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

Well-led – 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.

At our last assessment we rated this key question good. At this assessment, the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created, promoted high-quality, person-centred care.

The service had a shared vision, strategy and culture. It had inclusive leaders with the skills, knowledge and experience to lead effectively. Staff described a positive culture where they felt able to speak up. Systems and processes were in place to manage and deliver good quality, sustainable care, treatment and support. The service demonstrated learning and improvement, including changes to pathways, wound care processes and patient communication.

However, the service did not always have robust arrangements in place to support the assurance of training compliance, escalation, and timely management of practising privileges requirements.

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.

Leaders described how the service followed the corporate values and how this underpinned the delivery of care and the culture of the hospital. The corporate purpose was 'people caring for people', with a mission of 'changing what is possible for your health' and a vision to ‘be a leading healthcare provider of the future’. Staff were encouraged to work in accordance with 3 core values known as ‘The Ramsay Way’ – strong relationships, continuous improvement and sustainable growth. We saw evidence of these values being embedded within the culture of the service through our observations and conversations with staff.

The hospital was working towards developing departmental strategies aligned with corporate objectives.

Leaders described an open, visible and accessible approach, with regular engagement with staff across clinical areas.

Staff and managers described a positive, open and supportive culture. Staff felt able to speak openly with senior leaders, heads of department and the hospital director. Positive themes included strong multidisciplinary relationships, an open approach to incident reporting and learning, visible leadership and a focus on staff development. There was also a strong focus on developing existing staff and growing the workforce from within.

Managers described a strong team ethos, with staff willing to work across sites and departments to ensure patient needs were met.

Some staff said that the culture at the hospital was the strongest it had been during their time with the organisation.

Staff described positive working relationships amongst consultants and the wider multidisciplinary team. They told us consultants worked collaboratively and communicated effectively with each other and with departmental staff to support the delivery of patient care.

We spoke with an outpatient consultant who spoke positively about the hospital and described it as a good place to work, with knowledgeable and supportive staff.

Staff took part in annual staff surveys that focused on 4 key metrics. Data from the most recent staff survey (2025) showed that the outpatients department performed highly across most indicators, including 95% for engagement, wellbeing, and burnout, and 79% for inclusion. This was better than the benchmark average for the provider’s other hospitals.

We scored the service as 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.

The service was led by capable, compassionate and inclusive leaders with clearly defined responsibilities. They demonstrated the high levels of experience and capacity needed to deliver excellent care and ensure effective management of risk.

The service had a clear leadership structure. There was an outpatient manager responsible for the overall coordination and management of the service. The role provided additional leadership and support to the outpatient and pre-operative assessment service. They told us that there had been a focus on improving patient follow-up processes, infection prevention and control (IPC), and wound care practices. The manager described an open and honest culture within the department and said staff were receptive to change and improvement initiatives.

Physiotherapy was run by a physiotherapy manager who was supported by a physiotherapy team leader. Staff told us that they felt well-supported by the departmental manager and had opportunities to learn and progress.

The senior leadership team (SLT) included the hospital director, clinical services manager and operations manager.

The clinical services manager described routinely visiting departments each morning, attending huddles where possible and speaking directly with staff to identify concerns and provide support. Leaders described maintaining an open-door policy and encouraging honest communication.

We spoke with an outpatient consultant who described senior leaders as visible and approachable, with an open-door culture that enabled staff to raise concerns and discuss service improvements. They told us they felt supported by their peers and through Medical Advisory Committee (MAC) meetings and knew who to contact within the governance team if required. The consultant said the organisation was well run and confirmed they were required to provide information relating to appraisal, mandatory training and practising privileges to maintain oversight of their practice.

Managers and leads described positive support from senior leaders. They received regular one-to-one meetings with their line manager. One manager was completing a corporate sponsored management qualification, with protected time provided for study and assignments.

Staff spoke positively about senior leaders and described them as friendly, visible and supportive. For example, they regularly saw members of the leadership team within clinical areas.

Staff reported positive relationships with managers and described the management team as supportive and responsive to staff concerns.

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

Staff could access the ‘speak up for safety programme’ and were supported through training, tools and reporting processes to raise concerns. Within the outpatient department, a physiotherapist was involved in supporting staff training on ‘speaking up for safety’. The service had a Safety to Speak Up lead in each department.

In addition, staff were encouraged to raise concerns through the freedom to speak up (FTSU) process. The service had a FTSU guardian on site and we saw information promoting the process was visible in staff areas. Themes and learning from concerns were reviewed through governance processes and shared with teams.

