The Beaumont 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 well-led as good.

There were clear governance structures in place that provided assurance of oversight and performance against safety measures. The service had a vision and strategy that was aligned with the health priorities of the local area. Most managers and leaders at the service had the relevant skills and abilities to manage the services effectively. Most staff spoke positively about the visibility of leaders and the support they had received from their managers. However, some staff reported that not all managers and senior leaders were approachable or provided them with good support and guidance.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The hospital had a vision and strategy that was aligned with the health priorities of the local area. It was focused on meeting demand, expanding capacity and incorporated risk based decision making.

Managers and leaders at the service recognised the limitations of the hospital’s size, age and infrastructure. They had a site development plan that had incorporated the needs of people who use the service, staff and external partners. The plan included options to create more space for parking, increase bed capacity and enable more theatre activity.

There was a hospital wide strategy 2024 – 2025 that incorporated a strategic business plan. The ambition statement focused on delivering outstanding care, being innovative, and collaborative with health partners. The strategic objectives involved patient care, engaged staff and clinical outcomes.

The hospital vision was; ‘to be a leading provider of healthcare services, recognized for excellence in patient care, innovation, and collaboration. We aim to enhance the health and well-being of our community by ensuring timely, effective, and compassionate care for all patients.’

The vision was underpinned by clear values and principles; including selfless and compassionate, collaborative and committed, ‘patients come first’ and ‘we believe in our people’.

Senior leaders told us that the hospital strategy was fully integrated into hospitals vision and values of ‘patient-centred care’, ‘collaboration and innovation’ ‘commitment to excellence’ and ‘support for our people’.

We saw that the vision, values and principles were displayed throughout the hospital.

Staff we spoke with had a good understanding of the provider’s objectives, values and behaviours. Managers told us progress against the business objectives was reviewed as part of routine meetings.

Leaders had requested an external review in 2023 after concerns were raised about the culture. Several actions were identified and implemented including more engagement opportunities with senior leaders. Many staff we spoke with said there had been an improvement in morale and culture over the past year.

Most managers and leaders at the service had the relevant skills and abilities to manage the services effectively. They understood the risks to the services and had clear oversight on safety, governance and performance issues through daily involvement and quality monitoring. There were succession plans in place for key roles such as head of departments and directors.

The executive director for the hospital was the registered manager and had been in post two years. Staff we spoke with were consistently positive about the executive director and said they listened well to concerns and was responsive.

The overall lead for the surgical services at the hospital was the director of clinical services. The ward manager and the theatre manager were responsible for the day to day management of the ward and theatre areas. The theatre manager was new in post at the time of our inspection. There had been a significant gap with no theatre manager for over 6 months. Theatre staff told us this had been a difficult time with no permanent leadership in theatre.

There was a clear reporting line for both clinical and non-clinical staff.

The consultant surgeons and anaesthetists had clinical responsibility for the patients they treated. The medical staff were overseen by the chair of the medical advisory committee (MAC).

Most staff spoke positively about the support they had received from their managers and senior leaders. They told us all leaders were visible but some staff reported that not all managers and senior leaders were approachable or provided them with good support and guidance.

Staff listening forums took place in October and November 2024 with corporate managers. They were made aware of how some managerial communication and behaviours had negatively impacted on staff wellbeing. Feedback was shared with the hospital leadership team and an appropriate action plan was implemented to drive improvement.

Most staff we spoke with felt confident raising issues with their manager and that managers responded positively when concerns were shared.

The provider's whistle blower policy and freedom to speak up (FTSU) policy, provided guidance for staff around raising any concerns. Staff were also given information on how to raise concerns through the provider's intranet and information on boards throughout the hospital. Staff we spoke with knew who the FTSU guardian was and were aware of the whistleblowing policy.

FTSU month was recognised and celebrated through October 2024 by staff across the hospital. Staff were positive about the FTSU guardian and said they felt comfortable using the FTSU service if they had to. They understood how to contact the FTSU up guardian if needed. However, some staff told us that they did not feel supported by their managers and would be fearful about speaking up.

There had been 10 concerns shared with the FTSU service over the past 12 months and one of them had been shared with CQC. Actions had been taken and outcomes had been recorded.

Most staff told us the service had an inclusive working culture and they were treated with respect and equity. Staff told us managers engaged with them regularly but not all felt confident their concerns were listed to. Most staff we spoke with were positive about working for the service but some staff said they had experienced instances of unfair treatment or discrimination.

Managers told us equality, diversity and inclusion was embedded in the culture of the service. They told us staff recruitment processes enabled equal opportunities and they engaged with staff routinely to maintain an inclusive work environment.

