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

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.

We reviewed all quality statements. At our last assessment we rated this key question good. At this assessment, the rating remained good. This meant that service leadership and culture assured the delivery of high-quality care.

Leaders were well-respected, approachable and visible. They provided clear direction and promoted a positive and inclusive culture. Leaders and staff had effective support and opportunities to develop. Leaders promoted equality and diversity in daily practice, through mandatory training and a calendar of equality and diversity initiatives designed to raise awareness, promote inclusivity, and celebrate diversity. Leaders and staff consistently described a positive culture where staff could speak up, and their voices would be heard.

The hospital had clear and effective governance systems, supported by a committee structure, policies, and an established audit schedule. The service managed risks well. They reported and investigated incidents and shared learning from incidents across committees and teams.

Managers encouraged staff to share ideas to improve the service and listened to their feedback. They involved staff in the redesign of the pre-assessment service, which included initiatives such as adding follow‑up calls to check understanding and by improving access to local blood test results before appointments.

The culture supported continuous improvement, with staff encouraged to contribute ideas through structured approaches such as SWARMS. Theatres demonstrated leadership in sustainability through adoption of national green theatre practices. Although the service showed strong engagement in improvement, it did not provide evidence of involvement in research.

Leaders actively engaged with external stakeholders, including commissioners and the local NHS trust. The hospital had a service level agreement with the local NHS trust and transferred patients in the event of an emergency. However, the service still lacked a formal feedback process with the trust.

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. The strategies were developed in response to staff engagement events and results from the staff survey. 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.

The hospital’s vision was: “To be the hospital of choice, recognised as outstanding by patients, staff and the community.” The vision was supported by objectives across four strategic areas: patient experience, clinical outcomes, staff engagement and optimal value. Objectives included establishing a patient forum to strengthen patient experience. The hospital also developed a mechanism to improve clinical outcomes for patients following their discharge. This centred on support and monitoring. The service had identified departmental strategic objectives to support the delivery of hospital objectives.

Leaders provided clear direction and promoted a positive, inclusive culture aligned with the hospital’s shared vision and strategic priorities. Staff understood these values and described respectful, supportive relationships and strong teamwork.

Staff focused on meeting the needs of patients receiving treatment and worked effectively together to maintain a culture centred on patient experience and high-quality care.

Equality, diversity and inclusion were embedded through mandatory training, monitoring, and a programme of awareness initiatives.

The culture supported continuous improvement, with staff encouraged to contribute ideas through structured approaches such as SWARMS. Theatres demonstrated leadership in sustainability through adoption of national green theatre practices.

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.

The hospital had a clear management structure with well-defined 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 directly to 1 of the senior managers and there was a monthly head of department meeting to support consistent communication, oversight and coordination across teams.

Leaders had effective support and opportunities to develop. They attended leadership training to strengthen governance and staff development.

The service used role profiles and leadership competencies to define its leadership requirements. Leaders carried out regular staff performance and development reviews to identify where staff were performing well and where further development was needed. They used training to support staff to develop their clinical and leadership skills. Staff told us their appraisals were high quality and useful. The service achieved 100% appraisal compliance in December 2025.

Staff told us leaders were well respected, visible, approachable, and supportive, with an open-door policy. Departmental managers also worked clinically and supported staff working in patient-facing roles.

Leaders implemented awards schemes to recognise staff who performed well. Staff nominated colleagues for demonstrating positive behaviours, such as kindness, teamwork, and dedication.

The staff survey in October 2025 found that staff felt high levels of care were being delivered, colleagues were friendly with each other and there was a high level of team working and team spirit. Staff reported challenges around wellbeing needs, pay, and the need for additional administration staff. Leaders responded to these concerns by reintroducing team bonding days, improving signposting for staff training, and sharing quality improvement practice to encourage problem solving.

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 and staff consistently described a positive culture where staff could speak up and their voices would be heard.

Resident Medical Officers (RMO’s) had good relationships with consultants and felt comfortable to speak up if they were concerned. The service had an established process to ensure RMOs could raise issues and that their concerns were acted on promptly.

