The Hampshire Clinic

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.

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

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 hospital had a vision and strategy that was aligned with the health priorities of the local area and that of the provider, Circle Health. The provider’s organisational purpose was “to provide high quality, safe and compassionate care our patients need and expect”.

There was a hospital wide strategy for 2025/2026 that incorporated a strategic business plan. The strategy focussed on 4 objectives; clinical outcomes, patient experience, engaged staff and optimal value.

The hospital’s vision was to make a positive difference in patients lives through outstanding care. Their mission was to bring together the best people to deliver the highest quality patient care in excellent clinical environments.

Senior leaders described how the hospital strategy was fully integrated into the hospitals vision and values. We saw 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 and communicated to staff as part of routine meetings.

Staff told us there had been significant improvements made since their last staff survey was carried out and felt supported and valued by senior leaders and colleagues.

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 director was the registered manager and had been in post approximately 3 years 6 months at the time of the assessment. Staff we spoke with were consistently positive about the hospital director and said they listened well to concerns and was responsive.

The 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.

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 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.

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).

All staff spoke positively about the support they had received from their managers and senior leaders. They told us all leaders were visible and approachable and provided them with good support and guidance.

Staff meetings took place monthly and were chaired by the hospital director. Minutes from meetings demonstrated they were well attended. There was a formal agenda that covered a range of topics relevant to the both the hospital and the staff.

The hospital surveyed the consultant workforce annually to understand what worked well at the hospital, what could be done better and to provide a general forum for discussion. The survey was conducted anonymously, however respondents could provide contact details for further discussion if they wanted.

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.

Staff we spoke with felt confident raising issues with their manager and managers responded positively when concerns were shared. Staff we spoke with knew who the Freedom to Speak Up (FTSU) guardian was and were aware of the whistleblowing policy.

The provider’s whistle blower policy and 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 were positive about the FTSU guardian and generally said they felt comfortable using the FTSU service if they had to. They understood how to contact the FTSU guardian if needed. There was only one person covering the role and they was felt this may limit speak up options for staff. We were told of plans to expand the FTSU provision within the hospital to encourage confidence in speaking up.

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 they were treated with respect and equity. Staff told us managers engaged with them regularly and felt confident their concerns were listed to. Staff we spoke with were positive about working for the service and were proud to work there.

The hospital celebrated the ethnic diversity of its workforce. The reception area had a world map with pictures of staff associated with their ethnicity, celebrating a diverse workforce.

Managers told us equality, diversity and inclusion was embedded in the culture of the service. They described how recruitment processes enabled equal opportunities, and they engaged with staff routinely to maintain an inclusive work environment. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns. We heard from staff who had been offered adjustments to their working without needing to ask and they said that this made them feel valued.

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.

Managers had undertaken actions following the staff survey, which focused on leadership and culture.

The evidence showed some shortfalls. The service had clear responsibilities and roles, however there was a lack of accountability and effective governance.

Governance structures provided assurance and oversight of 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).

However, limitations in audit methods meant areas of non-compliance, such as missed implant pauses and debriefs in theatres, were underreported. This prevented leaders from identifying and addressing specific safety shortfalls. We observed poor compliance and adherence to infection prevention and control (IPC) practice within theatres potentially exposing patients to risk of infection.

Oversight was not robust and systems were not effective within the service to identify and ensure staff were adequately trained to meet the patients’ needs. These concerns were highlighted to the service during the inspection. The hospital director took immediate action to improve practice and adherence to provider polices for both surgical safety checklists and IPC. Information provided after the inspection demonstrated a proactive response from the service together with plans to maintain future performance.

Additionally, senior leaders approved practicing privileges renewals despite some mandatory training records appearing to be incomplete. When we raised concerns, senior leaders said they were assured consultants had the appropriate level of training, as they received copies of each consultant’s annual appraisal from their primary employment. This meant the responsible officer at their primary site of employment had approved consultant appraisals in line with NHS organisations.

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.

The hospital had regular communication and oversight from the corporate provider. The hospital director reported incidents, performance and outcomes data to the corporate provider and the partnering NHS trust monthly. This enabled effective monitoring and oversight of the service’s performance. Routine meetings with the partnering NHS trust took place regularly 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 policies to manage risk such as: VTE, caring for deteriorating patients, mental capacity, deprivation of liberty and restrictive practice. Staff told us they were alerted when policies were updated. All policies we reviewed were in date, comprehensive and in line with evidence-based practice and national guidance.

The hospital received regular updates on national guidance, drug alerts and policy changes from the corporate provider and shared these with staff.

The hospital risk register showed risks were recorded, reviewed and had actions in place to mitigate the risk. The service had a management plan in place for the prevention and management of unplanned and emergency situations.

Service leads outlined how the wider organisation were undergoing a transfer of system for electronic record keeping. The plan for the hospital was to wait for the transfer to be completed before moving over to electronic patient records.

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.

Patients 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.

The hospital provided services for NHS and private patients, over the age of 18 for outpatient, diagnostic imaging, inpatient and day case surgical care. The service provided elective surgery across several elective surgical specialties for NHS patients on the referral to treatment waiting lists, under commissioning arrangements with local NHS acute trusts.

Patients 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 hospital director and director of clinical services told us they worked closely with the local NHS trust to address long waiting times and ensure timely treatment for NHS patients.

The NHS bookings team held regular meetings with the NHS trust to discuss referrals where information was missing, in order to avoid unnecessary delays in offering appointments and surgery. This had reduced administrative delays, improving access for patients.

Staff worked in collaboration with the wider system to address regional healthcare pressures and ensure integration of care pathways.

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.

Innovations were taking place in the service. Leaders and staff valued the lived experience of people, using this to develop service improvements. Following provider initiatives, staff received guide dog training in April 2025 to improve patient experience. Leaders had established an autism and neurodivergence awareness committee in July 2025. The service was working towards a national accreditation to demonstrate their commitment to good practice in supporting autistic people.