The Ridgeway 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

At our last assessment we rated this key question ‘good’. At this assessment the rating has remained ‘good’. However, we found 1 breach of regulation in relation to good governance.

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 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 patient and their communities.

The organisation had had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives supported by a set of 4 principles and 4 values. These were displayed around the hospital to ensure awareness for staff, patients and visitors.

There was a strategy and action plan to achieve the vision which included an action plan with 6 key actions identified. Projects to support the strategy had been identified and most has been allocated a designated project lead. In addition, there was a separate ‘local patient experience strategy’ which set out engagement projects and initiatives.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff felt respected, supported and valued. Staff reported the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration. Staff told us, “It is a good place to work, we have the equipment we need and support to develop”.

Staff felt motivated about the future and planned changes for the service. The service was committed to support staff to develop and ‘growing their own staff’ through supporting apprenticeships across various job roles. In addition, staff also had opportunities to further their education through post-graduate training for example through the theatre development programme.

Team and Individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

Leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for patients and staff. Staff felt the leaders supported them to develop their skills and take on more senior roles.

High-quality leadership was sustained through safe, effective, and inclusive recruitment and succession planning. This was recognised as a key challenge in achieving the service’s strategy and was incorporated into the action plan to support delivery of the overall vision. The service was committed to supporting staff development to enable effective succession planning and improve staff retention.

Leaders took incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attended the wards and departments to assess for themselves how the service was running.

Staff and patient survey results were acted upon. Service leaders provided feedback following listening events using a ‘You said… We did/We are doing’ approach. This demonstrated that leaders had listened to concerns raised by staff and had identified and implemented actions to address them.

The service fostered a generally positive culture where patients felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and share ideas, and the culture enabled them to feel confident that their voices were heard. The service's strategy action plan included a specific objective to strengthen an open and transparent culture, ensuring staff concerns were listened to and acted upon. This was supported by several initiatives, including the promotion of the Freedom to Speak Up Guardian role and available reporting mechanisms.

There was an on-site Freedom to Speak Up Guardian who had received training for the role in line with national guidance. They were passionate about their responsibilities and actively promoted the role across the service. Staff could access the organisation’s Freedom to Speak Up Policy for further information about raising concerns and the support available to do so without fear of retribution. The Guardian received support from the corporate Freedom to Speak Up Guardian and worked alongside guardians from other group hospitals, providing opportunities for networking and sharing best practice. They had developed positive working relationships with service leaders, which enabled them to effectively support staff who wished to raise concerns.

Staff told us they knew how to raise concerns if needed. They told us they felt comfortable to raise concerns with their manager if needed and stated they knew who the freedom to speak guardian was and how to contact them. We heard of an example where staff had raised a concern through the freedom to speak up guardian. They had felt listened to and the issue had been resolved.

The Freedom to Speak Up Guardian regularly attended senior management meetings to report on the number of concerns raised, including any emerging themes, trends and patterns. However, only a small number of concerns had been raised, and these had been resolved locally.

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Senior staff on ward areas were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

Leaders acted to improve where there are any disparities in the experience of staff with protected equality characteristics. The organisation collected and submitted ‘Workforce Race Equality Standard’s data to comply with a mandatory framework to monitor race equality in the workplace. This was completed at corporate level and the information shared with us did not provide a breakdown to reflect the service we inspected.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. There was a corporate policy concerning Equality, Diversity & Inclusion’ setting out rights for all staff and in particular staff with protected characteristics. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

Staff were offered reasonable adjustments to support them in carrying out their roles effectively when this was required. We heard examples of adjustments that had been implemented in response to individual needs, demonstrating the service’s commitment to supporting staff wellbeing and enabling staff to work safely and effectively.

When policies were developed there was an Equality Impact assessment to ensure people for whom the policy was developed were not impacted negatively because of protected characteristics.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance processes were not always effective. We identified gaps in oversight, including the quarterly Medical Advisory Committee (MAC) agenda, which did not include discussion of clinical outcomes, incidents or shared learning from these events.

It was not always clear when local audits should be undertaken. We reviewed Governance Committee reporting slide decks from March, April and May 2026 and found documentation audits were not consistently reported. The only documentation audit completed during this period was on the inpatient ward in April 2026, which achieved an amber rating (80% compliance). Despite this result, the audit had not been repeated in May 2026. Following the assessment, service leaders informed us that documentation audits had ceased in April 2026.

Governance processes did not identify non-compliance with daily safety checks of emergency equipment, meaning opportunities to improve compliance were not always recognised or embedded. Oversight of medical equipment was also ineffective at times, as not all equipment had been serviced annually.

Although safe care audits were completed, they did not include documentation audits, limiting leaders’ oversight and assurance of record-keeping practices. For example, compliance with the assessment and documentation of patients’ wishes regarding cardiopulmonary resuscitation was not audited.

The service had reported 27 information governance breaches in the previous 12 months. However, during the inspection we found patient records were stored securely and computer screens were locked when not in use.

