Bromley Road Hospital

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• 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 hospital 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 good. At this inspection, the rating has remained the same.

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 this quality statement 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 service promoted organisational values centred on Kindness, Integrity, Teamwork and Excellence. These values had been co-produced and were understood by staff. Observations and feedback demonstrated many examples of these values being reflected in practice.

The service demonstrated a positive organisational culture characterised by openness, professionalism and commitment to continuous improvement. Leaders and staff engaged openly throughout the inspection and we observed a constructive and non-defensive approach to feedback and discussion.

There was evidence of shared commitment to recovery-focused practice, multidisciplinary collaboration and delivering person-centred care. Staff demonstrated pride in their work and commitment to supporting patients with complex rehabilitation needs.

Leadership responded positively to issues identified during inspection and demonstrated willingness to implement improvements where required

We scored this quality statement 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.

Leadership was visible, engaged and actively involved in supporting clinical care and service development. The Responsible Clinician demonstrated strong clinical leadership and was actively involved in multidisciplinary discussions and patient care. Leaders promoted collaborative working across professional groups and demonstrated a commitment to recovery-oriented rehabilitation and patient-centred care. Staff generally spoke positively about leadership support and leaders demonstrated awareness of service challenges and improvement priorities.

We observed positive relationships between leaders and frontline staff. Leaders were actively involved in quality improvement work to support better patient outcomes.

Leaders oversaw several improvement projects. These included the use of ReQoL-10 and ReQoL-20 outcome measures, improvements to care plan transitions, and the development of trauma-informed practice.

Leaders also supported smoking cessation, nicotine replacement therapy (NRT), and weight management initiatives to improve patients' physical health and wellbeing.

Staff were involved in these projects, and leaders monitored progress through governance and quality improvement processes. This helped ensure learning was embedded into practice.

Discussions with leaders and staff showed that learning from these projects was used to improve care planning, recovery-focused interventions, and physical healthcare support. This demonstrated a commitment to continuous improvement and better patient outcomes.

We scored this quality statement 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.

Staff were aware of the processes available to raise concerns, including speaking with managers, incident reporting systems and Freedom to Speak Up arrangements.

Staff told us they felt able to raise concerns and were confident these would be listened to and acted upon.

We observed an open culture, with staff engaging honestly with inspectors and discussing practice and service development openly.

Workforce survey results were broadly positive, however, some variation in staff experiences relating to speaking up and psychological safety suggesting not all staff were comfortable raising concerns.

Managers and staff had access to feedback from patients, carers and staff and used it to make improvements. Patients had opportunities to give feedback on the service. We saw examples of these within patient community meeting minutes and surveys.

We scored this quality statement 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider had policies and processes in place to promote equality, diversity and inclusion (EDI). Staff completed mandatory EDI training and described a diverse workforce with generally positive and respectful working relationships. Staff told us they felt valued and treated fairly, regardless of their background or protected characteristics.

Leaders monitored equality data as part of recruitment and workforce processes and promoted inclusive values across the service. Staff survey findings were generally positive in relation to respect, recognition and belonging. However, there was limited service-level evidence to demonstrate how leaders routinely analysed workforce data to identify disparities between staff groups or evaluated the effectiveness of actions taken to improve workforce equity and inclusion.

The service demonstrated a commitment to delivering inclusive, person-centred care that recognised people's individual needs, preferences and recovery goals. At the time of the assessment, Diversity, Equity and Inclusion training compliance rate was 100%.

We scored this quality statement 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.

The service had established governance arrangements, including governance meetings, audits, risk management processes and organisational oversight. Leaders monitored incidents, safeguarding concerns, complaints, medicines, staffing, training, MHA and MCA compliance, patient feedback and service risks through governance forums and the service risk register.

Leaders demonstrated a good understanding of the key risks facing the service and used audits to identify areas requiring improvement. These included MHA and MCA documentation, clinical record keeping and the timely updating of risk assessments. However, some concerns identified through audit processes, including Section 132 rights documentation, capacity assessments and the accessibility of clinical information, had reoccurred, indicating improvements were not always consistently embedded.

Although governance systems were effective in identifying risks and areas for improvement, they did not always provide full assurance that actions had resulted in sustained improvements in practice. However, leaders and staff demonstrated a good understanding of patients' needs and current risks, and the impact of these concerns was primarily on governance assurance and record-keeping rather than the care people received.

We scored this quality statement 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 shared information and learning with partners and collaborated for improvement.

The service maintained effective partnerships with a range of external organisations, including commissioners, local authorities, advocacy services, community teams and third-sector providers. The multidisciplinary team worked collaboratively with these partners to support rehabilitation, discharge planning and continuity of care. Staff liaised with external agencies to facilitate timely access to community support, education, accommodation and other resources that would be important to patients both during admission and following discharge.

Patients were supported to engage with opportunities beyond the hospital environment that reflected their individual interests, strengths and recovery goals. We saw examples of patients attending college courses, accessing community-based activities and progressing through graduated levels of leave as part of their rehabilitation. These opportunities helped patients develop confidence, practical skills and greater independence while maintaining meaningful links with their local communities.

Partnership working supported patients to prepare for future transitions and longer-term recovery. Staff worked with community services and external organisations to support goals relating to independent living, education, employment, social participation and community reintegration. Care planning demonstrated a focus on developing the skills, experiences and support networks required to help patients achieve successful outcomes following discharge.

Staff recognised the importance of maintaining community connections throughout admission and used community resources to reduce social isolation, promote inclusion and support patients' readiness for life outside hospital. Through collaborative working and access to community opportunities, patients were supported to build confidence, strengthen independence and progress towards their individual recovery goals.

We scored this quality statement 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 contributed to safe, effective practice and research.

Leaders demonstrated a strong commitment to learning and improving the service. Staff described several initiatives to improve patient experience, safety, rehabilitation, and physical health.

The service introduced ReQoL-10 and ReQoL-20 outcome measures to better understand patients' recovery, wellbeing, and quality of life. This information was used to review progress and identify additional support needs.

Leaders improved care plan transitions and discharge planning to strengthen continuity of care. Staff said this supported better multidisciplinary working and more personalised planning.

The service was also developing physical health initiatives, including smoking cessation, nicotine replacement therapy (NRT), and weight management programmes. These aimed to support healthier lifestyles and improve long-term wellbeing.

We saw evidence that learning from incidents, audits, outcome measures, and patient feedback informed service development. Leaders used incident reviews, reflective practice, and multidisciplinary discussions to improve care planning, risk management, and therapeutic support.

Rehabilitation initiatives supported greater independence, daily living skills, and community participation. Examples included self-catering, graded leave, education, and community-based activities.

Psychology staff supported service improvement through formulation-led approaches, trauma-informed practice, CBT-informed interventions, and motivational interviewing. These approaches helped staff better understand patients' needs, improve care and risk planning, and strengthen therapeutic engagement.

Ongoing work to improve multidisciplinary working, care planning, and rehabilitation pathways demonstrated the service's commitment to continuous improvement and better patient outcomes.