Spire Cambridge Lea Hospital

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• 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 means 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.

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 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 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.

Staff were familiar with the hospital’s site‑specific strategy, which described its purpose of making a positive difference to people’s lives through outstanding, personalised care.

Leaders reinforced a culture that was uncompromising on patient safety and focused on improving patient experience, so the hospital became a provider of choice. Staff said the senior leadership team communicated this vision clearly and that they understood how it applied to their own roles.

There was a strong emphasis on inclusion, respect and collaboration. Staff described a supportive culture where colleagues checked in on each other, shared information and helped part‑time staff stay up to date with organisational changes. They said the environment helped them deliver compassionate, individualised care and aligned with the organisation’s values.

Leaders encouraged staff to contribute to discussions about the service’s development, particularly as activity increased and the hospital adapted its layout and processes. Staff felt their views were listened to and that they were involved in shaping how the service worked as it grew.

The hospital continued to invest in infrastructure and sustainability. Leaders demonstrated a proactive commitment to environmental responsibility. Actions included installing solar panels, introducing electric vehicles for operational use, providing electric charging points and reducing single‑use items where clinically appropriate. Staff recognised these efforts as part of a wider strategy that aligned with NHS sustainability priorities and reflected a forward‑looking organisational culture.

Staff said they felt well supported by the outpatient manager, deputy manager and senior leadership team. Leaders were described as skilled, knowledgeable and experienced, with a clear understanding of how the service operated and what was needed to deliver high‑quality care.

Staff reported a more open and transparent culture under the new hospital director, with clearer expectations around safe practice and stronger oversight of consultant activity.

Leaders were visible and approachable throughout the department. Staff felt confident raising concerns and trusted that issues would be acted on. Regular team meetings ensured information was shared consistently.

The introduction of a designated clinical lead for early and late shifts, including weekends, improved leadership presence across the hospital. Staff said this strengthened clinical oversight, supported faster decision‑making and provided more responsive support for both staff and patients.

The department promoted an inclusive and supportive culture. Staff described strong teamwork and said they felt safe to speak up or challenge concerns respectfully. Leaders were flexible when staff needed adjustments following sickness and were approachable when workload or rota issues arose.

Although staff acknowledged that the outpatient environment could be busy and unpredictable, they felt managers were committed to improving systems, including the digitalisation of workflow tools.

Leaders demonstrated effective oversight of safeguarding, with named leads displayed daily and consistent Level 4 coverage. Managers recognised indicators of vulnerability in staff and escalated concerns appropriately, even when thresholds were unclear. Safeguarding leads maintained strong working relationships with Local Authorities, supporting shared understanding of thresholds and expectations. Duty of Candour processes were well governed through corporate induction and clear systems, and leaders ensured safeguarding training remained up to date and aligned with national guidance.

Patients and carers were encouraged to give feedback in a range of accessible ways, including electronic surveys after appointments. Results were reviewed regularly by managers and shared with teams so improvements could be made. Staff said leaders acted on concerns raised through patient forums and surveys, and changes such as improved communication during appointments and adjustments to clinic processes were made in response to this feedback.

The organisation promoted a strong Freedom to Speak Up culture. There were appointed Freedom to Speak Up Guardians and Ambassadors who were visible and accessible to staff. They collected and logged soft intelligence, which helped leaders identify potential issues early. Concerns were coded, investigated and managed appropriately. Cases involving professional conduct were escalated to the Group Medical Director and, where required, reviewed independently.

Staff said they felt confident raising concerns and trusted that issues would be taken seriously and addressed.

Patients, staff and carers had opportunities to meet members of the senior leadership team during walk arounds and engagement events, which gave them a direct route to share feedback. Leaders were described as approachable, open and responsive, which supported a positive culture where people felt their voice mattered and where concerns could be raised without fear.

The service promoted an inclusive and fair culture for its workforce. The team was diverse, with 9 nationalities represented. Staff said they felt valued and treated equitably.

Leaders supported staff to observe important religious days and celebrations, and flexible working arrangements were made where possible to accommodate personal circumstances. Managers also put reasonable adjustments in place, including providing clearer communication, reducing sensory load and identifying quieter working areas to support neurodiverse colleagues.

Staff described the department as welcoming and inclusive, with a culture that encouraged open discussion about individual needs. Equality, diversity and inclusion were promoted across the team, and there were visible sources of support.

A Mental Health First Aider was available to staff across the hospital. These practices helped ensure that people from different backgrounds, cultures and identities could thrive in their roles and contribute fully to the service.

The service had a clear governance framework that supported safe, high‑quality and sustainable care. The Registered Manager provided strong oversight and led a robust practising‑privileges process for consultants, including biannual reviews, monitoring National Governance Reporting and British Society Reporting data, and multidisciplinary reviews to ensure consultants worked safely within their agreed scopes.

