Springfield 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

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 requires improvement. At this assessment, the rating has changed to 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 strategy for what it wanted to achieve. The strategy for 2023-2026 encompassed 7 main areas such as; putting patients first, advancing patient safety and developing staff.

Leaders shared with us the clinical vision and strategy plan for 2026-2029. We saw evidence that this strategy was developed by clinical leaders to respond to changing risks and operational pressures and retained putting patients first as a core objective.

The service displayed posters of the clinical strategy and staff told us they understood the strategy and how their roles contributed to achieving these aims.

Leaders promoted a culture that placed patients at the centre of decision-making. Staff consistently described the service values and demonstrated how these were reflected in their daily practice.

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 service celebrated both team and individual staff achievements and ensured staff felt valued and appreciated for their work. For example, managers shared compliments and positive patient feedback with the teams and recognised outstanding contributions through staff recognition awards. This helped promote a positive culture and boost staff morale.

We scored the service as 4. The evidence showed an exceptional standard. The service had exceptionally 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 always did so with integrity, openness and honesty.

Leaders understood the challenges and risks facing the service and maintained oversight of safety, quality and governance through daily operational meetings and quality monitoring.

Staff spoke positively about the senior leadership team and said leaders listened to concerns and were responsive. They told us leaders were visible and approachable. We observed professional and friendly interactions between staff and leaders.

Staff told us leaders valued their opinions regardless of their role, seniority or professional background. Staff described an inclusive culture where all team members were encouraged to contribute ideas. For example, we saw evidence of a patient falls prevention initiative that had been proposed by a junior member of the clinical team. Leaders had embraced the idea, worked with staff to further develop the initiative and supported its implementation across the service.

Leaders encouraged staff to take part in reflective practice to support learning and development. The head of clinical services provided staff with the opportunity for confidential clinical supervision following challenging situations.

Staff told us they had regular appraisals and access to opportunities to develop new skills and take on greater responsibility. We saw evidence of leadership development programmes and apprenticeship schemes for both clinical and non-clinical staff.

Leaders promoted integrity, credibility and respect for individuals. The service had a “ten-point dignity challenge” to reinforce expectations around dignity, inclusion and respect. Staff told us leaders promoted an inclusive culture where people felt valued and treated fairly.

Leaders had developed an action plan in response to the 2025 staff survey to improve confidence in leadership and recognition of staff. During our assessment, staff told us they had confidence in site and departmental leaders. We saw evidence of staff recognition schemes and awards, demonstrating that leaders had acted in response to staff feedback.

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. Staff told us of a culture where speaking up was encouraged and seen as a part of maintaining patient safety and they felt confident raising concerns.

Staff gave us examples where concerns were raised through the speaking up process that had resulted in service improvements, such as changes to nurse staffing levels.

Leaders told us they saw ‘speaking up’ as an opportunity to learn and manage potential risks.

Patients, their families and carers were provided with clear information about how to raise concerns. The service had a “don’t take your troubles home” initiative that encouraged people to raise concerns so they could be acted upon in a timely way.

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. Staff spoke positively about the service and said they felt proud to work there. They told us they felt valued and included regardless of their role, background or personal characteristics and described the service as a welcoming and supportive place to work.

Leaders supported staff-led initiatives designed to promote inclusion and wellbeing. For example, they had supported the establishment of a menopause support group that was available to all staff. Staff told us attending the group had improved their understanding of menopause and helped them better support colleagues experiencing menopause related symptoms.

The provider had embedded equality, diversity and inclusion (EDI) within its policies and processes. Staff with protected characteristics had access to support mechanisms, including a dedicated prayer and quiet room.

Staff received training on EDI and compliance stood at 100%.

Staff told us they had not witnessed any disrespectful, discriminatory or abusive behaviour from colleagues or patients. They said they felt confident they could report poor behaviours to their manager and that appropriate action would be taken.

Leaders had arranged events to celebrate religious events, for example the Japanese Buddhist event the Obon festival.

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 service had clear governance structures that provided assurance of effective oversight of quality, safety and performance. Staff held clinical governance meetings every two months and meeting minutes demonstrated leaders discussed key governance areas, including incidents, risks, audit findings and patient feedback.

The service undertook routine audits of key processes to assess compliance with safety standards and organisational requirements. We saw action plans in response to identified concerns, and leaders monitored progress to ensure improvements had been implemented and sustained. Staff told us they received feedback from audits to support learning and improvement. For example, leaders provided reminders to staff about the completion of patient risk assessments.

The service had a range of policies to support the management of risk. All policies we reviewed were current, comprehensive and aligned with evidence based practice and national guidance.

Leaders maintained a local risk register that clearly identified operational and clinical risks. Risks were reviewed regularly and appropriate mitigating actions had been implemented.

Sustainability formed part of the governance and strategic approach. Leaders told us the hospital had established a committee to oversee environmental initiatives and monitor progress. The service had replaced part of the hospital roof in 2025 and installed 126 solar panels. Data provided by the service showed this initiative had reduced carbon dioxide emissions by 34.5 tonnes, demonstrating a measurable commitment to environmental sustainability.

We saw evidence that sustainable travel was encouraged through incentives, including free meals for staff who travelled to work using sustainable methods.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The service worked with local organisations to support the needs of the wider community. The service had partnerships with local universities and provided student placements across clinical areas. This supported the development of future healthcare professionals while enabling students to gain practical experience within the service.

Leaders supported the local community through the provision of training and support for community first aiders. This helped to develop knowledge and skills within the community and demonstrated the service's commitment to sharing expertise beyond the hospital environment.

The service provided educational events to the local community. For example, leaders hosted an educational event for patients, healthcare professionals and members of the public that provided information about reflux symptoms, current diagnostic and treatment options, and the support available. Attendees were able to hear from clinicians and gain practical advice to help them better understand and manage reflux.

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.

The service had a focus on learning, improvement and innovation. A dedicated Quality Improvement (QI) Lead supported staff to identify opportunities for improvement and implement changes that enhanced the quality and safety of care. Staff were encouraged to contribute ideas and participate in improvement initiatives across the service.

We saw evidence of a range of quality improvement projects that had been implemented. For example, the service had focused learning on the recognition and treatment of sepsis to improve the early identification and management of deteriorating patients.

Leaders had introduced an initiative to help staff understand CQC key questions and how these related to their daily work. This supported staff engagement with quality improvement. An example of improvement made through this approach was staff receiving level 1 sign language training to improve communication with patients.

The service had achieved Aseptic Non-Touch Technique (ANTT) Gold Accreditation to promote excellence in aseptic technique. ANTT is a nationally recognised framework that promotes safe aseptic practice and helps reduce the risk of healthcare-associated infections during clinical procedures.

The service demonstrated a commitment to improving patient safety through targeted improvement initiatives. These included the introduction of a patient information leaflet to increase awareness of venous thromboembolism and help patients reduce their risk of developing a blood clot. The service had also implemented falls prevention initiatives to reduce the risk of patient harm and promote safer care.

The service promoted learning through a newsletter. This provided staff with information about incidents, lessons learned and actions taken to reduce the risk of recurrence. Staff told us this helped them understand how improvements had been implemented in response to identified risks.

These initiatives demonstrated a culture where learning, innovation and continuous improvement were embedded within the service and used to support positive outcomes for patients and staff.