Spire Norwich 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

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.

This key question was previously rated good and has remained as good.

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 patients and their communities.

The service 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. Staff understood the vision and values and this was evident in the care they provided and information provided to us.

Staff told us they felt respected, supported, and valued. They were focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients. Staff were positive and proud to work for the service.

Staff reported that there were insufficient team meetings and often communication would be verbal or via email. The last departmental meeting that was held was in September 2025. Staff mentioned that this may be due to current low staffing levels. Leaders informed us that this was due to different shifts between modalities and lack of substantive staff.

The culture of the staff was positive and were passionate about making changes that were required.

Further details of how the hospital shared direction and culture can be found in the surgery report.

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 had the skills, knowledge and experience to perform their roles. The radiology manager led the diagnostic imaging service and demonstrated extensive experience and a clear understanding of the service and how it operated. Staff spoke positively about the support they received from local managers and told us that development opportunities were available to them.

The radiation protection supervisor (RPS) had a good understanding of the diagnostic imaging service and was able to explain how they worked with senior leaders to provide high quality care.

The RPS was very visible in the diagnostic imaging department to patients and staff however other members of the senior leadership team were not very visible in the service but staff knew where to locate them and how to contact them. Staff felt comfortable to approach them when and if needed.

Further details regarding capable, compassionate and inclusive leaders can be found in the surgery report.

We scored the service as 3. The evidence showed a good standard. The service generally fostered a positive culture where patients felt they could speak up and their voice would be heard.

The hospital had a freedom to speak up (FTSU) policy in place which clearly set out the roles and responsibilities of all staff and provided guidance on how to raise concerns. Staff could raise concerns either internally or externally. The FTSU policy was supported by the Freedom, to Speak Up Standard Operating Procedure, which clearly and comprehensively described the process to follow when staff raised a concern.

Staff were aware of the Freedom to Speak Up guardian but told us they did not feel they would need to contact them, as they felt comfortable raising concerns with their direct line manager. Therefore staff did not use the service.

Patients and carers had opportunities to provide feedback about the service they received in ways that reflected their individual needs.

Further information on Freedom to Speak up can be found in the surgery report.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

The service promoted workforce equality, diversity and inclusion through established policies and by ensuring staff completed the mandatory training.

Staff we spoke with did not raise any concerns about the inclusivity of the working culture and told us they were treated with respect and fairness. Staff said they felt confident that managers would listen to any concerns they raised. We did not identify any concerns relating to unfair treatment, discrimination or harassment within the diagnostic imaging department based on discussions with staff.

Staff felt there was the option to work flexibly if needed. The service had a freedom to speak up champion who was visible to all staff.

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.

There was a risk register for diagnostic imaging.

The service had a morning huddle everyday with all departments form the hospital and the agenda was the same everyday and diagnostic imaging had their own individual huddles for each modality and discussed verbally or by email if needed.

The imaging department had good governance arrangements in place which were in date and regularly reviewed.

Staff had access to the equipment and information technology they needed to carry out their roles effectively.

Training compliance across staff groups within the diagnostic imaging department was good. This demonstrated that the service had effective systems in place to identify training needs and ensure staff had the appropriate skills and knowledge to meet patients’ needs. Information was on an accessible format. Staff felt they were given time away from clinical duties to complete these.

The service participated in numerous audits relating to quality of imaging and hygiene.
There was a risk register for diagnostic imaging.

The department’s business continuity plan focused on hazard vulnerability assessments and what plans to follow.

Further details on governance, management and sustainability can be found in the surgery report.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for patients. They did not always share information and learning with partners or collaborate for improvement.

The service worked together internally but we did not see evidence of benchmarking with other diagnostic imaging providers.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. They actively contribute to safe, effective practice and research.

Staff were committed to continually learning and improving services. The evidence showed a number of audits undertaken by the diagnostic imaging department relating to equipment, imaging quality and hygiene. The business continuity plan described a hazard vulnerability assessment and plan for it.

There were processes for learning when things went wrong or of good practice, either locally or nationally. We were told about incident reporting.

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, and we heard about some of the staff being supported to completes masters degrees and courses related to diagnostic imaging.

Staff and leaders were committed to excellence that centred on the patient experience.