Staff had access to a range of policies relating to raising concerns and speaking up for safety, which encouraged and supported them to report safety issues without fear of reprisal. These policies emphasised that speaking up was viewed as a positive action, contributing to patient and staff safety and the continuous improvement of care.

During our assessment, we spoke to staff to ask about who they would speak to if they had a concern. Staff were able to tell us who they would escalate concerns to.

Senior leaders and mangers described a positive and open culture. While there had been no Speak Up for Safety cases reported, leaders continued to promote the process and identify opportunities to further embed the culture.

The service followed corporate grievance and disciplinary procedures, which provided staff with clear guidance on raising employment-related concerns.

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.

The outpatient department had not conducted any surveys or engagement specifically relating to workforce race equality or disability standards. However, this was done at corporate level and reported in an annual Workforce Race Equality Standard (WRES) report. The report provided a summary of the findings and recommendations for improvement in respect of the WRES which contributed to the wider equality and diversity strategy.

Staff had access to policies related to equal opportunities, diversity and human rights.

There were support mechanisms available for staff with protected characteristics, including flexibility around working arrangements and shift patterns. Staff told us that they appreciated the working patterns, which better supported their personal circumstances.

We saw examples of how staff were supported through reasonable adjustments such as changes to clinical workload, working environments, assistive technology, and flexible working practices to meet individual needs.

We scored the service as 2. The service did not always have robust arrangements in place to support the assurance of training compliance, escalation, and timely management of practising privileges requirements. However, systems and processes were in place to manage and deliver good quality, sustainable care, treatment and support.

The service had clear governance, management and accountability arrangements, and staff understood their roles and responsibilities within these structures.

Leaders described clear governance arrangements with regular oversight of performance, quality and safety. The SLT met monthly to review key projects, monitor progress against objectives and benchmark performance. Progress was also reviewed through monthly heads of department meetings and clinical governance meetings to identify areas for further improvement.

However, 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.

At the time of our assessment, compliance with mandatory training, safeguarding training, life support training, and learning disability and autism training among outpatient consultants was low, despite these being key requirements for maintaining practising privileges.

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.

We also identified inconsistencies in the reporting of life support training compliance across 2 different datasets. This meant we were unsure how accurate and how reliable the information was when providing oversight of training compliance.

The service monitored consultants’ professional registrations and we reviewed data that showed they were up to date. Practising privileges audits were undertaken every 3 months. Leaders told us that any gaps in documentation had been re-requested and was in the process of being updated. Audit data showed an overall improvement from 54.3% in April 2025 to 80% in April 2026.

The service had processes in place to monitor compliance with recruitment requirements. Recruitment files were audited at the point of onboarding to ensure all pre-employment checks met requirements, including identity, right to work, references, DBS, occupational health clearance, and professional registration. We reviewed 5 staff files (including consultants) and found that some references were not initially available within the files. However, these were subsequently located and provided during the inspection process

Leaders and managers monitored a range of performance indicators including: Referral to Treatment (RTT) pathways, outpatient waiting times, activity levels, DNA rates, mandatory training compliance and medical device monitoring. ICB activity reports were reviewed monthly and RTT performance was reviewed weekly across all open pathways.

There was a structured programme of audit covering key processes such as infection control, patient records, National Safety Standards for Invasive Procedures (NatSSIPS) instruments and histology. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through routine team meetings, safety huddles, performance dashboards and newsletters.

Electronic systems (such as to store records and manage patient appointments) required password access. Diagnostic scan results, reports and images were stored electronically and could be accessed by staff in other parts of the hospital, such as during routine outpatient consultations.

Updates to NICE guidance was received through Independent Healthcare Provider Network (IHPN) safety alert summaries and circulated by the corporate team. Relevant updates were reviewed on a monthly basis and forwarded to the appropriate clinical lead or consultant for assessment. Guidance changes and feedback was discussed at the clinical governance committee meetings every 3 months to ensure appropriate implementation and oversight.

Department governance audit data from April 2026 showed that the outpatients department compliance was 95%.

Leaders and managers received and logged central alerting system (CAS) patient safety alerts. We saw evidence of the alerts being shared in various committee meetings and cascaded to staff.

The hospital had a risk management framework that provided a structured approach to identifying, assessing, managing and monitoring risks. Risks were recorded on the electronic system, assigned to a risk owner and reviewed through departmental and governance committee processes. The framework included clear escalation arrangements based on risk scores, with higher-risk issues requiring oversight at hospital and corporate level. Departments were also required to maintain local risk assessments and review risks regularly to ensure appropriate controls and actions were in place.

