Spire Little Aston 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 as Good. This key question has improved to Outstanding. This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved 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 service had a clear shared vision, strategy and culture that built on the organisational vision and strategy. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of patients and their communities.

The service had a vision and objectives for what it wanted to achieve and turn it into action. The hospitals' purpose was to make a positive difference in people's lives through outstanding personalised care. There was also a clinical strategy which included patient experience, quality improvement, and innovation.

Leaders supported the wider health economy in ways such as expanding the children and young people phlebotomy service and increasing community-based engagement. They also maintained regular engagement with the Integrated Care Board to ensure services were aligned with local health priorities and population needs. Additionally, the hospital had GP liaison officers who worked with GPs to build relationships, facilitate communication, and support collaborative pathways of care.

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. We heard several examples of staff who had been promoted into more senior roles.

The service had a diversity champion; they told us how they had arranged events such as liaising with the restaurant to offer staff the opportunity to taste food from other cultures. They had also produced a diversity calendar for staff with different dates and decorated the hospital with flags. They kept staff up to date with any new events via an email and were supported in their role by senior leaders.

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 that 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.

Leaders held staff forums every 3 months where they could feed back to staff and a time staff could just go along and have a chat about anything. Leaders told us how they had glass doors to their office for a reason so staff would feel it easier to approach and ensure visibility.

Team and individual staff achievement and success was recognised and celebrated. Staff were thanked for their work. For example, we saw a staff member from the outpatient service had gone above and beyond during a charity fundraising event. They had visited local businesses whilst on annual leave to obtain gift vouchers and cards to give away to add to the in-house raffle for a local children’s hospice. This had been celebrated and the staff member given recognition.

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.

Leaders told us how they had a good support network of other hospital directors as they were 1 of 38 hospitals and 1 of 13 in the central division.

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

The service fostered a 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 raise concerns and offer ideas. The culture allowed staff to be confident their voices were heard.

Staff were able to raise concerns through the Freedom to Speak Up Guardian and were aware they could do this and who they were. There was also 2 Freedom To Speak up ambassadors and a Freedom To Speak Up consultant in the hospital.

Staff were able to enter concerns on the electronic incident recording system and select the category Freedom to Speak Up. They could leave their name if they wished or raise the concerns anonymously. There were no concerns raised that related to outpatients with Freedom To Speak Up Guardians between May 2025 and May 2026.

Staff told us when they had raised valid concerns or felt they would be able to, were or would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially.

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. It had an inclusive and fair culture which had improved equality and equity for staff.

The mission of the hospital was to champion equity, dignity and diversity both within the staff teams and in the care provided to patients. The hospital monitored disclosed ethnicity with 12.77% identifying as a minoritised ethnic group, 14.66% preferring not to make a disclosure and 72.5% of the total workforce at Spire Little Aston Hospital identifying as white.

They also monitored disclosed disability with 2.36% reporting a disability and 16.54% not stating a response, they as such recognised there were additional colleagues who had chosen not to disclose this. The disclosure of ethnicity and ethnicity was voluntary; staff could also decide to disclose this later via systems in place.

The hospital provided access to occupational health for colleagues who required workplace adjustments, advice on health and wellbeing, support with mobility or long-term conditions or guidance on area such as stress, menopause or other health related needs.

To ensure staff had the knowledge and skills to help build an inclusive, respectful culture mandatory training such as equality, diversity and inclusion, compassion in practice, learning disability training had been put into place. An equality diversity and inclusion board was provided staff with support, guidance and details of staff networks.

Any incident, concern or allegation relating to discrimination or inequality was required to be reported through the electronic reporting system. Once logged this was reviewed by the local management team or clinical governance, any safety, cultural or raining themes. The hospital monitored potential inequalities through the annual colleague survey which included questions such as confidence in raising concerns and inclusion and respect in the workplace.

Staff had opportunities to apply for project work, new roles and to undertake external studies. They felt everyone was treated fairly and that they would be able to report negative behaviour or attitudes.

Staff were offered reasonable adjustments to support them to carry out their roles well. For example, we heard how staff hours had been adjusted to support a staff member when it was needed. Leaders told us how arrangements could be made to work flexibly if needed. They gave examples of when staff had been able to do specific shifts to meet their needs and how there were a range of shifts available such as long and short days.

The hospital had an equality and inclusion strategy which included how they were hoping to achieve it and how they were going to deliver it. These were placed under headings such as Encourage, Celebrate, Educate, and Equip and Adapt and Approach.

There was a hospital diversity including LGBTQ+ champion. They had also established colleague network groups such as LGBTQ+, race equality, and Mental Health First Aiders. There were 3 mental first aiders in post whose role was to act as a point of contact and reassurance for those experiencing mental health issues and emotional distress.

Leaders also promoted a comprehensive calendar of events and initiatives that celebrated different cultures and traditions. These had included Race Equality Week and International Women’s Day, with others planned for the year ahead. The hospital had also hosted LGBTQ+ educational events such as lunch and learn speaker sessions, and a podcast had been introduced to promote a more inclusive workforce.

The service had clear responsibilities, roles, systems of accountability and effective governance. Staff used these to manage and deliver high-quality, sustainable care, treatment and support. Staff always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The hospital had an integrated quality governance national meetings and assurance structure that had been developed to provide guidance and support for all meetings taking place across the group from ward to board.

