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 this key question was rated good. At this assessment the rating remained good.

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.
 

Staff told us they understood the service’s vision and values and felt empowered to deliver care that reflected these values in their day-to-day practice. Feedback from patients consistently supported this, with many describing positive experiences of care. Staff spoke positively about future plans for the service and teams shared the passion to deliver excellent care. Staff survey results from 2025, further supported this culture, with 81% of respondents reporting that patient safety was a top priority for the Rivers. 
 

Staff and leaders promoted equality and diversity in daily work and provided opportunities for career development. The hospital had an open, blame free culture where incidents and complaints were seen as a learning opportunity to improve and develop the service. 
 

The People and Culture Forum was launched in 2025 in response to staff feedback and demonstrated the organisations commitment to listening and engaging with its workforce. The forum met monthly and included senior leaders as well as representatives from each department. Its purpose was to drive meaningful and sustainable improvements by supporting initiatives that invested in staff wellbeing, strengthened links with the local community, and promoted the hospital’s values. The forum also produced a newsletter that was shared with all staff to share detail of projects and initiatives. 
 

In addition to Ramsay’s wider corporate strategy, which was built around outlined by 4 pillars to ‘Strive for Excellence,’ Rivers had developed its own site specific ‘strategy on a page.’ This was developed with staff and patient feedback and reflected the services aspirations for the future. Rivers had added an additional pillar ‘Focus on the Fundamentals’ which enabled a hyperfocus on the core staffing goals, such as mandatory training targets and staffing allocation. 
 

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 were positive throughout the department about their leaders. Departmental and senior hospital leaders maintained a visible presence across the service and demonstrated effective oversight of daily operations. They chaired daily departmental meetings and ensured the safe and effective running of the entire hospital.

We observed inclusive interactions between senior leaders and staff of all grades. Staff knew their department leaders and how to contact them. They were comfortable and confident in escalating concerns and leaders were responsive. Staff were supported to develop their skills and take on more senior roles.

Surgery leaders were proud of their team’s commitment to delivering safe and compassionate care. They were well supported by senior hospital leaders who were responsive to any requests for changes and improvements to the service.

Leaders had a wide range of experience, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They collaborated with colleagues across other Ramsay locations and external organisations to share learning, adopt best practice and drive service improvements.

Leader actively sought staff feedback. Results from the 2025 staff survey identified that 21% of respondents lacked confidence in senior leaders’ ability to make the right decisions for the organisation. In response, leaders developed and implemented a staff survey action plan to address the concerns raised and improve engagement. Leaders understood the importance of being visible and maintaining open communication with staff and introduced ‘Day in the Life’ sessions for all senior leaders. This initiative involved hospital executives joining surgery service teams for the day. Leaders benefited greatly from their experience working alongside staff. This active engagement had been an opportunity to strengthen inclusive leadership and role model organisational values.

Senior leaders shared monthly newsletters with teams, which provided service level updates, learning from incidents, policy updates and organisational priorities. The newsletters also celebrated individual and team achievements, recognising long service milestones and highlighting staff members who had been nominated by their peers for demonstrating Ramsay’s vision and values in their work. 

Leaders demonstrated a commitment to continuous improvement across all departments, with a particular focus on staff engagement and wellbeing. They recognised the importance of living and demonstrating inclusive leadership skills and shared goals to continue to learn and improve services for staff and patients. 
 

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.

Staff were confident to raise concerns without fear of negative consequences. They were aware of the services ‘Speaking Up for Safety’ guidance and support available. The surgical service had a speak up champion as a point of confidential contact for staff. Information about speaking up for safety was displayed in all staff areas and information on how to raise concerns externally was also shared with staff.

The service fostered an open transparent working environment where staff felt confident in raising patient safety concerns. Staff were confident their voice would be heard and were empowered to speak up if they had reason to. The service promoted professional accountability and positive personal behaviors for all staff.

Leaders saw ‘speaking up’ as an opportunity to learn and manage potential risks. Speak up for safety themes were escalated to senior leaders if necessary and actions taken in line with an accountability and response framework.

Patients, their families and carers were provided with clear information about how to raise concerns or make a complaint and what to expect from the investigation process. Senior staff in ward areas responded promptly to concerns raised at the point of care, seeking to resolve issues quickly and effectively in line with the service’s complaints policy.

We scored the service as 3. The evidence showed a good standard. The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

Staff told us they were treated fairly by leaders and colleagues. The work environment was positive and was described as a ‘family’ atmosphere. They were confident to report negative behaviors or attitudes and said leaders would act quickly to address any concerns of bullying or harassment.

Staff were encouraged to participate in the People’s Resource Groups (PRGs). There were 7 in total, Pride, Disability and Neurodiversity, Wellbeing, Social Impact, Ethnicity, Generations, and Armed Forces. These groups were staff lead with senior leadership support. Each group was active within the organisations staff support and wellbeing provision.

The service supported staffs’ faith and culture. Events were held in support of national awareness days such as Black History Month, Ramadan and Easter. Wellbeing events such as World Act of Kindness and World Mental Health Day was promoted and supported by PRGs and leaders.

Staff had access to multi-faith prayer and quiet rooms as well as trained mental health first aiders across the hospital. The service also offered access to a qualified-on-site mediator to support inclusive conversation between staff. Examples of reasonable adjustments to support neurodivergent staff were seen.