Leaders used the organisation’s Med 06 policy, and governance teams met fortnightly to check documentation, scopes of practice, and audit actions were up to date.

Leaders held regular governance meetings, including quarterly quality reviews and rapid‑response meetings, to review incidents, trends and performance. Themes were identified, learning was discussed, and actions were tracked through governance systems.

Staff reported that learning from incidents, complaints and audits was shared consistently at team meetings, with actions assigned, monitored and revisited. Minutes from October 2025 showed discussions on audit results, incident themes, complaints and health and safety actions, demonstrating a structured approach to learning and follow‑up.

Staff participated in a comprehensive audit programme that provided assurance of safety and quality. Departments were allocated audits and expected to evidence completed actions, and audit outcomes were reviewed at both monthly and quarterly meetings.

Leaders monitored risks closely through accessible risk registers, and staff confirmed that the risks they identified matched those recorded formally. Systems for escalation were clear, with heads of department reviewing electronic pre‑operative assessments and escalating high‑risk cases through cross‑departmental forums involving clinical and operational leads.

Information governance systems supported confidentiality, secure handling of patient records and compliance with national standards. Team managers had access to timely data on performance, staffing and incidents, and this information was used to inform decision‑making and identify areas requiring improvement. Governance processes ensured that data collection was routine but not burdensome for clinical teams.

The service demonstrated strong sustainability planning and resilience. Leaders used a detailed business continuity plan that set out how clinics would continue during disruptions. This included on‑call engineering support, prioritisation of essential services, backup documentation processes and three‑day consumable reserves. A recent power outage required activation of this plan; leaders responded effectively, coordinating senior managers and operational teams to maintain patient safety and continuity of care.

Staff were confident in escalation routes and emergency procedures, and quarterly oversight meetings with regional partners ensured wider system coordination for transfers and emergency planning.

Leaders were proactive in responding to concerns raised by staff. Examples included correcting charging processes in audiology and addressing inefficiencies identified through staff feedback or soft intelligence.

Safeguarding arrangements were well led, with Level 4 leadership always available and strong links to Local Authorities. Leaders ensured training compliance and supported staff through new HR learning systems, succession planning and development opportunities.

Overall, governance structures provided clear accountability, effective risk management, strong performance oversight and a culture of continuous learning. These systems supported sustained high‑quality care and effective planning for both immediate and long‑term operational needs.

Leaders worked closely with partner hospitals to verify practising privileges and confirm clinicians’ suitability quickly and safely. These inter‑hospital discussions supported prompt sharing of information about qualifications, scope of practice and performance. This approach demonstrated positive collaborative relationships that helped maintain safe clinical cover across organisations. Staff described these partnerships as open and constructive, with learning shared between teams to support safe and effective joint working.

Leaders held regular meetings with local NHS and independent sector partners. Although these meetings were not routinely minuted, diary records showed they were scheduled consistently and provided a forum for organisations to share updates, raise concerns and support joint learning. This helped ensure that any issues affecting patient care or service delivery were identified early and addressed collaboratively.

Leaders engaged with system partners through the Integrated Care Board assurance programme, which included compliance monitoring and onsite visits.

Leaders completed the Patient Safety and Quality Review during the year and were rated Good, demonstrating constructive engagement with external regulators and a willingness to share information and learning for improvement.

Senior leaders were accessible to patients and staff through walk arounds and engagement opportunities, giving people a direct route to share feedback and contribute to wider discussions about service development.

Leaders demonstrated a strong commitment to continuous learning and improvement. Staff were supported to develop ideas for service changes. Leaders encouraged innovation where it could improve patient experience or outcomes.

The hospital achieved Joint Advisory Group (JAG) accreditation for endoscopy, demonstrating high standards in patient safety, quality and service delivery. It was also accredited as a British Society for Gynaecological Endoscopy (BSGE) Endometriosis Centre of Excellence, recognising its specialist expertise and its contribution to improving outcomes for people with complex endometriosis.

Leaders used Patient Reported Outcome Measures to understand the quality of care from the patient perspective and was awarded GOLD quality data provider status by the National Joint Registry for excellence in data submission, accuracy and outcomes reporting. These national programmes helped staff benchmark performance, understand where improvements were needed and share learning across the wider system.

Staff were involved in ongoing quality improvement activity and understood how to apply QI methods in their areas. Innovation was encouraged, including the introduction of new diagnostic services, such as HyCoSy (minimally invasive ultrasound procedure used to assess the uterus and fallopian tubes), which strengthened pathways and improved access for women undergoing fertility investigations.

Leaders and teams continued to adapt processes based on learning from audits, incidents and patient feedback, demonstrating a culture of continual improvement and forward‑looking practice.