The structure included various meetings and committees. These included a quarterly Hospital Safety, Quality and Risk Committee, Quarterly Health and Safety Committee and a Quarterly Medical Advisory Committee.

There was also a health and safety subcommittee with various subgroups as well as a Patient Safety Sub Committees a quarterly patient experience group, bi monthly head of department meetings and a quarterly departmental team meeting. There was also a whole hospital weekly rapid response meeting.

Oversight of waiting lists and outpatient clinic risk was provided by twice weekly monitoring to track demand and capacity. This was then reviewed at a weekly capacity meeting and forecasting meeting which was attended by the senior management team.

The outpatient's department had team meetings which included topics such as risk, safety, complaints, incidents, learning, complaints and audit results and actions. We reviewed the minutes from the most recent Hospital Quarterly Safety, Quality and Risk Committee meetings and saw topics that were discussed included mandatory training, Risk, incidents, and audit.

Key performance indicators relating to area such as clinical incidents, safeguarding and complaints were monitored through the hospital’s Excellence in Care Delivery and Safety Dashboard and Dashboard meetings.

There was a programme of audits in place with compliance above 94% over the last 3 audits. All audits except for the sharps audit achieved the required target. Actions had been put into place such as reminding staff to put sharps in the correct bins and putting notices above the sharp's bins.

The outpatient's department had its own risk register. The risks were colour coded and had recently been reviewed. Top risks related to transitioning to a new electronic learning platform, the risk of being unable to fully comply with Spire’s data retention policy and the risk of delays in transferring acutely unwell patients to an NHS provider due to pressures on the ambulance service. Top risks were discussed in team meetings.

We reviewed the last 3 senior management team meetings and noted topics discussed included quality improvement, training, complaints, service level agreements, waste and carbon and quarterly fire updates from the engineer.

There were systems and processes in place relating to practicing privileges including reviews. The hospital had a medical governance co-ordinator whose sole position was to ensure these systems were implemented effectively. The co-ordinator worked closely with the interim hospital director. The governance co-ordinators role included requested documentation to support the application including requesting any references, disclosure and barring certificates, General Medical Council licence to practice and whole practice appraisal summary.

There was a mapping consultant performance concerns policy. Leaders told us how soft intelligence was regularly discussed. They were able to give an example of when staff had raised a concern about a consultant and how they had led to a positive outcome. We noted practicing privileges were discussed in a team meeting and senior managers team meetings. This included information staff needed to know such as which consultants could see children and young people, resuscitation requirements and how to find the practicing privileges tracker. It also included how to escalate concerns.

The hospital operated a succession planning framework since 2021 incorporating talent mapping, contingency planning, and leadership development. This was reviewed every 6 to 12 months to maintain workforce resilience.

We noted that the hospital had implemented various initiatives one of which had resulted in in a saving of 2’018 kg of C02, equivalent to approximately 7 trees planted annually, one car removed from the road, or on house powered for a year.

Patients were given electronic tablets to check in on arrival at the outpatients' department. However, staff told us some patients did not like using these and that they could sometimes cause delays. If they needed support staff were happy to help them to check in.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared via huddles, team meetings, drop ins and emails.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution. Staff contributed to decision-making to help improve sustainability and improve quality of care.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to positive changes.

The service had plans to cope with unexpected events and had a business continuity plan which included major incident plans.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

There were governance procedures for managing and monitoring any service level agreements with third parties. For example, they had a register of all standard operating procedures, service level agreements, and contractual arrangements with third parties. All third party standard operating procedures and service level agreements underwent a formal annual review through the senior manager team meetings. This ensured regular scrutiny of third-party performance as well as escalation of risks or gaps through governance processes.

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

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

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.

Leaders told us how they worked in partnership with the NHS through completing NHS work and how they met with the integrated care board.

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

Staff were committed to continually learning and improving services. There were processes for learning when things went wrong or of good practice, either locally or nationally. Staff were supported to have the time to develop their skills and leaders encouraged innovation.

There was evidence of shared learning, we heard of an example when learning had been identified, and actions implemented following a patient attending the outpatient department post-surgery. The learning including training for staff on expected documentation standards and having a resident doctor involved in assessments when severe pain was mentioned.

Leaders participated in quality improvement initiatives. For example, in response to a patient experience of treatment outcomes a quality improvement project in physiotherapy led to the adoption of an alternative orthotic device for patients with foot drop.

The outpatient department had launched nurse led phlebotomy clinics to reduce time patients waited for blood tests. They had also relocated the audiology service to a larger room to ensure patients had more space.

Staff had designed a post-operative wound care form as a team of 4, and this had been rolled out centrally through the group. They could use 2 forms; 1 for simple wounds or if the wound was more complex, they would complete the complex form to record additional information. The complex form contained body maps, National Early Warning Scores, condition of surrounding skin and if there were any indicators of local infection.

Leaders told us how 1 of the outpatient nurses had attended an accredited course on wound care to support other nurses and improve care of post-operative wounds.

There was a framework in place for managing telephone enquiries from patients with concerns. The calls were logged and checked by leaders daily. The department had organised education to support common themes with post discharge telephone calls.

We saw ‘you said we did’ examples. For example, a patient reported they felt they had waited too long to see a nurse, so the hospital had aimed to improve communication between nurses and reception staff to help with any delays.

We noted that in the reception area toilets there were posters advising patients they could discreetly request sanitary supplies at reception by asking for a white envelope. Leaders also told us how they recognised that men may also need sanitary bins, so these were placed in all the toilets.