Equality, diversity and inclusion was incorporated in the provider's recruitment policies and processes. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers and senior leaders engaged with staff to monitor work culture and identify any bias or discrimination.

The service carried out annual staff surveys to gain feedback from various staff groups about their experiences. The most recent staff survey dated October 2024 had a low overall response rate (43%) which meant the data did not reflect the full workforce. The lowest scores across nursing, theatre and administration staff included the factors ‘leadership', ‘my manager', and ‘giving something back'.

Managers had undertaken actions following the staff survey, which focussed on improving the work environment and staff engagement.

The service had a workforce race equality standard (WRES) Action Plan 2024-2025. There were 5 actions regarding WRES data and most actions had been completed. This included the improvement of diversity data and self-reporting by ethnicity, other diversity information and protected characteristics.

There were clear governance structures in place that provided assurance of oversight and performance against safety measures. There were committees for risk and audit, infection control, workforce and health and safety feeding into the clinical governance committee and medical advisory committee (MAC). Minutes for the last two MAC meetings demonstrated that key governance areas were discussed including incidents, complaints and practising privileges.

Staff told us information on performance, risks and governance was discussed during daily huddles and routine team meetings. Meeting minutes showed key discussions routinely took place around performance, risk, governance, audits, and incidents. Action logs were in place for key performance indicators that required improvement and these were followed up at subsequent meetings.

Managers were aware of their responsibility to report notifiable incidents and any incidents related to the General Data Protection Regulation (GDPR). The hospital reported there had been no data breaches that were reportable to the Information Commissioner's Office (ICO) in the past 12 months.

There was regular communication and oversight from the corporate provider and the hospital. The executive director reported incidents, performance and outcomes data to the corporate provider and the partnering NHS trust monthly to enable effective monitoring and oversight of the service's performance. Routine meetings with the partnering NHS trust took place every three months to discuss performance, outcomes and key risks.

The ward and theatre managers logged identified risks on local risk registers. Key risks were placed on the hospital-wide risk register. Key risks were identified and control measures were put in place to mitigate risks. Individual risks had a review date and an accountable staff member assigned to them. A risk scoring system was used to identify and escalate key risks to the corporate provider.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives. Staff told us they participated in the audit processes and they received feedback following audits to aid learning and improvement.

The service had a number of policies to manage risk such as VTE, caring for deteriorating patients, mental capacity, deprivation of liberty and restrictive practice. Staff told us that they received emails when policies were updated. However, we observed some policies that were out of date such as the managing conflict policy that had expired October 2023 and management of the diabetic patient that had expired April 2024. Of the policies we reviewed that were in date, all of them were comprehensive and in line with evidence-based practice and national guidance.

An investigation into a no harm medicines incident from November 2024 found a lack of guidance for the management of delirium. This was because the policy was only available for sites that had an intensive care unit. This was escalated to the corporate team for access to the delirium policy and the action log said this policy would be included in staff training and made available in clinical areas from January 2025.

People told us care and treatment was well co-ordinated between the service, their GP and the partnering NHS trust. They felt there was timely communication and sharing of information about their care and treatment between the services.

People spoke positively about being able to access treatment within their local area and told us this was convenient and reduced travelling times.

Managers told us they had an effective working relationship with system partners such as the NHS hospital and Integrated Care Board (ICB). The executive director told us that they worked closely with the local NHS trust to address long waiting times and ensure timely treatment for NHS patients. They had weekly meetings to review and discuss patients being transferred, address any concerns and share learning.

Staff worked in collaboration with the Greater Manchester system to address regional healthcare pressures and ensure integration of care pathways. Managers told us that the hospital was the only independent sector provider included on the local planned care board.

The partnering NHS trust told us there was a positive working relationship and shared learning. They told us they were fully cited on service performance, outcomes, incidents and complaints.

Staff told us there was a culture of learning and improvement across the service. The service had been nominated for an award in March 2024 to recognise the progress made in reducing wound complications and reduction of SSI's.

The hospital shared best practice with partners and offered them support and training. Staff had shared their local surveillance practice and wound management strategies with a local NHS hospital. We observed positive feedback from partners who had implemented some of the hospital's processes to improve their service provision.

Incidents and complaints were investigated and learning was shared with staff to improve the services. The service provided evidence of shared learning with their local NHS hospital and other external partners.

Staff spoke positively about improvements in recruitment of new staff and how this would improve the working culture and delivery of services.

Staff gave examples of collaboration and shared learning with staff at NHS hospitals. They told us they had visited local schools to provide IPC and environmental education. The service had recently implemented a new initiative using reusable cups throughout the hospital which was more sustainable and had reduced waste.