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

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.

This was the first assessment of this assessment service group. This key question has been rated good. This meant there was good service leadership and governance. Leaders and the culture they created assured the delivery of high-quality care.

Leaders and staff shared a positive culture based on listening, learning, and trust. Leaders were visible, supportive, and knowledgeable, helping staff develop in their roles. Staff felt able to give feedback, were treated fairly, and experienced a workplace free from bullying or harassment, with people with protected characteristics feeling supported. Roles and responsibilities were clearly understood. Managers engaged with the local community and were open to new ideas, promoting continuous improvement by giving staff the time and resources to innovate.

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 endoscopy service sat within the surgical division and demonstrated clear leadership with a well-defined vision for service development, including plans to expand and improve provision.

The hospital’s values and clinical priorities were clearly displayed on notice boards within the department. The service had a strategy that was fully aligned with both the corporate mission and the corporate strategy. There was a strong commitment to system-wide collaboration and leadership. The Ramsey Way was to deliver high-quality healthcare through 3 key values: strong relationships, continuous improvement and sustainable growth. They had been cascaded to staff across the services and the staff we spoke with had a good understanding of these. Objectives were also incorporated into individual staff appraisals.

Leaders described inclusive leadership practices, including regular team meetings, open communication, and staff involvement in service changes. Leaders were visible within the department and had a good understanding of both the service and associated challenges.

Staff spoke positively about a culture that prioritised safe, high-quality, compassionate care, and reported feeling supported and able to raise concerns. Both leaders and staff demonstrated a clear understanding of equality, diversity, and inclusion, with these principles embedded in daily practice. There were no concerns raised within the service about any types of bullying, harassment, or discriminative behaviours.

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 had a clearly defined leadership and governance structure with clinical, nursing and managerial lead roles.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities.

Leaders at every level were visible and led by example, modelling inclusive behaviours. Leaders told us that they had an open-door policy for staff to access support.

Staff told us most leaders including the hospital executive team were visible and supportive, and modelled positive behaviours.

The service had a robust fit and proper persons (FPPR) process in place to carry out comprehensive checks to assure that all leaders were suitable, safe and fit to hold their roles.

We looked at the recruitment files for 3 consultants (who worked across both the medical and outpatient services). We found evidence that suitable checks had been carried out prior to commencement of employment in the files we looked at. This included identification checks, proof of qualifications, at least two employment references, Disclosure and Barring Service (DBS) checks and professional body registrations and revalidations.

The hospital reported there were no outstanding queries relating to practising privileges. The 3 consultants’ files we looked at showed up to date appraisals and indemnity certificates and the consultants were listed on the General Medical Council (GMC) specialist register, relevant to their specialty area. 

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 had a speaking up for safety policy that encouraged and enabled staff to voice concerns about safety issues without fear of reprisal. It emphasised a culture where speaking up could be seen as a positive action that contributes to patient and staff safety, and improved care. Speak up for safety was part of the mandatory training package for all staff, and leaders had encouraged staff to take up refresher sessions to ensure this was well-embedded. Managers supported staff and could give examples of how speak up for safety helped to maintain best practice and build strong relationships through a multidisciplinary approach.

During our assessment, we spoke to staff to ask about who they would speak to in endoscopy if they had a concern. Staff told us they were confident to escalate concerns and were able to speak up and highlight their concerns within the service without using the speak up for safety process, although were aware of this initiative were it to become necessary.

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 we spoke with from various backgrounds told us that they felt supported by their managers and could raise either work or personal concerns, as managers had an open-door policy.

We saw during the assessment that there was a diverse workforce with a positive sense of inclusion. 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. The service made workplace adjustments where necessary and we heard leaders give examples of these.

Managers told us that 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 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.

The hospital, as part of a larger provider network, actively monitored and supported the Workforce Race Equality Standard (WRES) and the wider Workforce Disability Equality Standard (WDES) principles through its equality, diversity and inclusion policies.

The Equality and Human Rights Policy was in date at the time of our assessment and was scheduled for review in July 2026. However, the Equal Opportunities and Diversity Policy was not in date, having had expired in December 2025.

We scored the service as 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The endoscopy service was included within the hospital’s governance framework, with oversight provided through the theatres subcommittee. This subcommittee reported into the wider hospital governance structure and contributed to key provider-wide groups, including patient safety, clinical governance, and infection prevention and control. The service had an endoscopy lead.

The key risks relating to the endoscopy services were recorded on a departmental risk register that were incorporated into the hospital-wide risk register. The risk register 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 (such as the theatre manager) responsible for managing that risk. Staff were aware of how to record and escalate key risks on the risk register, and a risk scoring system was used to identify and escalate key risks.

The service had regular, minuted team meetings as well as routine clinical governance, medical advisory committee and senior leadership team meetings that occurred at a hospital-level. These meetings followed a structured agenda with risk register entries, with standing items that included accreditation requirements, staff training, patient safety, equipment management, incidents, audit activity, and updates on new guidance. Records of these meetings were shared with all relevant staff, including those unable to attend, through routine team meetings, safety huddles, performance dashboards and newsletters.

The service had a comprehensive audit schedule on an electronic system that was clear to follow, consistently completed and findings could be overseen easily by leaders. Staff we spoke with did not feel like data-gathering processes such as audits were burdensome on their time and they could complete their clinical duties appropriately. Audit information and various other metrics such as waiting and reporting time performance were stored within the system and easily accessible by the necessary staff.

Staff followed effective policies to keep information confidential. Digital and physical records which contained patient identifiable information were stored securely and staff demonstrated good understanding of information governance requirements.

Business continuity plans for the hospital were comprehensive and had been initiated effectively in recent months in response to external events.

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.

The service operated as part of a network of hospitals and there were regular meetings at service and hospital level between the different locations across the country. They utilised these meetings to share information and learning that has come from either incidents or complaints, as well as updates to practice and management.

We saw examples of good practice being shared across the provider’s other hospitals and that all staff were informed through safety flashes to take actions and implementation in the service.

Leaders told us they worked to maintain positive relationships with both local GPs and other providers within the local authority. The service supported the GPs alliance and had transfer protocols in place with the local NHS 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.

The endoscopy services and decontamination facilities were JAG accredited and had achieved 100% compliance in recent internal and external audits.

The service demonstrated that staff engaged in continuous learning and improvement. For example, all endoscopy staff had attended a “360 reprocessing cycle” session specific to endoscopy and aseptic non touch technique (ANTT) training.

In line with JAG accreditation guidance the leadership team and workforce engaged in innovation, sharing quality improvements, and research other endoscopy services.