The Beardwood 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. We assessed 7 quality statements.

At our last assessment we rated this key question good. At this assessment, the rating has remained good.

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 the service had good governance processes in place. The service followed the provider's values. There was an open culture where staff were encouraged to speak up safely. Leaders has skills and knowledge to manage the service. The embraced a diverse workforce, innovation and worked closely with the local community.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

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 provider had a values-based behavioural framework. Their purpose was: “to provide the high quality, safe and compassionate care our patients need and expect.”

The provider’s principles included that patients come first while supporting staff to provide safe and excellent care in environments open to innovation.

Staff knew and understood the organisation’s values and how they applied to the work of their team. They could explain how they were working to deliver high quality care.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

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.

Senior leaders had the skills, knowledge and experience to perform their roles.

They had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Senior leaders had an open door policy and encouraged managers on the ward to adopt the same approach.

Leaders were visible in the service and approachable for patients and staff. Staff told us that positive changes had being made since the appointment of the senior leaders.

Leadership development opportunities were available, including opportunities for staff.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

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.

There was a provider freedom to speak up (FTSU) policy that replaced the whistleblowing policy. There was a national FTSU guardian.

There were two FTSU guardians for the service and staff knew who they were and how to contact them. FTSU were supported by senior leaders for the organisation.

FTSU information was displayed on an information board for staff.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

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 were able to apply to work flexibly if needed to account for personal circumstances such as caring responsibilities or health issues.

There was a diverse mix of staff who had worked at the hospital for varying amounts of time.

Data was submitted to the Workforce Race Equality Standard (WRES), however; this was at provider level and not specific to this service. The WRES was introduced in 2015 to help NHS organisations identify improvements to manage and monitor inequalities by measuring disparities in experience between white and Black, Asian or minority ethnic (BAME) colleagues.

Annual staff awards dinners took place to celebrate staff achievements. There were a number of celebrations throughout the year including team participation in Ramadan and breaking their fast together, easter eggs for all, ice creams in the summer, charity coffee morning event and staff appreciation days.

There were a number of themed events such as world hygiene day when staff could check hand hygiene in a light box.

Monthly newsletters were introduced for staff with articles sharing local information such as welcoming of new staff, celebrating long service, promotion of flu vaccinations, highlighting workshops with local GP’s and seasonal festivities. Historically staff were given hampers at Christmas but his year, there was a party being scheduled for 2026. The newsletters spotlighted certain topics of focus such as sepsis.

Feedback Friday had also been introduced with a video message to staff to celebrate successes and provide updates.

Staff could access a mental health first aider if needed.

A staff forum had provided the opportunity for staff to discuss possible improvements such as technology, career progression and communication to support daily activity.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

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 provider demonstrated that they had governance processes were in place with clear structures of accountability.

The service held ward meetings for staff bi-monthly. These included a standard template that focused on welcoming new staff, specific themed weeks including falls awareness week “call don’t fall” with a focus on actions from the audit including lying and standing blood pressures (BP) and recording of falling stars. Risks such as staffing highlighted. Discussed training, appraisals, reminders re processes and actions to take to improve audit results. Patient feedback was shared and, any notable improvements or successes we celebrated.

The service held monthly leadership team meetings for heads of department at the location. This included a standardised agenda with updates from the executive director, finance, clinical and people as well as any departmental escalations.

There was a committee for infection, prevention and control that included core members and departmental links. This committee met quarterly and discussed set agenda items such as audits, risks and training compliance.

The clinical audit and effectiveness committee discussed the local audit plan, complaints, outcomes and risks.

The hospital patient experience group meetings were planned monthly although had a break in the summer. There were representatives from each department where feedback was discussed.

The clinical governance committee for the service met monthly with attendances from leaders across the hospital departments. There was a standardised agenda template and reporting deck for the provider that included review of top risks on the risk register and any regulatory updates, Incidents were reviewed including summaries where any emerging theme could be highlighted, cancelled operations, any pressure ulcers, medicines and infection incidents. Information submitted for patient reported outcome measures (PROMS) and the National Joint Registry (NJR) was discussed. The service had achieved gold status for NJR. Patient experience and feedback was reviewed including summaries of complaints. Actions were produced based on this information. There was an opportunity for individual department escalations as well as raising any other business.

The service completed monthly quality review reports for the provider that included a range of metrics including staffing, training compliance, dementia care, safeguarding and a range of audits.

The service maintained a quality dashboard that was colour coded to show compliance or non-compliance with targets. In addition to the year summary, information was presented for each specialty including wait times and cancellations. In the last report, inconsistencies were highlighted in reporting, however; the dashboard seen at this inspection was electronic and included a breakdown of the type of incidents reported.

The service maintained a risk register locally. Risks were mainly health and safety and environmental risks. The register included review dates and controls in place to mitigate risks.

There was a provider policy for resourcing / talent acquisition for staff recruitment. This was scheduled for provider review in December 2025. There was an additional policy for sourcing employee references. This supported the recruitment and selection process including pre-employment screening requirements for all candidates including director positions that need to fulfill the fit and proper persons requirement (FPPR) to be suitable for the role.

The provider outsourced certain processes with service level agreements (SLA) in place such as decontamination and sterilisation of surgical instruments at a designated location off site. The copy of the agreement provided did not include names or signatures from either party.

There was a provider SLA in place for the disposal of clinical waste and an additional SLA for the disposal of general and recycling waste products.

Notifications were submitted externally such as notifications of serious injury to CQC.

Mandatory training requirements included information governance with a compliance rate of 95%.

The provider confirmed that there was a designated information governance lead for the service who was responsible for organising, publicising, and coordinating standards for information handling including compliance with data protection laws, internal policies, and best practices. The service confirmed that there were no data security/confidentiality breaches which were reportable to the Information Commissioners Office (ICO) in the 12 months prior to inspection.

The service had reported 11 incidences (although duplicates were included on the spreadsheet) where patients notes had been stored in the incorrect folders. The provider recorded the immediate actions they took and lessons learned.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

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.

The service had been engaging with organisations in the local community such as local schools, mosques and sports clubs as well as health providers such as GP’s and hospice care. The training lead had delivered free basic life support in a diverse range of venues.

They engaged appropriately with NHS partners including commissioners and trusts in the event of needing to transfer patients who became ill during their stay.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

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.

A quality improvement lead had recently been appointed to support and identify any learning needs for staff.

The service had focused on topics such as IPC, falls, blood transfusion and acquired kidney injury (AKI) to promote improvement on the ward.

In the preoperative clinic, following learning from incidents, a Methicillin-resistant Staphylococcus aureus (MRSA) positive swab results pathway had been implemented to assist staff with knowing who required swabs or who just needed a wash.

In addition to the BLS sessions delivered, orthopaedic surgeons facilitated free joint injection workshops for local GP’s.

Hospice engagement was planned in order to see how they could work together to provide a positive experience for patients.

Magseed procedures had been introduced, in breast surgery, at the service and there were plans to introduce robotic surgery for orthopaedics in the near future. The magseed procedure places a tiny magnetic seed (smaller than a grain of rice) into breast tissue to guide surgeons in removing hard-to-feel cancers during a lumpectomy.

The service achieved accreditation with the association of perioperative practice. (AfPP) in November 2025. AfPP theatre accreditation assesses the quality of perioperative care, helping hospitals uphold the highest standards while promoting continuous improvement.