Staff and leaders acted with openness, honesty, and transparency. Leaders encouraged staff to raise concerns with their managers.

There were 2 dedicated Freedom to Speak Up (FTSU) Guardians within the hospital. They attended mandatory speak up training which was also available to managers. Leaders held quarterly FTSU forums to promote awareness of the role and organised an annual FTSU conference to share best practice and drive positive cultural changes.

The service had an up-to-date FTSU policy, and a FTSU notice board provided staff with key information and routes for raising concerns.

The service provided patients with information on how to raise a concern and how this would be investigated, including in accessible formats. The hospital reported 16 complaints in the past 12 months, but the data did not specify how many of these related to the surgery service.

The evidence showed a good standard. 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.

Leaders collected equality and diversity data for staff and completed an annual Workforce Race Equality Standard (WRES) report and action plan. They promoted the benefits and opportunities of a career within the service, highlighting their commitment to an inclusive workplace.

Leaders contributed to provider-level reports on equality objectives such as the gender pay gap and ran a monthly diversity metrics tool which monitored parameters that looked at ethnicity, disability, and gender representation within the service.

Leaders promoted equality and diversity in daily practice. All staff completed mandatory equality and diversity training, with 100% compliance in December 2025. Leaders also completed unconscious bias training, achieving 100% compliance in the same period.

Leaders maintained a calendar of equality and diversity initiatives designed to raise awareness, promote inclusivity, and celebrate diversity. The calendar featured culturally significant events across different faiths, people characteristics, and kindness initiatives.

Policies and processes ensured the hospital operated in a fair and inclusive way. Every policy underwent an equality impact assessment to ensure proposed changes did not adversely affect equality and diversity. This was mandatory to ensure polices were fair for everyone and did not disadvantage any group.

Leaders maintained an accessible and regularly updated equal opportunity policy which was communicated to staff. Equality and diversity champions monitored workforce diversity to ensure it remained representative of the local patient group.

Leaders prioritised staff wellbeing and a positive workplace culture. They held monthly staff forums that included listening events, communications and long-service awards, designed to enhance staff engagement. Wellbeing and inclusion were further supported through access to a quiet room, diversity initiatives, and fundraising events.

The hospital achieved Workplace Wellbeing Charter accreditation in 2024, demonstrating its commitment to supporting staff health, safety and wellbeing through a nationally recognised framework. The Charter provides clear wellbeing standards and an independent benchmarking process, confirming the hospital met requirements across key areas including leadership, culture, communication and mental and physical health support.

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 acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

The executive director held overall responsibility for governance within the hospital. The hospital had clear and effective governance systems, supported by a committee structure, policies, and an established audit schedule. This governance framework and supporting policies provided structure for managing and reporting on a range of auditable metrics, which leaders used to oversee performance and deliver sustainable care, treatment, and support.

The clinical governance committee (CGC) reviewed key risks and assurance, with the senior management team (SMT) maintaining oversight to ensure governance processes were effective. Committees such as health and safety, water safety, medicines management, infection prevention and control (IPC), and the medical advisory committee (MAC), reported into the CGC.

Leaders kept an up‑to‑date risk register to record known or potential risks and identify mitigations. They reviewed hospital risks during key meetings, including the quarterly MAC and monthly CGC. They updated risks monthly, or sooner if the risk score changed.

Managers maintained department risk registers and shared these, along with the top 5 hospital risks with staff during team meetings and explained how these risks were managed. The highest risk on both the hospital and theatre risk registers was the potential for a power interruption in theatres due to non-essential electrical items falling outside the uninterrupted power supply (UPS). The service mitigated this through readily available backup battery packs and torches, and a planned upgrade to emergency lighting. Policy updates were communicated through the committee structure.

The service had effective processes for staff to report incidents, near misses, and safety events. Leaders and managers consistently shared learning from these at key meetings. The most common incident theme continued to be same-day surgery cancellations, communication issues, equipment failure or unavailability and surgical complications.

