthly face to face meetings. The hospital director spoke highly of this support.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. The service maintained a risk register locally for both theatres and the ward. The departmental risk registers were incorporated into the hospital risk register to allow oversight at all levels. Risk registers were reviewed regularly and updated quarterly. We saw the top 3 risks displayed on the theatre notice board for staff. Risks were mainly health and safety and environmental risks. The register included review dates and controls in place to mitigate risks.

Information governance systems included confidentiality of patient records. Mandatory training requirements included information governance with a compliance rate of 96% for theatres and 97% for the ward staff.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, liaising with local GPs, community nurses, social workers for treatment/discharge plans and safeguarding concerns. They would also use feedback from regulators or external auditors to improve services.

Some senior leaders were part of regional networks to understand the needs of the community and the provider’s ambitions. For example, members of the senior leadership team would attend regional healthcare planning meetings to discuss local population health trends and the demand for services, such as physiotherapy, diagnostics and mental health support. The waiting list pressure for the local population would also be discussed.

The service had been engaging with organisations in the local community such as local schools, mosques and sports clubs as well as health providers such as GP’s and the local NHS acute trust.

The provider engaged appropriately with NHS partners including commissioners and trusts in the event of needing to transfer patients who became ill during their stay. There were service level agreements in place with the local NHS acute trust for pathology and the decontamination of equipment.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patient. Staff actively contribute to safe, effective practice and research.

Staff were committed to continually learning and improving services. Several staff we spoke with had a good understanding of quality improvement methods and had been trained in this area of work. We were told about some of the areas of work which they had focused on, which included robotic-assisted orthopaedic surgery, for hip and knee replacement surgery. The benefits of this were, more precise surgery, improved recovery, reduced surgical error risk and better patient outcomes and mobility.

Staff were supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. Leaders encouraged innovation and participation in research, and we heard that staff participated in national audits relevant to the service and learned from them.

Wards participated in accreditation schemes relevant to the service and learned from them. The service received the gold standard in Aseptic Non Touch Technique (ANTT) 2026. ANTT is the national standard designed to minimise healthcare-associated infections. The Gold standard is a prestigious recognition showing the dedication of the service in implementing best practice techniques.

The hospital won the Most Improved Hospital for 2025 within the Nuffield group. This was by increasing their patient satisfaction and staff engagement scores, by focussing on colleague well-being, face to face communication to build trust and stronger working connections, and the contemplation room.

Staff and leaders were committed to excellence that centred on the patient experience. Where they saw a need, they worked together to find a solution.