Staff groups represented the diverse community they served. Recruitment processes were developed to remove bias and support equal opportunities for staff. This included specific guidance for supporting overseas applicants and international staff.

Staff received training and guidance in relation to equality, diversity and inclusion (EDI). With a focus on protected characteristics under the Equality and Human Rights Acts. Staff understood the values and principles of an inclusive workplace. Staff survey results for 2025 showed 63% of participants felt positive the organisation was inclusive and 25% had a neutral opinion.

The service had policies and guidance that incorporated key elements of EDI and included equality impact assessments. For example, the uniform policy was tailored to peoples’ cultural and religious beliefs. The service’s People and Culture committee met monthly to discuss EDI and inclusivity, information and concerns were shared with senior leaders.

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 understood the governance and reporting structures within their department. There was a clear line of accountability from the service to hospital executives. Local team meetings were held with staff that were documented and feedback was shared with heads of departments. This ensured essential information, such as learning from incidents and complaints, was shared and discussed.

The hospital operated effective governance processes through a range of committees such as clinical governance, health and safety and medical advisory committee. These were structured to support escalation and management of risk. Meetings were documented with associated action logs to monitor actions and improvements.

Leaders collected data for all services through a schedule of audits and service performance reviews. This was monitored through service dashboards, reviewed in performance meetings and shared within the wider organisation for benchmarking. Where areas for improvement had been identified, action was taken with clear timeframes for achievable compliance targets.

Incidents and complaints were investigated in line with the services policies. Senior leaders were informed of all incidents and complaints to enable executive oversight and accountability.

The hospital had a risk register that was monitored and reviewed daily. These were department and hospital specific and shared throughout the hospital and discussed at head of departments, executive and corporate meetings. Staff contributed to decision-making to help improve sustainability and improve quality of care.

Information about risk, performance and service benchmarking was shared with all staff. Data was shared in a variety of formats and incorporated visual graphics to support accessibility and understanding.

The hospital had 9 data security incidents reported 1 January 2026 to 7 April 2026. Incidents related to missing information in patients notes or notes being placed in the wrong files. None required reporting as data breaches to the Information Commissioner’s Office (ICO). Incidents were discussed at the information security committee, actions were taken following incidents and learning was shared. Patient identifiable information was handled correctly. Data security training was part of mandatory training requirements. Compliance for this training was 93% for permanent and bank staff.

The hospital had a business continuity plan that included emergency planning. For example, extreme weather or flu outbreaks. In events of emergencies being declared there was a clear structure of command and an activation of the Local Disaster Response and Recovery Team. 
 

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 collaborated with relevant external stakeholders and agencies to improve care and treatment outcomes. This included local national health services (NHS), integrated care boards (ICBs) and general practitioners (GPs).

The service offered complimentary learning sessions for local GP services in collaboration with the ICB. Events were hosted at the hospital and learning topics included; hip and knee management, basic life support, referral processes and medicine management. These sessions were positively received by the partners and feedback collected with positive.

Leaders worked with local primary networks to share learning and provide tailored educational training. Feedback received stated ‘there had been a direct contribution to improving clinical knowledge’ because of the training Rivers provided.

The service took a proactive approach to supporting local communities, charities and global relief initiatives. Staff were supported with charity events throughout the year, raising money for local hospices, Alzheimer’s and cancer charities. Leaders also supported donation of a range of unused consumables to humanitarian initiatives abroad. Donations had been collected since 2021 from staff and patients for a local food bank, this initiative was staff lead and supported by leaders.

The hospital also sponsored local football and cricket teams.

At the beginning of 2026 the hospital had invited local therapy businesses to run beauty and wellbeing workshops for women living with cancer. There were multiple public health events held in partnership with the Rivers. These community awareness sessions on diabetes, stroke and blood pressure monitoring helped strengthen community partnerships and health education.

To further embed the importance of community within the service, leaders had implemented a ‘Giving Back Day’. This was a Ramsay wide initiative that gave staff the opportunity for a paid volunteering day within their community. This could include supporting in a school, library or hospice as well as volunteering for the Samaritans.

We scored the service as 4. The evidence showed a exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 and leaders were committed to continually learning and improving services across all departments. There was a focus on excellence that centred on a positive patient experience. Departments actively sought feedback from staff and patients to improve the quality of care provided.

There were effective processes in place to support positive learning when things went wrong or good practice was seen. Best practice was shared between teams and nationally. Examples were shared of learning from incidents and complaints that showed effective and timely action was taken. Ward staff were practically proud of their falls prevention scheme that saw a reduction in inpatient falls. This was shared nationally as an example of best practice. 
 

Staff were supported to learn and develop their skills. This included talent recognition in teams. Staff who demonstrated a passion for learning and career progression were supported to do so. For example, the services ‘Grow Our Own Scrub Nurses’ program that supported health care assistants to become registered nurses. 
Physiotherapists had developed a ‘Back School’ program for staff that shared advice and information on good back health following spinal interventions. 
 

The hospital had received several external recognition awards. In April 2025 the hospital received a Highly Commended award from the Health Service Journal (HSJ) and in July 2025 it was awarded a gold award for its Defence Employee Recognition Scheme.