Rivers 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

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.

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 service had a clear vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff understood the vision and how their roles contributed to achieving these aims.

The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear of reprisal.

Staff told us they felt respected, supported and valued. They described the leadership culture as inclusive and said leaders treated them with respect and appreciation. This made them feel valued.

We observed positive relationships between staff at all levels, with evidence of effective teamwork and collaboration.

The organisation recognised and celebrated individual and team achievements. It operated an awards scheme to recognise staff who demonstrated behaviours aligned with the hospital’s vision and strategy.

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 managers were supportive, compassionate and approachable. Staff told us senior leaders were visible and approachable.

Managers were enthusiastic about the services they led and collaborated with their teams.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service.

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 speaking up for safety policy, provided guidance for staff around raising any concerns. Staff were also given information on how to raise concerns through information boards throughout the hospital. Staff we spoke with told us they were aware of the policy and said they felt confident in raising issues. We were not aware of any concerns raised in the service.

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 that leaders treated them with respect and dignity. Staff we spoke with spoke positively about the service and said they felt proud to work there.

The service promoted equality, diversity and inclusion through the Equal Opportunities and Diversity Policy and a local Equality, Diversity and Inclusion strategy which set expectations for fair treatment and respect at work.

Staff had access to 7 people resource groups across the Ramsay Health Care group.

• Wellbeing
• Social impact
• PRIDE
• Disability and neurodiversity
• Ethnicity
• Generations
• Armed forces

These groups provided peer support and were encouraged to contribute to shaping a more inclusive and compassionate organisation.

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 act on the best information about risk and share this with others when appropriate.

The service had clear governance structures in place that provided assurance of effective oversight and performance against safety measures. Staff held regular clinical governance committee meetings. The minutes from these meetings demonstrated leaders discussed key governance areas, including incidents, risks, safeguarding concerns, audit results and associated actions and complaints.

The service had a range of policies to manage risk. Staff told us they were informed when policies were updated. All the policies we reviewed were current, comprehensive and aligned with evidence-based practice and national guidance.

Leaders recorded risks on a local risk register. They clearly identified key risks and put appropriate control measures in place to mitigate them. Leaders we spoke with showed a clear and well‑informed understanding of risks across their departments.

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 worked collaboratively with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, they shared information of concern with other local providers to ensure a coordinated response to safety concerns.

Senior leaders were accessible to patients and staff through walk arounds and engagement opportunities, giving people a direct route to share feedback and contribute to wider discussions about service development.

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.

Leaders demonstrated a commitment to continuous learning and improvement. Staff were supported to develop ideas for service changes. Leaders encouraged innovation where it could improve patient experience or outcomes.

The hospital achieved Joint Advisory Group (JAG) accreditation for endoscopy, demonstrating high standards in patient safety, quality and service delivery.

The hospital achieved the Macmillan Quality Environment Mark (MQEM) in recognition of its environment meeting the standards required by people living with cancer.

Leaders and teams continued to adapt processes based on learning from audits, incidents and patient feedback, demonstrating a culture of continual improvement and forward‑looking practice.

Staff investigated incidents and complaints and shared learning with teams to improve services. Leaders provided evidence to demonstrate how they shared learning with staff.