Oaklands 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

At our last assessment we rated this key question good. At this assessment the rating has remained good.

Leadership of the service was clear and there were systems in place for governance and oversight of risk in the service. Staff were clear about their roles and responsibilities. They understood the service's vision and values, and how to apply these in their work. Staff we spoke with felt respected and valued, leaders supported staff if they needed to speak up or raise concerns. There was an open culture in the service based on principles of equality, diversity and inclusion. Leaders understood the key risks to the service and had plans to make improvements.

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 people and their communities.

All senior leaders were able to articulate the strategy for the future. We saw documents which detailed the short-term vision for the next 12-18 months. Senior leaders were also able to articulate the vision for the longer term.

The hospital had a vision and strategy that was aligned with the health priorities of the local area. The strategy ‘We strive to continually improve and are dedicated to providing high standards of clinical quality and service excellence’ was in its second of three years’ delivery. Staff told us the provider’s mission, values and objectives had been shared with them, and they had a good understanding of these. Staff we spoke with at all levels felt they had been engaged in developing the strategy and described a positive, supportive culture among colleagues. Leaders were visible and accessible; staff were confident to raise any issues they had about the service with their managers and leaders. Several staff we spoke with said there had been an improvement in their morale and day to day experience of the organisation’s shared direction and culture since the last inspection.

We reviewed documents that detailed how the provider was in the process of making long term investments that would benefit the local community.

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.

Leaders understood the risks to the services and had effective systems for oversight of safety, governance and performance issues at the hospital. There were arrangements for quality monitoring and routine reporting to provide service leaders with information about themes and trends arising in the service. There were plans to mitigate any risks arising from service changes or absences of people in key roles including for example, clinical leads of service, or directors.

At the time of our inspection an interim hospital director was in post following the departure of the previous registered manager in December 2024. The interim hospital director had previously submitted their application to CQC and was in the process of completing the registration process to be registered manager. Staff we spoke with were positive about the interim hospital director who was acknowledged for having made a positive impact. The interim hospital director had overall leadership responsibility for services at the hospital, with immediate support from HR, and administrative services, with the head of finance and head of operations, and the head of clinical services and deputy head of clinical services comprising the senior leadership team. Both the head and deputy head of clinical services were interim roles. Various roles with different areas of responsibility were identified within clinical services and operations. Among these were roles in clinical services for theatre and ward managers, physiotherapy and radiology staff. Alongside these, staff worked in operations’ roles included facilities, patient administration, medical records, housekeeping and business support.

There were clear reporting processes for both clinical and non-clinical staff.

We reviewed five staff recruitment files, which included the registered manager and head of clinical services and found no errors or omissions.

We reviewed five consultant files who worked under practising privileges and found no errors or omissions. We also reviewed the practising privileges policy and process and found a robust system for ensuring compliance.

Consultant surgeons and anaesthetists had clinical responsibility for patients receiving care and treatment. The hospital had a medical advisory committee (MAC) with quarterly meetings to review and discuss any issues.

Staff spoke positively about the support they had received from their managers and senior leaders. Staff described opportunities they had to develop, and leaders supported them in these. We were given multiple examples of staff who had been identified for role succession. There were examples of non-registered nursing staff being given the opportunity to become registered nurses. We were also given an example of a non-clinical member of staff being supported to undertake an MBA (Masters in Business Administration qualification).

At the time of the assessment all senior leaders were in interim roles that were at a higher level than initially employed at. All senior leaders were able to articulate how the provider ensured that all staff were able to undertake more senior roles and do so effectively.

The service held regular employee engagement meetings to share ideas and receive feedback. These were appreciated and valued by staff, with actions followed up to improve staff and service user experience. Feedback was also shared with staff in regular newsletters from the hospital director.

The service also engaged with staff in corporate staff surveys undertaken by the provider Ramsay Healthcare Operations UK, with a ‘One employee, one voice – you said, we did’ newsletter publication for employees. Results for staff engagement were positive, with scores above 80% for staff recommending the company as a great place to work; feeling positive about themselves at work; and seeing patient safety as a priority in the organisation.

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

The service used their process ‘speak up for safety’ to encourage staff to raise concerns. The service also used alternative pathways to give staff multiple ways to raise concerns. These included the national freedom to speak up guardian at Ramsay Healthcare, and the Ramsay whistleblowing hotline. We were given an example of how staff speaking up led to improvements in the service’s culture.

Staff were aware of the service policy ‘raising concerns about patient safety’ and understood how to follow this and related procedures if needed. Staff were also given information on how to raise concerns through the provider’s intranet and information on boards throughout the hospital.

All senior leaders were aware of how closed cultures could develop and took action to prevent a closed culture developing. Senior leaders were able to give examples of how they managed these issues with specific examples.

Staff concerns and complaints were reviewed and learning shared through the provider’s processes. There had been one concern shared by staff with CQC. Actions had been identified and implemented following these.

The service valued diversity in their workforce. Staff 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 managers engaged with them regularly and they felt confident their concerns were listened to. All the staff we spoke told us they had not experienced any instances of unfair treatment, discrimination or harassment.

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.

The service had an equality, and human rights policy which was also incorporated in the recruitment policies and processes. There were support mechanisms available for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers engaged with staff regularly to monitor work culture and identify any bias or discrimination.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

All the senior leaders knew their role, their responsibilities and their accountabilities. All senior leaders felt empowered to adapt their roles to benefit the service and the patients.

There were clear governance structures in place to provide assurance of oversight and performance against safety measures. There was a committee structure to review key areas, including for risk and audit, infection control, workforce and health and safety. Where releveant, reports were shared for to the clinical governance committee and medical advisory committee (MAC). Minutes for the latest three 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. Staff participated in quality monitoring and audit processes. They told us their performance was routinely monitored and they received feedback following audits to aid learning and improvement.

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.

We saw and were given examples of safety alerts and how the provider ensured that all necessary staff groups received the information. We saw that staff were informed through meetings, safety huddles, emails and safety flashes. The registered manager was aware of their statutory and regulatory requirements. We saw examples of notifications made by the provider at both statutory and regulatory levels.

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. There were regular meetings held with the partnering NHS trust to review performance, outcomes and key risks.

Managers understood the key risks to the service and maintained a risk register. Staff were aware of how to record incidents and escalate any key risks to the risk register. The hospital identified three risks at the time of inspection, one regarding diagnostic waiting times in breach of 6 weeks contract monitoring; one regarding a concern raised externally about patient safety; and an information governance risk about potential risk of compromise.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

Patients we spoke with told us care and treatment was well co-ordinated before, during and after their surgery.

We saw examples of good practice being shared across the provider’s other hospitals and that all staff were informed through daily ‘safety flashes’. Managers told us they had an effective working relationship with service leads and system partners in primary and secondary care, including GPs and NHS trust services.

We saw examples of effective partnership working between the hospital and local NHS trusts especially regarding bariatric surgery. We noted that 95% of all activity was NHS funded.

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 people. Staff actively contributed to safe, effective practice and research.

We saw evidence of learning and improvement resulting from findings from audit results and incidents and shared learning was cascaded to staff to aid learning.

Senior leaders were able to articulate how the service had received accreditation for bariatric surgery and were waiting for assessments for accreditation in other services. They were also able to articulate plans to look at traditional times for surgery and time on ward to identify if this could be improved.

Senior leaders were all able to articulate how they used incidents both locally and from the wider areas to identify learning and drive improvement.