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 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. This vision reflected the overarching provider aims and objectives. Staff told us they understood the vision and how their roles contributed to achieving these aims.

The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear of reprisal.

Staff told us they felt respected, supported and valued. They described the leadership culture as inclusive and said leaders treated them with respect and appreciation. This made them feel valued.

We observed positive relationships between staff at all levels, with evidence of effective teamwork and collaboration.

The organisation recognised and celebrated individual and team achievements. It operated an “excellence awards” scheme to recognise staff who demonstrated behaviours aligned with the hospital’s local vision and strategy. From 1 January 2025 to 20 February 2026, the organisation presented 158 excellence awards to staff.

We scored the service as 3. 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.

Leaders understood the risks to the services and had a clear oversight of safety and governance through daily meetings and quality monitoring.

Leaders had succession planning arrangements in place for key roles, such as heads of departments. Staff we spoke to told us they had access to good development opportunities.

Staff spoke positively about the senior leadership team and said leaders listened to concerns and were responsive. They told us leaders were visible and approachable.

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.

The provider’s freedom to speak up (FTSU) policy, provided guidance for staff around raising any concerns. Staff were also given information on how to raise concerns through information boards throughout the hospital. Staff we spoke to told us they were aware of the FTSU policy and said they felt confident in raising issues.

Leaders told us that for 2025 a total of 4 FTSU concerns were raised. They provided evidence that appropriate action had been taken in an effort to address these.

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.

Staff told us the service had an inclusive working culture and that leaders treated them with respect and dignity. Staff we spoke with spoke positively about the service and said they felt proud to work there.

The provider embedded equality, diversity and inclusion (EDI) into its policies and processes. It had support mechanisms in place for staff with protected characteristics, including a designated room for prayer, quiet time or sensory deescalation.

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 95%.

We scored the service as 3. 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had clear governance structures in place that provided assurance of effective oversight and performance against safety measures. Staff held clinical governance committee meetings on a quarterly basis. The minutes from these meetings demonstrated leaders discussed key governance areas, including incidents, practising privileges and complaints.

Staff told us they discussed information about performance, risks and governance during daily huddles and routine team meetings.

The service carried out routine audits and monitoring of key processes to assess performance against safety standards. We saw action plans in place to address any concerns identified, and staff told us they received feedback to support learning and improvement. For example, leaders reminded staff about the correct use of medical sharps’ waste disposal containers.

The service had a range of policies to manage risk. Staff told us they received alerts when policies were updated. All the policies we reviewed were current, comprehensive and aligned with evidence-based practice and national guidance.

The service had local business continuity arrangements in place to support escalation and manage relevant emergencies, in line with the Health and Social Care Act (2012).

Leaders recorded risks to the ward on a local risk register. They clearly identified key risks and put appropriate control measures in place to mitigate them.

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 worked collaboratively with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, they shared information of concern with other local providers to ensure a coordinated response to safety concerns. Leaders attended quarterly governance meetings with the local NHS provider and other private healthcare provider.

Leaders 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 told us the service promoted a culture of learning and continuous improvement and encouraged them to suggest improvement initiatives.

Staff investigated incidents and complaints and shared learning with teams to improve services. Leaders provided evidence to demonstrate how they shared learning with staff.

Staff told us about improvements made to the service following feedback from staff or patients.

We saw information displayed that shared learning from incidents which included lessons learnt and celebration of what had gone well.

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 reduce patient length of stay, improve compliance with ‘sip to send’ to enhance patient recovery as well as documentation improvement of local anaesthetic in theatres.