The service had a clear governance structure supported by a range of committees and governance activities. The Hospital Leadership Team oversaw the Clinical Governance Committee, which had four subgroups: Health and Safety, Medicines Management, Infection Prevention and Control, and the Medical Advisory Committee. Additional groups were responsible for water safety, fire safety, and patient experience and engagement. Information and performance data were shared with regional and corporate governance and operational committees.

Clinical Governance Committee meetings were held monthly and were generally well attended. However, one core member had not attended any meetings between January and May 2026.

The Medical Advisory Committee, chaired by a consultant and supported by the leadership team, met quarterly. It provided advice on practising privileges and reviewed consultants’ clinical outcomes. Processes were ongoing to manage performance concerns and share information with relevant professional bodies when required.

Committees and working groups met regularly in line with corporate requirements. Agendas included actions, risks, patient feedback, training, clinical outcomes, audits, and governance updates. However, attendance at some departmental meetings was inconsistent. For example, only 20 of 54 staff (37%) attended the theatre team meeting in May 2026. Seven staff submitted apologies and 27 (50%) were absent. Records showed nine staff (17%) had not attended any of the previous four monthly meetings. Minutes were circulated to all staff to ensure key information was shared.

Leaders communicated relevant information effectively through daily ‘comms cell’ meetings attended by representatives from all departments. Updates were cascaded within teams and shared via email. Staff also received information on performance and quality outcomes. For example, the Quarterly Quality and Innovation Report, displayed in the theatre staff room, included information on incidents, cancelled operations, infections, medicines issues, pathology issues and complaints.

Staff understood their roles and responsibilities, supported by clear job descriptions. Senior staff responsible for audits and quality monitoring demonstrated a good understanding of their duties.

Staff could access the information they needed in a timely and accessible format to support decision-making and service improvement. Information systems were integrated and secure, and statutory notifications and required data submissions were completed appropriately.

Risks were clearly identified and recorded on the hospital risk register. Each risk was rated according to likelihood and impact, allocated to a lead, and reviewed regularly. Mitigating actions were monitored to ensure risks were managed appropriately.

Patient safety alerts were reviewed corporately and shared with services as required. Actions were allocated to nominated staff and patient safety alerts were discussed daily as a standing agenda item at the 'comms cell' meeting.

The service had arrangements to respond to unexpected events and maintain continuity of care, including business continuity and major incident plans. Staff had access to the Incident Response Plan: Emergency Preparedness, Resilience and Response Policy (2025), which provided a framework for managing business continuity incidents, critical incidents and major incidents while maintaining patient and staff safety.

We reviewed a range of service-level and provider-wide policies, which were easily accessible to staff, and subject to appropriate leadership oversight.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patient. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service.

Leaders and staff actively and openly engaged with patients, staff and the public and to plan and manage services. For example, the service has a ‘patient participation group’ made up of patients from the local community who had attended the hospital. Service leaders collected feedback from the group including implementation projects such as the right to seek a second opinion (Martha’s rule) and on new patient leaflets being developed. Service leaders had also worked with ‘patient safety partners on the development and implementation of improvements related to fluid balance monitoring by including this as part of a ‘nurse quality rounding tool’ in addition to enhanced awareness campaign for staff. There were ‘Feedback cards’ available for patients and their relatives to make suggestions for improvements. In addition, patient led assessments of the care environment were carried out annually and we saw the action plan generated from the latest review (2025) with 2 of 4 actions having been completed.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patient. Staff actively contribute to safe, effective practice and research.

There were processes for learning when things went wrong or of good practice, either locally or nationally. For example, leaders worked with staff to improve compliance with fluid balance monitoring after identifying poor performance. They also increased the frequency of audits to monthly to monitor compliance and support improvement. Data showed that between April and June 2026, the compliance was 84% which was an improvement from audit results between September 2025 and January 2026 where compliance varied between 64% and 76%. Actions taken included a designated ‘fluid balance board’ to improve visibility and support timely completion. This board also displayed a correct example of a correctly completed fluid balance chart.

Staff demonstrated a commitment to learning and improving patient experience. Following feedback and learning from incidents, staff identified opportunities to further promote patient dignity when attending theatre. At the time of the inspection, staff were exploring options for providing appropriate sterile underwear for patients to wear during surgical procedures, rather than relying solely on theatre gowns, to help maintain privacy and dignity.

Several staff we spoke with had a good understanding of quality improvement methods and had been trained in this area of work. We were told about some of the areas of work which they had focused on, which included correct identification of and reporting of suspected surgical site infections (SSI) as these were reported without fulfilling the SSI criteria, improved arrangements for the management of controlled drugs and processes to establish out of date stock to avoid impact on patient safety and experience.

Practice was informed by reflective learning. Staff told us about team reflections following a resuscitation incident, which supported improvements in clinical response and reinforced safe and effective care delivery.

Learning was systematically shared across the service, including learning from other group hospitals. Learning was shared in daily communication meetings and emails, and organisational newsletters. This ensured consistent dissemination of safety information and supported evidence-based practice.