Fulwood Hall 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 requires improvement. At this assessment the rating has been changed to good.

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 provider had a values-based behavioural framework. Their purpose was: “to deliver exceptional quality care in a compassionate, professional manner to every patient, every time” The framework was underpinned by the provider’s values of ‘people caring for people.’

Staff knew and understood the organisation’s values and how they applied to the work of their team. They could explain how they were working to deliver high quality care.

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 and understood the impact their behaviours and leadership had on patient outcomes and experience.

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. Many of the leaders had developed their careers within the service working operationally in clinical roles before progressing into senior leadership positions.

Members of the leadership team had offices throughout the hospital which the staff and leaders told us made them visible and approachable to staff and patients. Staff felt the leaders supported them to develop their skills and take on more senior roles.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attend the wards and departments to assess for themselves how the service was running. For example, a member of the leadership team would carry out a morning walk round and attend the daily pre-op and theatre staff meetings. The leadership team also had workdays in departments working with colleagues in clinical roles.

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

There were provider policies for Raising Concerns about Patient Safety Policy, Speaking Up for Safety and Whistleblowing.

Staff attended training sessions specifically for speaking up for safety and there was a speak up for safety champion to support staff.

Staff and leaders acted with openness, honesty and transparency. There were regular drop-in sessions with the senior leadership team., staff were encouraged to raise concerns and offer ideas for solutions. The culture allowed staff to be confident that their voices were heard.

Staff told us they could raise concerns and felt that they would be supported, without fear or detriment. When concerns were raised, leaders investigated sensitively and confidentially.

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

Staff were able to apply to work flexibly if needed to account for personal circumstances such as caring responsibilities or health issues.

There was a diverse mix of staff who had worked at the hospital for varying amounts of time.

Data was submitted to the Workforce Race Equality Standard (WRES), however; this was at provider level and not specific to this service. The WRES was introduced in 2015 to help NHS organisations identify improvements to manage and monitor inequalities by measuring disparities in experience between white and Black, Asian or minority ethnic (BAME) colleagues.

Staff could access a mental health first aider if needed. The service proactively promoted the availability of this support.

The services staff survey was completed in 2025 by 80% of staff and 77% indicated that they felt included.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders told us that they audited processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders told us they developed action plans and the monitoring of these led to positive changes. However, we did not see the outcomes of these audits as these were not provided to us.

The provider had policies to govern processes. However, 1 policy provided to us were past the review date, and 1 policy that was externally owned was past the review date.

The provider demonstrated that governance processes were mostly in place with clear structures of accountability.

The service held bi-monthly senior leadership team meetings. This included a standardised agenda with updates covering key projects, finance, clinical, operational matters and people and culture, health and safety, as well as any departmental escalations.

Clinical governance meetings were held monthly which were attended by heads of department and clinical leaders.

The service operated effective governance processes through various committees and on-site activities. For example, an infection prevention and control committee. 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 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.

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.

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. Data or notifications were submitted to external organisations as required, such as notifications of serious injury to the CQC.

Risks were identified and a formal log of these were used to keep oversight and manage mitigation. Risk registers and management reports contained analysis of concerns over time and associated action plans.

There was a provider policy for staff recruitment. This supported the recruitment and selection process including pre-employment screening requirements for all candidates including director positions that need to fulfil the fit and proper persons requirement (FPPR) to be suitable for the role.

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.

The service worked in partnership with a number of different types of community organisations and events. For example, physiotherapists attended local schools to educate children on anatomy and moving and handling, business relationship events were arranged with GP practices to offer information and guidance on the hospitals exclusion criteria, and a consultant gynaecologist had presented at a local sports club on pelvic pain and the use of testosterone with hormone replacement therapy (HRT).

They engaged appropriately with NHS partners including commissioners and trusts in the event of needing to transfer patients who became ill during their stay.

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.

The hospital is involved in an improvement project incorporating orthopaedic and spinal surgery to improve access to data and how that data is used to improve data analysis and detection of outcomes with the objective of getting it right the first time.