Leaders investigated either locally at department level, or where incidents indicated more significant actual or potential harm, through enhanced learning responses. They shared learning from investigations with staff, to support improvement in practice and patient safety. Leaders had completed training in the Patient Safety Incident Response Framework (PSIRF) methodology which prioritised compassionate engagement, systems-based learning, proportionate resources, and supportive oversight of incident responses.

Leaders and staff completed an annual 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 CGC monitored compliance against the target of 95%.

The service had an audit programme comprising of 18 (mostly quarterly) audits. This included audits such as resuscitation trolley checks, IPC mattress audits, VTE and falls risk assessments, fluid balance monitoring, chaperone compliance, temperature checks and prescription chart audits. All audits met the 95% target except fasting (91%), VTE risk assessment (90%) and prescription chart audits (94%).

The service had a MAC which met every 3 months to advise the senior management team on medical and operational matters. Meetings were attended by a consultant representative from each specialty, and minutes showed attendance requirements were met. Meeting minutes followed a structured agenda aligned to the terms of reference and reflected decision-making, risk assessment, and follow-through of any concerns.

Leaders had a planned maintenance programme which covered key infrastructure areas. This included heating, ventilation and medical gas systems. Scheduled servicing and maintenance logs were up to date.

Leaders had a business continuity policy and folders for each department, to guide staff during emergencies. Planned scenarios were completed throughout the year to practice emergency procedures. Examples included outbreaks of diarrhoea and vomiting, bleep failures, and chemical spillage. Allocated leaders completed annual emergency response training and were responsible for running these scenarios.

Staff were informed of service updates. Relevant information was displayed on noticeboards and shared through team 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 actively engaged with external stakeholders, including commissioners. They submitted statutory notifications, shared incidents and learning, and responded promptly to our requests for information.

The service 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, at the last assessment some theatre staff reported feeling less integrated into the main hospital as interdepartmental meetings had stopped, although it was not clear why. We did not review this as part of this assessment.

Staff reported effective multidisciplinary working with medical, nursing, pharmacy and administrative teams. Pharmacy staff valued the collaborative approach and felt medicine-related queries from ward staff helped drive improvements in process.

Staff worked with the local GP surgeries and contacted them to highlight any concerns and share key information with patient consent. The hospital had introduced a patient forum, to encourage feedback and patient involvement in planning services.

The hospital had a service level agreement with the local NHS trust to support the urgent transfer of deteriorating patients.

We identified that the service had a higher-than-expected number of patient transfers to the NHS. We reviewed a sample of 5 recent transfers and found no concerns regarding the clinical decision-making or the timeliness of these individual cases.

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.

Managers encouraged staff to share ideas to improve the service and listened to their feedback. Staff told us about improvements within the pre‑assessment service, including follow-up calls to ensure people understood the information provided at pre-assessment, and improved access to local blood test results before appointments. These changes had strengthened the pre‑assessment process.

Theatres demonstrated clear leadership in sustainability by embedding national green theatre recommendations into routine practice. Teams adopted low‑impact anaesthetic techniques, reduced unnecessary equipment use, improved recycling, and implemented energy‑saving measures. These actions showed a proactive, well‑led approach to reducing environmental impact while maintaining safe, effective perioperative care.

Leaders encouraged collaborative problem‑solving through team meetings known as “SWARMS”. These were triggered when an issue or opportunity was identified and followed a structured method to explore improvements. Staff valued this approach and felt it generated fresh perspectives. While SWARMS themselves are not a new concept, the hospital’s structured, consistent, and staff‑led way of applying them was innovative in practice.

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 surgery service continued to participate in relevant accreditation schemes and used learning from these to improve practice. These included the Association for Perioperative Practice (AfPP) accreditation (March 2025), where the accreditation report described standards as exemplary.

Other accreditations included

• 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 maintained a focus on sustainability and environmental responsibility. A Sustainability Committee established in 2025 alongside an Environmental Focus Group, reviewed energy, waste management and water conservation reports and met quarterly. They led initiatives such as reducing food and plastic waste, identified as a key priority within the theatre team. However, the service did not provide any evidence of involvement in research.