Claremont 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

The service had an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities.

There were effective governance systems and processes in place to monitor outcomes and patient safety, lessons learned were disseminated at a local and national level.

The service had capable and compassionate inclusive leaders, the teams had a hospital huddle each day where all departments were represented, and any concerns were escalated. During the huddle they also recognised any staff who had been nominated as going above and beyond for colleagues or patients.

Staff we spoke to were positive about the leadership culture across the organisation, they said senior leaders were visible and accessible, and they had support from their immediate line managers.

There was a management programme in place for managers and aspiring managers and staff told us they had been encouraged to attend. The service had a talent management framework which they had incorporated into the appraisal process.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Managers and leaders at the service recognised any limitations of the hospital. They had a site development plan that had incorporated the needs of patients, staff and external partners. The plan included options to create more space for parking for example.

There was a hospital wide strategy for 2025/2026 that incorporated a strategic business plan. The strategy focussed on 6 priorities; patient experience, provision of outstanding care, people, patient pipeline, productivity and commerciality and prioritising environmental, social and governance.

The hospital's vision was to make a positive difference in patients lives through outstanding care. Their mission was to bring together the best people to deliver the highest quality patient care in excellent clinical environments.

Senior leaders told us that the hospital strategy was fully integrated into the hospitals vision and values. We saw that the vision, values and principles were displayed throughout the hospital.

Staff we spoke with 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.

Staff told us that there had been significant improvements made since their last staff survey was carried out and felt supported and valued by senior leaders and colleagues.

Managers and leaders at the service had the relevant skills and abilities to manage the services effectively. They understood the risks to the services and had clear oversight on safety, governance and performance issues through daily involvement and quality monitoring. There were succession plans in place for key roles such as head of departments and directors.

The hospital director was the registered manager and had been in post approximately two years. Staff we spoke with were consistently positive about the hospital director and said they listened well to concerns and was responsive.

The lead for the surgical services at the hospital was the director of clinical services. The ward manager and the theatre manager were responsible for the day to day management of the ward and theatre areas. The theatre manager was relatively new in post at the time of our assessment.

There was a clear reporting line for both clinical and non-clinical staff. The consultant surgeons and anaesthetists had clinical responsibility for the patients they treated. Medical staff practice was overseen through the practicing privilege process for which the medical advisory committee (MAC) provided the Hospital Director with clinical advice around.

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

Staff listening forums took place in October and November 2024 with senior leaders. They were made aware of how some managerial communication and behaviours had negatively impacted on staff wellbeing and led to some negative responses in the staff survey. Feedback was considered by the hospital leadership team and an appropriate action plan was implemented to drive improvement. This has led to much improved feedback from staff at the time of our assessment.

Staff we spoke with felt confident raising issues with their manager and that managers responded positively when concerns were shared.

The provider’s whistle blower policy and freedom to speak up (FTSU) policy, provided guidance for staff around raising any concerns. Staff were also given information on how to raise concerns through the provider’s intranet and information on boards throughout the hospital.

Staff we spoke with knew who the FTSU guardian was and were aware of the whistleblowing policy.

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

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 and felt confident their concerns were listed to. Staff we spoke with were positive about working for the service and were proud to work there.

Managers told us equality, diversity and inclusion was embedded in the culture of the service. They told us staff recruitment processes enabled equal opportunities and they engaged with staff routinely to maintain an inclusive work environment.

Equality, diversity and inclusion was incorporated in the provider’s recruitment policies and processes. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns. We heard from staff who had been offered adjustments to their working without needing to ask and they said that this made them feel valued.

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 actions following the staff survey, which focused on leadership and culture.

Spire Healthcare provided reports annually in relation to workforce race equality standard (WRES). We reviewed the most recent report, however we were unable to see data by location, rather by organisation. This included diversity data and self-reporting by ethnicity, other diversity information and protected characteristics.

There were clear governance structures in place that provided assurance of oversight and performance against safety measures. There were committees for risk and audit, infection control, workforce and health and safety feeding into the clinical governance committee and medical advisory committee (MAC).

Minutes for the last two MAC meetings demonstrated that key governance areas were discussed including incidents, complaints and practising privileges.

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. Action logs were in place for key performance indicators that required improvement and these were followed up at subsequent meetings.

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

There was regular communication and oversight from the corporate provider and the hospital. The hospital director reported incidents, performance and outcomes data to the corporate provider and the partnering NHS trust monthly to enable effective monitoring and oversight of the service’s performance. Routine meetings with the partnering NHS trust took place regularly to discuss performance, outcomes and key risks.

The ward and theatre managers logged identified risks on local risk registers. Key risks were placed on the hospital wide risk register. Key risks were identified and control measures were put in place to mitigate risks. 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 corporate provider.

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 and they received feedback following audits to aid learning and improvement.

The service had a number of policies to manage risk such as VTE, caring for deteriorating patients, mental capacity, deprivation of liberty and restrictive practice. Staff told us that they were alerted when policies were updated. All policies we reviewed were in date, comprehensive and in line with evidence-based practice and national guidance.

Patients told us care and treatment was well co-ordinated between the service, their GP and the partnering NHS trust. They felt there was timely communication and sharing of information about their care and treatment between the services.

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

Managers told us they had an effective working relationship with system partners such as the NHS hospital and Integrated Care Board (ICB). The hospital director and director of clinical services told us that they worked closely with the local NHS trust to address long waiting times and ensure timely treatment for NHS patients. They had weekly meetings to review and discuss patients being transferred, address any concerns and share learning.

Staff worked in collaboration with the wider system to address regional healthcare pressures and ensure integration of care pathways.

Staff told us there was a culture of learning and improvement across the service.

The hospital shared best practice with partners and offered them support and training. We observed positive feedback from partners who had implemented some of the hospital’s processes to improve their service provision.

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

Staff spoke positively about improvements made in the service following feedback from staff or patients and said that the senior leadership team were focused on acting upon this.

Staff gave examples of collaboration and shared learning with staff at NHS hospitals. They told us they had visited local schools to provide IPC and environmental education. The service had recently implemented a new initiative where they had provided staff with reusable cups which was more sustainable and had reduced waste.