Spire Cambridge Lea 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 patient 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 patient’s needs were met through good organisation and delivery.

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.

We scored the service as 3. 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 service had a clear vision for what it wanted to achieve and a strategy to turn it into action. Improvement actions included expanding the imaging available, for new and existing services, supporting quality improvement , and engaging with GP and consultant networks. This vision reflected the overarching provider aims and objectives. Staff told us they were aware of how their work contributed to achieving targets, they were aware of the hospital and department strategies and where these were located.

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 said they felt respected, supported and valued. Staff told us the service’s leadership was visible, the culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration.

Staff felt motivated about the future and planned changes for the service.

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

We scored the service as 3. 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 and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

Staff told us they felt able to raise a concern, they felt they would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially. The local senior leadership and provider level were made aware when whistleblowers had raised serious concerns. The service had a Freedom to Speak Up (FTSU) Guardian and 6 ambassadors around the hospital, including an ambassador for the imaging department.

Risk registers and management reports contained analysis of concerns over time and associated action plans. Staff were supported by the service’s Freedom to Speak Up policy, which provided clear guidance about how to raise a concern and what could and could not be raised.

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

We scored the service as 3. 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.

Leaders acted to improve where there are any disparities in the experience of staff with protected equality characteristics. They had support mechanisms in place for staff with protected characteristics, including a designated room for prayer, quiet time or sensory deescalation. Staff felt they were treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for their workforce within their place of work, and throughout their employment. Leaders told us they had established an EDI working group made up of a broad cross section of clinical and non clinical staff. This group aimed to ensure the service remained a safe and inclusive place to work. Leaders gave examples of activities delivered by the group, including events to mark South Asian Heritage Month.

Staff received training on equality, diversity, inclusion and belonging and compliance stood at above 90% but below the service target of 95%, although remaining staff had until the end of March 2025 to complete the training.

We scored the service as 3. 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.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, staff told us they shared information of concern with NHS colleagues, which ensured a coordinated response to safety concerns.

Some senior leaders were part of regional networks to understand the needs of the community and the provider ambitions.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They worked with the local NHS provider to ensure patients awaiting NHS funded treatment are clinically prioritised alongside private patients and higher priority patients are treated first regardless of payor status.

We scored the service as 3. 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.

Staff were committed to continually learning and improving services. They told us the service promoted a culture of learning and continuous improvement and encouraged them to suggest improvement initiatives.

Leaders took part in quality improvement projects as part of the wider group that followed the plan-do-study act (PDSA) cycle. The service had participated in projects to improve MRI capacity, efficiency and patient access by implementing AI-enabled technology by contributing to through early adoption of the technology and participation in nation performance and workflow improvements.

The imaging team also took part in the radiology ways of working programme, which are strategic initiatives and guidance driven by NHS England and the Getting It Right First Time (GIRFT) Programme to modernise clinical imaging. The programme focuses on improving workforce capacity, upgrading digital infrastructure and establishing regional diagnostic imaging networks.

All this work had improved productivity, shortened scan times, reduced lost scan time by 0.6%, and reduced wait times by almost a day.

There were processes for learning when things went wrong or of good practice, either locally or nationally with other Spire serves. We saw information displayed that shared learning from incidents which included lessons learnt and celebration of what had gone well. These included wait times and modality splits (which types of imaging are used the most and by which group of patients). The service sat within the national imaging innovations governance structure, with performance, risks and actions reviewed monthly.

Staff were supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. Leaders encouraged innovation and participation in research.

Staff and leaders were committed to excellence that centred on the patient experience. Where they saw a need, they worked together to find a solution, for example by providing patients with speedy advice about incidental findings in scans and x-rays, and making sure follow on healthcare was provided.