The outpatient department risk register showed that key risks were identified, and risk assessments were in place to mitigate risks.

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. They share information and learning with partners and collaborate for improvement.

Staff and leaders described positive working relationships with a range of external stakeholders and partner organisations to support care provision, service development and joined-up care. The service worked collaboratively with Integrated Care Boards (ICBs), GP practices, NHS hospitals and other provider hospitals to coordinate patient care, manage referrals and support access to services.

Staff also worked with mental health services, including Mental Health Crisis Teams, when patients required additional psychological support or safeguarding interventions.

Where patients' needs could not be met within the service, staff liaised with external providers to ensure timely escalation and continuity of care. Leaders told us they maintained open and transparent communication with partner organisations and used these relationships to support patient pathways, share learning and respond to changes in local healthcare needs and commissioning arrangements.

The physiotherapy team actively engaged with the local community to promote health and wellbeing beyond the hospital setting. Staff described supporting a local football club's community programme, where physiotherapists delivered exercise sessions and wellbeing support to individuals affected by cancer. The team had also established relationships with local gyms to support patients' ongoing rehabilitation and recovery, enabling referrals between services where appropriate. In addition, physiotherapists participated in local school events, providing health promotion sessions focused on physical activity, injury prevention and safe participation in sport.

The service operated as part of a network of other provider hospitals. There were regular meetings between the different hospitals across the country. These meetings were utilised to share information and learning as a result of serious incidents and or complaints.

We scored the service as 4. The service showed an exceptional standard for continuous learning, innovation and improvement. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff and leaders ensured that patients, their families and carers were involved in developing improvement and innovation initiatives.

The outpatient department had demonstrated learning and improvement that involved a patient who was living with dementia. The patient has experienced an on-the-day cancellation of elective surgery due to concerns regarding their capacity to consent and additional support needs. Outpatient and pre-operative assessment staff identified that, although the patient had been able to discuss their medical history during assessment, further consideration of their capacity and support requirements was needed before admission. Following review in clinic, the outpatient team coordinated multidisciplinary discussions and a best interests meeting involving the patient, their family and members of the multidisciplinary team to ensure appropriate plans were in place.

Learning from the case was shared through governance committees and resulted in changes to the hospital's exclusion criteria and patient pathways for people living with dementia. There were now clearer requirements for mental capacity assessments, best interests meetings and multidisciplinary planning before admission where dementia was identified.

Staff also supported the implementation of a dementia framework and enhanced staff education through the development of Mental Capacity Champions. Staff told us that these improvements helped strengthen patient assessment processes, support personalised care planning and reduce the risk of avoidable cancellations for patients with additional cognitive needs.

Staff were supported to prioritise time to develop their skills around improvement and innovation.

The outpatient manager had identified wound care and IPC as key areas for improvement. This included the introduction of 14 new wound dressings, and 2 members of staff had completed specialist wound care training. A registered nurse had developed a wound care proforma which was implemented in November 2025. Staff told us this provided a consistent approach to wound assessment and management, ensuring all patients received the same standard of review for routine wound care and complications.

Wound care monitoring was strengthened through the introduction of dedicated audits. Results from the One Together Incision Management: Wound Care audit showed compliance of 75% in December 2025 and January 2026, improving to 100% in April 2026, demonstrating sustained improvement in wound care practices and assurance processes.

Staff and leaders had a good understanding of how to make improvement happen and included measuring outcomes and impact. The service had recently introduced a new system for recording and tracking specimens, including blood samples and wound swabs. Patient identification labels were attached to records, the reason for testing was documented, and actions taken following the result were recorded. Staff explained this reduced the risk of results being overlooked and improved traceability and follow-up. The manager told us the new process had encouraged staff to report more infections and helped to promote a positive reporting culture.

Staff spoke positively about opportunities for development. We heard examples of staff being supported to attend wound management courses, undertake blood-taking training and complete formal qualifications. One healthcare assistant had been supported to secure a place on a university programme, and another member of staff was completing a nursing associate course.

The hospital had implemented Hybrid Mail, a digital communication system designed to improve the reliability, consistency and timeliness of patient correspondence. Staff told us that for the outpatient department this new process had improved the reliability and timeliness of appointment communications. The reduction in manual administrative tasks meant that outpatient staff had more time to focus on patient‑facing activity and proactive follow‑up, supporting reduced DNAs and improved patient preparedness for appointments.

Staff could access a professional advocacy programme that provided support through education and clinical supervision. This included support to build quality improvement initiatives, develop improvement strategies and to develop their abilities in clinical roles.