Fulwood Hall 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

Our rating of well-led stayed the same. We rated well-led as good.

Leaders promoted a positive work culture based on equality, diversity and inclusion. Staff felt respected, supported and valued. Leaders worked collaboratively with stakeholders and partners to plan and manage services.

However, the service did not always have effective governance processes for managing recruitment and training records for consultants working under practising privileges.

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 the service as 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 hospital’s vision and purpose was ‘delivering exceptional quality care in a compassionate, professional manner to every patient, every time’. The hospital's culture and values were driven by ‘The Ramsay Way’ which was based on ‘people caring for people’ and focused on three core principles; strong relationships, continuous improvement and sustainable growth.

The hospital’s overall strategy (2024-27) included strategic objectives based on quality, people, transformation, service business development and profitability and value creation. The hospital also had a separate clinical strategy 2024-27, which outlined key clinical objectives linked to the Care Quality Commission’s domains for safe, effective, caring, responsive and well-led.

The strategic objectives for the diagnostic imaging service had been incorporated into the overall hospital and clinical strategies. This included specific objectives such as developing a static magnetic resonance imaging (MRI) service to improve diagnostic pathways.

Progress against key objectives was monitored and reported as part of routine departmental meetings as well as hospital-wide senior management meetings and medical advisory committee meetings.

The vision, values and strategic objectives were clearly displayed on notice boards across the areas we inspected. They had been cascaded to staff across the diagnostic imaging service and the staff we spoke with had a good understanding of these.

All the staff we spoke with were highly motivated and positive about their work. They told us there was a friendly, safety-focused and open culture and that they received good support from managers. They all told us there was a positive culture within the service and that staff worked well as a team.

The annual staff survey (October 2025) for the diagnostic imaging service showed mixed results in key indicators. Survey responses showed the proportion of respondents that held a favourable opinion about inclusion (56%), engagement (44%), well-being (44%) and burnout (22%) was worse than national averages and the 2024 staff survey results.

An action plan had been developed to make improvements following the 2025 staff survey. Remedial actions included undertaking staff rota reviews, improving communication on activity and equipment downtime and strengthening modality forums.

The service also implemented ‘you said, we did’ processes which identified improvements undertaken as a result of feedback from the 2025 staff survey. Actions taken included improving communication and engagement with senior leaders through the introduction of bi-monthly staff forums, improving wi-fi connectivity, and strengthening well-being support mechanisms such as psychological support and the introduction of rest spaces, hydration points and mid-shift pause huddles.

Staff told us there had been a period of leadership instability during 2025 after the previous imaging manager left the service. Managers told us this had affected the culture and morale across the service and this was reflected in the October 2025 staff survey results. Staff told us the culture, morale and staff engagement had improved following the appointment of the current imaging manager in November 2025.

We scored the service as 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.

The provider’s whistle blower and speaking up for safety policies provided guidance for staff around raising any concerns. Most staff (90%) across the diagnostic staff had also completed speaking up for safety training. The hospital had appointed 4 speak up for safety champions to support staff. Staff could also raise concerns internally to senior managers or to the corporate provider’s freedom to speak up guardian.

Staff told us they felt confident they could raise any issues with their managers and that managers listened to them. Staff were aware of the whistleblowing and speaking up for safety policies and understood how to raise concerns if needed.

There had not been any whistle blower concerns of freedom to speak up concerns raised by the service or received by the Care Quality Commission during the 12 months prior to our inspection.

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.

Staff told us the service had an inclusive working culture, and they were treated with respect and equity. Staff told us the imaging manager and senior leaders engaged with them regularly and they felt confident any concerns they raised would be listened to. The staff we spoke with told us they had not experienced any instances of unfair treatment, discrimination or harassment.

All radiology staff had completed training in equality, diversity and human rights.

The provider’s quality and human rights policy and equal opportunities policy provided support and guidance for staff. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers told us equality, diversity and inclusion was embedded in the culture of the service and they engaged with staff on a daily basis to maintain an inclusive and supportive work environment. Staff engagement also took place through daily discussions and routine team meetings.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have effective governance processes relating to the management of recruitment and training records for consultants working under practising privileges. However, systems and processes were in place to manage and deliver good quality, sustainable care, treatment and support.

We found governance gaps in the assurance, escalation and timely management of practising privileges requirements. Whilst the hospital had recently introduced measures to strengthen credentialing processes, including a dedicated consultant credentialing lead and regular compliance audits, these arrangements had not ensured that concerns regarding consultant mandatory training compliance were identified and addressed in a timely way.

The hospital’s practising privileges policy stated practising privileges for consultants were granted by the hospital director, the hospital credentialing committee and the medical advisory committee. Practicing privileges were reaccredited every 5 years.

