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

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.

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.

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 this quality statement 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 set a clear vision and strategy for the service, and staff told us they understood this vision and how their roles helped achieve it. Many staff told us leaders supported them and encouraged development, including access to 2 professional advocates in the department. Most staff spoke positively about the support available to them, although a small number of staff raised concerns about aspects of local operational arrangements.

The organisation recognised and celebrated staff achievements. Leaders held monthly staff forums to discuss workforce‑focused initiatives. The service used a colleague recognition board, updated each month, to highlight positive practice. Staff also received long‑service awards to recognise their commitment. Senior leaders took part in a “day in the life” initiative by spending time in the outpatient department. This helped leaders understand daily challenges and promoted openness and a positive workplace culture.

We scored this quality statement 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.

Leaders regularly reviewed staffing in the outpatient department to make sure services were safe and worked well. They used local staffing tools, rota planning and clinic reviews to match staff numbers and skills to patient demand. Leaders maintained daily oversight through regular safety meetings, which helped them identify risks early, raise concerns quickly and take action to maintain safe care.

Leaders oversaw clear governance arrangements. They made sure Duty of Candour processes were embedded through induction and established systems, and they monitored safeguarding training to ensure it remained up to date and in line with national guidance. This helped leaders assure themselves that staff were supported, informed and working to safe standards.

Leaders were supported to complete appropriate management training. Staff generally spoke positively about the senior leadership team and told us leaders listened to concerns, were visible in the service and responded when issues were raised.

We scored this quality statement 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 encouraged people to share feedback and made it easy to do so. Outpatient teams collected and monitored feedback through several routes, including patient feedback trackers and online platforms. Leaders reviewed feedback regularly and shared learning and key themes through structured monthly updates. This helped ensure patient voices influenced service improvements and supported openness and transparency.

Staff told us they felt confident raising concerns and trusted that leaders would take issues seriously and act on them. Staff said they could raise concerns through their line managers and access support from professional advocates within the department. Staff told us they felt comfortable speaking up and felt their concerns would be listened to.

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 provider embedded equality, diversity and inclusion into its policies and processes. Staff received training in equality, diversity and inclusion to support this approach. The service supported a range of staff resource groups that promoted inclusion across areas such as disability, LGBTQ+, ethnicity and wellbeing. The provider had also signed the Armed Forces Covenant and achieved the silver award, which showed a commitment to supporting current and former service personnel.

The service had a flexible working policy in place. Staff told us leaders supported them to apply for flexible working patterns to help manage personal and caring responsibilities. This helped staff feel valued and treated fairly at work.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified significant gaps in the outpatient and phlebotomy team meetings. Team meetings were scheduled to take place monthly, but only 5 outpatient team meetings had been held between April 2025 and 2026. Phlebotomy team meetings had also been inconsistent, with only 4 sets of meeting minutes available for the same period. Staff told us meeting schedules had been disrupted due to staffing pressures following recent staff absences.

The service had a risk register and policies to manage risk, but some policies were out of date. Leaders told us staff were updated on risks during team meetings; however, because meetings had not taken place consistently, risks were shared through other methods such as email, phone messages and updates to a department whiteboard. Some staff told us this made it harder to stay informed during busy periods.

The service had an audit policy and schedule, but some audits were not always completed as planned, including a weekly scanned patient documents audit. We also found that policies for environmental cleaning, waiting list management, sharps handling and disposal, and staff grievances were out of date.

A spot check audit of patient medical records completed by the provider in November 2025 showed that 1 consultant had not uploaded 70% of their patient consultation notes to the hospital records system. Staff told us this was a known issue. Leaders had introduced a standard operating procedure in 2023 to improve record keeping compliance; however we observed gaps in patient records which demonstrated that this remained an issue at the time of inspection.

The service had clear governance structures intended to support safe, high quality and sustainable care. Governance meetings were bimonthly with a quality lead reviewing incidents daily and escalating concerns to department managers when needed. Leaders held weekly departmental meetings, where managers and senior leaders discussed safety incidents and action plans as part of a multidisciplinary team.

Leaders responded when staff raised concerns. For example, they replaced patient chairs in clinic rooms that staff had identified as a trip hazard. Following feedback from our inspection, senior leaders started a full audit of patient records and reminded consultants of their responsibility to keep records up to date.

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.

Leaders worked proactively with patients to understand their experience of outpatient services. The service made it easy for people to share feedback by offering multiple ways to contact the service and comment on their care. Leaders used this feedback to understand patient views and inform service improvements.

The service also hosted patient advice sessions that were open to members of the public. These sessions gave people the opportunity to learn more about different specialties, understand the services available and ask questions about their care.

Leaders also worked with the local Integrated Care Board to manage resources for patients waiting for NHS‑funded treatment. This partnership approach supported effective planning and helped ensure patients continued to access care in a coordinated way.

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.

Staff told us there was a positive culture of learning and development. Leaders encouraged staff to explore development opportunities and supported them to complete postgraduate and specialist courses to help them progress in their roles.

The provider had a central learning academy where staff could apply for funding. Leaders told us funding requests for courses were rarely refused, which showed a commitment to staff development and leadership growth.