Rivers 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 people 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 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
 

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 lead radiographer and department lead were responsible for oversight and monitoring to deliver a safe service.  

Leaders were described as having the skills and abilities required to run the service. The priorities faced by the service were understood or managed appropriately.  

Staff told us that learning was shared in team meetings and that all staff, regardless of their role in the clinic, were encouraged to share knowledge with the wider team. Staff we spoke to told us leaders managed training and new areas of learning were shared with the team.  

A vision or strategy for the service was in place. Staff told us they felt confident they understood the aims and vision of the service of delivering good care, continuously improving and having strong relationships with patients.  

A clinic policy outlining expected values and behaviours was in place. Staff expressed confidence in the function and purpose of the service.  

Leaders told us that the direction of the clinic was shared with all staff, and there was a formal strategy document.  

Staff told us they felt respected, supported and valued. Focus was placed on the needs of patients receiving care. An open culture was evident, in which patients, their families and staff were able to raise concerns without fear.  

Staff told us they felt teams and departments worked effectively. Team members spoke highly of one another. Confidence in and approachability of the department lead were expressed, and staff told us they felt empowered to make changes and offer suggestions.  

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.

Staff told us the lead radiographer and department lead were visible and approachable. They made themselves available to staff. Staff told us they felt supported by leaders, for example they were supported to develop their skills and to work in other modalities. Staff told us some radiographers were trained across the different types of scanners to ensure there was enough staff cover across the department. Staff told us this also offered professional development for radiographers to gain experience using other equipment.  

Active and open engagement with patients and staff was undertaken to plan and manage services. Leaders understood areas the department needs to work on to improve and leaders were enthusiastic about improving quality of care. Leaders told us they felt confident senior leadership supported these aims.   

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 Freedom to Speak Up champion, staff we spoke to reported they felt confident in raising concerns and they felt their views would be listened to. Staff spoke highly of the department lead and that they felt supported to raise concerns.   

Staff told us they understood Duty of Candour and the responsibility to take responsibility and accountability when things go wrong.  

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 to said they felt respected. When there was an incident where a colleague felt another was discriminatory, it was resolved sensitively and appropriately. Staff told us if they escalated concerns to their manager, they felt the matter was resolved sensitively and appropriately.  

We spoke to staff who told us they felt leaders acted quickly when items needed replacing. Leaders told us they encouraged staff to use the employee wellbeing service.  

Staff told us they knew how to access the employee wellbeing service and felt there was appropriate support available.  

The workplace culture was described as close knit. Staff told us they knew they could request workplace adjustments if needed. Staff knew who to approach and what the process was. One member of staff told us they needed a new chair. This was ordered quickly by their line manager.  

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.

Staff had access to policies, procedures and training. Staff told us time was given to complete training. Training was monitored through a tracking system and staff were notified if training was due to be renewed. A clinical governance policy was in place and in date.  

Governance meetings were held and discussions were documented. Staff told us meeting minutes were recorded and retained.  

Leaders told us the service held regular radiation protection committee meetings and if there were any concerns these would be escalated appropriately. Areas for improvement would be shared with staff.  

Systems used by leaders and teams effectively managed performance. Relevant risks and issues were identified, escalated, and actions to reduce their impact were formalised.  

A risk register was in place. The clinic lead described risks verbally, including staffing shortages—where off duty staff would be contacted or patients rebooked—and equipment failure, in which case patients would be rebooked or referred elsewhere.  

Data was collected and analysed. Staff had access to necessary data in accessible formats to understand performance, support decision making and implement improvements. Information systems were integrated and secure.  

The service held an in date registration with the Information Commissioner’s Office (ICO), ensuring accountability to UK data protection requirements.  

Electronic access to diagnostic results was provided via the PACS system. Images were backed up to compact disc and stored securely in locked patient records. The PACS system and all clinic computers were protected with secure usernames and passwords.  

Correspondence for patients referred by NHS GPs or hospital consultants was sent directly and recorded in patient files unless patients opted out of information sharing.  

All diagnostic imaging images were logged with details including the radiographer responsible. Staff had received training on GDPR, supporting compliance with regulations designed to give individuals greater control over their personal data  

There had been zero ionising radiation medical exposure regulations (IRMER) reportable incidents in the 12‑month period prior to inspection.  

Duty of candour was understood by staff. The service promoted people’s independence, so people knew their rights and had control over their care, treatment, and wellbeing. Staff spoke to us about the duty of candour and understood when it was required. No duty of candour notifications had been issued in the 12‑month period prior to inspection.

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.

Daily huddles and handovers took place, as well as monthly staff meetings to discuss capacity, staffing, and recent or anticipated incidents. These meetings were minuted.  

If there were issues, these would be shared appropriately with departments or external organisations if appropriate. Staff told us leaders are transparent and departments across the hospital communicate effectively.  

The service saw some patients whose GPs required their discharge summaries. Leaders told us they ensured they maintained good communication for continuity of care.  

Communication with NHS colleagues was by phone or email and this was effective. Staff told us some members of staff also worked for the NHS, and they provided valuable insight into processes and ways of working.  

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. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Monthly team meetings were held covering training, clinic procedures, and team morale. Practice was discussed and any concerns were raised and alternative ways of working. This meant people’s outcomes were consistently good, and feedback confirmed this. Minutes showed discussions relating to service improvement and innovation. IRMER-related audits were shared and discussed at these meetings.  

Independent learning was encouraged and supported. Staff told us clinicians sometimes offered free training and all staff, regardless of their role, were encouraged to attend. Leaders told us learning from radiological research was shared appropriately with the team. External learning was undertaken by radiographers was sometimes partially funded by the service. 

Staff demonstrated a commitment to continuous learning and service improvement. Good understanding of quality improvement methods and the skills to use to improve practice were evident. Staff told us some doctors hosted free training. Innovation and participation in research were encouraged. Staff told us doctors offered training on specialist topics and all staff, regardless of rank, were encouraged to attend. This training was free. Although we did not see evidence of blind application processes, staff were from diverse backgrounds.