A consultant credentialing lead had been appointed to oversee consultant’s practising privileges records across a number of local hospitals, including this hospital. Consultants working under practising privileges were required to submit supporting documents such as appraisals, mandatory training, indemnity insurance and professional body registration records on an annual basis. Records were stored electronically and maintained by the consultant credentialing lead.

We looked at the practising privileges records for 2 consultant radiologists. These contained up to date appraisal records, GMC revalidation records, indemnity certificates and Disclosure and Barring Service (DBS) checks. However, one of the consultant files did not include any references or occupational health clearance records. The service reported these records could not be located and they planned to update the references and occupational health documents.

The consultant credentialing lead carried out an audit of 5 randomly selected practicing privileges records every 3 months to check all relevant documents had been received and were up to date. Audit results between April 2025 and April 2026 showed compliance ranged between 54.3% in April 2025 and 80% in the most recent audit in April 2026. Whilst the audit showed an improving trend in compliance, we found limited evidence of effective scrutiny or escalation of non-compliance.

Medical Advisory Committee (MAC) meeting minutes from September 2025 and February 2026 contained no discussion regarding outstanding practising privileges requirements or low mandatory training compliance. This reduced assurance that governance processes were effectively monitoring consultant compliance, identifying emerging risks and taking timely action to ensure consultants continued to meet the requirements necessary for safe practice.

The provider’s recruitment policies outlined the recruitment and fit and proper person checks carried out for newly employed staff. We looked at recruitment records for 4 substantive and bank radiology staff. They were all up to date and showed appropriate recruitment and pre-employment checks had been carried out.

The service had governance structures that provided assurance of oversight and performance against safety measures. Staff told us information on performance, risks and governance was discussed during daily safety huddles and during routine departmental team meetings, which took place every 3 months.

There were a number of departmental and hospital-wide meetings in place where information about the diagnostic imaging services were discussed, such as clinical governance, heads of department, audit, patient experience, infection prevention and control, health and safety and medical advisory committee and senior leadership team.

Recent meeting minutes showed key discussions took place around performance, staffing, patient safety, risk, governance, audit findings and incidents and complaints. Action logs were in place for key performance indicators and progress against planned actions was reviewed at subsequent meetings.

There was regular communication and oversight from the corporate provider. The senior management team and departmental leads routinely reported governance, performance and risks to the corporate provider and the senior managers and departmental managers participated in regular peer meetings to share learning and benchmarking with the provider’s other hospitals across the region and nationally.

There was a risk management framework and risk policy in place that outlined the process for identifying, assessing and mitigating risks to the service.

The key risks relating to the diagnostic imaging service were recorded on a departmental risk register. This showed that key risks were identified and control measures were put in place to mitigate risks. Risks had a review date and an accountable staff member responsible for managing that risk. Staff were aware of how to record and escalate key risks on the risk register. A risk scoring system was used to identify and escalate key risks to the hospital risk register.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives. There was a structured programme of audit covering key processes such as radiation protection, infection control, patient records and medicines management. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through daily huddles and team meetings. Staff told us their performance was routinely monitored and they received feedback following audits to aid learning and improvement.

Managers were aware of their responsibility to report notifiable incidents. There was a system in place to ensure safety alerts relating to safety, medicines and medical devices were cascaded to staff and responded to in a timely manner.

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.

The diagnostic imaging service had service level agreements in place and worked collaboratively with local commissioners, integrated care boards (ICB’s), NHS trusts, independent healthcare providers and NHS and private GP’s to plan and deliver services.

Staff told us there was daily engagement with referring clinicians to plan and deliver scans. Staff submitted routine performance reports to service commissioners, stakeholders and partners and held regular engagement meetings to discuss key safety and performance indicators.

We looked at the minutes for recent engagement and contract review meetings for service commissioners and NHS health care providers. These showed key discussions around quality, safety and performance took place.

Staff told us they did not routinely engage with local communities due to the nature of the diagnostic scan services they provided. There was a hospital-wide patient experience group which held meetings every 2 months and included representatives from all the departments from across the hospital.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system.

Staff told us there was a culture of learning, innovation and improvement across the service. They told us learning from audits, incidents and patient feedback was shared to aid learning and improvement. We saw evidence of shared learning and improvement during our inspection.

The service had made improvements to address the regulatory breach relating to the cleaning and maintenance of radiology equipment during our previous inspection in December 2018.

There had been investment in new equipment to improve services. This included the purchase of disinfection equipment for cleaning ultrasound probes and plans to install additional ultrasound scan equipment.

Staff were able to give examples of improvements made to services, including improvements to booking and referral processes, healthcare assistant duties and upgrades to the electronic patient record system to enable automated patient letters.