Chaucer 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 meant 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 all quality statements.

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

Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued which was an improvement from our previous inspection. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and all staff were committed to improving services.

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.

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 corporate philosophy and hospital vision were embedded to align values and behaviours across teams. The hospital vision and strategy were launched in August 2021 and updated annually. There was also a strategy for pre-operative assessment and theatre. The strategies were developed in response to staff engagement events and publication of results from the company’s first b-Heard staff survey which covered 8 key areas. These activities gave leaders insight into the views and aspirations of staff, and their vision for the future of Chaucer hospital. The strategies were developed between staff and leaders during engagement sessions and updated in 2022 and 2025. Leaders also undertook a separate listening exercise with theatre staff in 2025.

Staff wellbeing and a healthy culture were prioritised. The hospital introduced monthly ‘Team Time’ sessions and a range of initiatives. This included listening events, ‘You Said, We Did’ communications, long service awards and enhanced staff engagement. Wellbeing and inclusion were prioritised through a quiet room, diversity initiatives, and fun fundraising events.

The hospital ran an initiative known as ‘A Day in My Shoes’ which supported staff to spend a day shadowing a colleague in a different department, regardless of job role or grade. This aimed to foster a better understanding of each other's roles, improve cross-department collaboration, and offer insights into different career paths within the hospital.

Staff were focused on the needs of patients receiving treatment and worked well together to ensure they achieved good outcomes for patients. The culture was centred on the needs and experience of people who used services. Staff described the culture in theatre as “a great team.’’ Leaders created a positive, compassionate, and listening culture within the service. Staff across various areas reported healthy working relationships and were not afraid to raise concerns. This was an improvement from our previous inspection.

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 had effective support and opportunities to develop and maintain their credibility and skills and attended leadership training to strengthen governance and staff development. The hospital used the Circle Health Group role profiles and leadership competencies to define the leadership requirements. Annual staff performance and development reviews identified areas where staff were performing well or where there were areas for improvement. The hospital used leadership and management training to support staff to develop leadership skills.

There was a clear management structure with clear lines of responsibility and accountability. The senior leadership team consisted of the executive director, director of clinical services and operations director. Each head of department reported into 1 of the senior managers and there was a monthly head of department meeting.

Staff told us leaders were well respected, visible, approachable, and supportive with an open-door policy. Departmental managers worked clinically. For example, the theatre manager worked 1 clinical shift every week. They told us this helped them to balance management duties and stay engaged with the team. We were told managers were approachable at all levels and staff felt listened to, engaged and supported.

Leaders implemented an ‘Above & Beyond’ awards scheme that recognised staff who went the extra mile. Colleagues nominated team members based on the behaviours expected by the hospital and highlighted acts of kindness, teamwork, or dedication. The winner received a certificate, had their photo displayed in main reception, and chose a reward (champagne, half-day annual leave, or a gift voucher). In addition, all nominees received personal feedback and were thanked by senior management.

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.

Leaders fostered a positive culture where staff felt they could speak up and their voice would be heard. This was an improvement from our previous assessment. Staff and leaders acted with openness, honesty, and transparency.The service encouraged staff to raise concerns with their managers.

There was a corporate Freedom to Speak Up (FTSU) Guardian and 1 dedicated for the hospital. They attended mandatory Speak Up training which was also available for managers. The hospital held quarterly FTSU forums to raise awareness about the role and an annual FTSU conference to share best practice and drive positive cultural changes.

The hospital had an up-to-date FTSU policy and a FTSU board was available, and staff were familiar with both.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The hospital collected equality and diversity data for staff and completed an annual Workforce Race Equality Standard (WRES) report and action plan. The corporate Talent Acquisition team launched a website with a modern, avatar-based design, showcasing the benefits, opportunities, and inclusivity of a career within Circle Health Group.

Leaders promoted equality and diversity in daily work. All staff attended mandatory training in equality and diversity, and training compliance was 100%. Leaders also completed training in unconscious bias.

The hospital had a calendar of equality and diversity initiatives to raise awareness, promote inclusivity and celebrate diversity. For example, celebrating Diwali during October by sharing cultural awareness and Indian sweets and sharing cultural information with staff during Ramadan (March 2025).

Policies and processes were in place to ensure the hospital operated in a fair and inclusive way. All policies had an equality impact assessment to ensure there was no impact of proposed changes on equality and diversity. This was mandatory to ensure all polices were fair for everyone and no one was unfairly impacted.

The hospital had an equal opportunity policy which was easily accessible, regularly reviewed, updated and communicated to staff. Equality and diversity champions monitored equality and diversity of staff to ensure it was diverse in its make-up and representative of the patient group.

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 executive director was responsible for governance within the hospital. The hospital had clear and effective governance systems, policies and audit schedule. The framework and supporting policies provided the structure for managing and reporting on a range of auditable metrics, which were used to manage and deliver sustainable care, treatment and support.

The hospital had a risk register to record known or potential risk and identify mitigations. We saw this was regularly reviewed, discussed during key meetings and updated monthly or more frequently if the risk score changed or needed updating.

The hospital had an effective system for reporting incidents and learning was shared. The main incident reported was cancellation of patient’s surgery on the planned date. This was predominantly due to clinical reasons (such as a patient not being well) and showed staff commitment to patient safety.

There was a clear audit programme for 2025/26 which included the frequency of audit, sample size and links to national guidance and policy. Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on results when needed.

There was a Medical Advisory Committee (MAC) which met quarterly and were responsible for providing assurance and advice to the senior management team on medical and operational matters. It was attended by a consultant representative from each specialty and meeting minutes showed quorum was met. We reviewed the meeting minutes which were well documented. There was a structured agenda aligned with the terms of reference and minutes reflected thoughtful decision-making, risk assessment, and follow-through.

The hospital had a comprehensive planned maintenance programme which covered key infrastructure areas. This included heating, ventilation and gas scavenging systems and we saw evidence of scheduled servicing and maintenance logs which were all up to date.

The hospital had a business continuity policy and folders in every department with refreshed Q-cards. We saw evidence that regular scenarios were completed and scheduled throughout the year. This included, but was not limited to bleep failure, an outbreak of diarrhoea and vomiting and chemical spillage.

The executive director and quality and risk manager had recently completed emergency response training, and the director of clinical services was scheduled to complete the training in September 2025.

Communication processes were embedded in daily routines, such as safety briefings and debriefings. We saw evidence of regular feedback to staff from the governance committee, leaders and internal audit processes. Minutes from a range of meetings were readily available, and audit results were stored on the hospital’s internal system.

Staff were aware of key outcomes and updates, and relevant information was visibly displayed on noticeboards and shared in a variety of ways including huddles, meetings and news bulletins.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They always shared information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders such as commissioners. They submitted statutory notifications, shared incidents and learning and responded to our requests for information in a timely way.

The hospital had a service level agreement with their local NHS trust so they could transfer a deteriorating patient urgently. However, we received mixed feedback about the hospitals’ relationship with the NHS trust and there was no formal feedback process following patient transfers. This appeared to be a missed opportunity for sharing updates, learning and improvement.

The hospital had implemented monthly multidisciplinary skills scenarios and 6-monthly cross sector scenarios. For example, the scenario for managing a major haemorrhage (blood loss) included theatres, blood bank, the local NHS ambulance service and NHS trust. However, some theatre staff advised they did not feel integrated into the main hospital as interdepartmental meetings had stopped although it was not clear why.

Staff reported effective multidisciplinary working with the medical, nursing, pharmacy and administrative staff. They worked together to achieve the best outcomes for patients.

Staff worked with the local GP surgeries and contacted them to highlight any concerns and share key information with consent.

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.

Leaders encouraged staff to speak up with ideas for improvement and actively invested time to listen and engage.

We saw evidence that corporate clinical staff conducted reviews of overall hospital performance and regulatory preparedness. This supported teams to ensure clinical standards were maintained.

The hospital participated in accreditation schemes relevant to the service and learned from them. These included:

• The Association for Perioperative Practice (AfPP) accreditation (March 2025). Standards were described as exemplary in the accreditation report.
• Joint Advisory Group on Endoscopy accreditation (2025).
• Workplace Wellbeing Charter (2025), which acknowledged the commitment to employee wellbeing and the benefits available to support their physical and mental health.
• Chaucer Hospital's oncology unit, (The Becket Suite), held the Macmillan Quality Environmental Mark. This indicated its adherence to high standards for cancer care environments.

Leaders encouraged and supported innovation. There was a focus on sustainability and protecting the environment. A Sustainability Committee was established in 2025 and an Environmental Focus Group. The committee reviewed the energy, waste management and water conservation reports and agreed to meet quarterly. They led on initiatives such as reducing food and plastic waste.

The hospital had a Green Guardian who transformed an unused patch of land into a herb garden. The herbs were used to compliment food for patients and staff. The Green Guardian advised staff on how to recycle and key messages and celebrations were displayed with pride on a sustainability board.