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.
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.

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 strong strategy and vision to deliver personalised, high quality, safe patient care. Staff were fully aware of this strategy and vision and how they played a part in its delivery, making a positive difference to the patients they cared for.
Staff told us they were happy to work in the department and were supportive of their peers and management team and felt supported. They were confident within their role to provide the care and treatment that met the expectations of the people using the service.
The department continued to receive investment. New ophthalmology equipment was procured; physiotherapy had improvements to gym equipment and consultancy rooms that moved to the Ella May Barnes site. Plans were in place to expand cardiovascular services within the outpatient department that would be based at the Ella May Barnes satellite clinic.
Further details of how the hospital shared direction and culture can be found in the surgery report.

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.
Senior leaders were skilled, knowledgeable and experienced to perform their roles, they led and support staff in providing safe patient care. They had effective oversight of the service.
Staff said the Head of the Department and the deputy manager were visible and supportive; they were confident in raising concerns with them. The department promoted an inclusive and supportive culture. The Head of Department had an open-door policy for staff to raise any concerns. Staff we spoke to acknowledged this.
Daily safety huddles were held every morning within the department; staff meetings were held quarterly allowing for information and learning to be shared. Staff also had access to other engagement opportunities and forums throughout the year.
Further details regarding capable, compassionate and inclusive leaders can be found in the surgery report.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.
Patients were encouraged to speak up if they had concerns. Information on how to complain was displayed within the department for patients to see and staff told us how they would direct a patient to complain if they were asked. None of the patients we spoke to had felt the need to complain or raise concerns but said they would if they had to and felt confident that they would be listened to.
“You said we did” information boards around the department illustrated changes that had been implemented following patient feedback from patient surveys, forums or complaints.
The department promoted a culture where staff felt confident to speak up. The service had Freedom to Speak up Guardian and 7 ambassadors; photographs were displayed within the department, so staff knew who they were. Staff were confident that any issues raised would be listened to and addressed.
Further information on Freedom to Speak up can be found in the surgery report.

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.

The workforce was diverse and representative of the community.
We spoke to both clinical and non-clinical staff of all genders, at varying stages of their career within the department. They told us that they were treated fairly and equitably within the department and the organisation. Career development opportunities were available. Staff told us reasonable adjustments had been made for flexible working to achieve a better work life balance and accommodate personal circumstances. Staff felt safe coming to work and there were not any concerns around bullying, sexual safety or inappropriate behaviours. Spire introduced a Code of Conduct to provide guidance on behaviours and professional conduct within the hospital.
The service had an Equality Diversity and inclusion (EDI) pledge to create an environment that was inclusive and people were free from discrimination and harassment. The hospital had an EDI plan that was effective to support inclusivity. There was a LGBTQ+U Champion and EDI forums had taken place quarterly; these were both examples of what was set out in the plan that had been actioned and achieved. The service also had a celebration calendar that recognised key events and awareness days, for example International Women’s Day, Pride Month and Black History Month amongst others.
The service collected and monitored data to identify any underrepresentation within the workforce. Staff were invited to take part in a menopause awareness webinar. Staff received training in EDI; 94% of staff had completed this training. EDI updates were included in bi-monthly staff newsletters
The service had 4 Mental Health First Aiders that staff could approach for help. Further details on workforce equality, diversity and inclusion can be found in the surgery report.

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-maintained risk registers at a departmental level. The Ella May Barnes Clinic site had its own risk register, and the Hill House/main hospital site had a combined risk register. Each site had its own risk register displayed showing the top three risks. Staff were aware of these, and the Head of Department had good oversight. The registers reflected what we were told verbally by staff.

Policies we reviewed were detailed and reviewed regularly. The policies outlined roles and responsibilities and gave guidance to leaders and staff. Staff undertook mandatary training; data received showed a good level of compliance. The service took part in patient engagement and feedback. Local audits were undertaken and quality improvement measures and actions were put into place. Incidents were investigated and learning shared. Collectively these measures contributed to the effective delivery of care and treatment supporting the safety and wellbeing of both staff and patients.

The service handled patient care records securely following the patient health(paper) records policy. Staff received information governance training which supported staff knowledge in data privacy, security, risk and patient confidentiality.

Leaders attended quarterly clinical governance meetings that had an agenda and were documented. Themes were identified and learning discussed. The outpatient manager was present at these meetings, which enabled relevant information to be shared with staff. These meetings together with daily safety meetings, daily department huddles and quarterly staff meetings allowed for information sharing and learning from incidents.

The service demonstrated contingency planning and resilience. The service had arrangements in place for business continuity should something occur that caused disruptions to the services provided. Potential incidents were Red, Amber and Green (RAG) rated and numbered 1-4, with red and 4 being the most significant level of incident causing disruption to the service. Examples of disruption could range from leaks and general maintenance issues to fire on wards; severe weather causing structural building damage.
Staff undertook and participated in local audits to provide assurance of safety and quality. If audits did not reach the target compliance of 95% they would be reviewed and actions put into place to monitor for improvement. 15 out of 16 local department quarterly audits reached the compliance target or higher.

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

The service clearly 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.

The service worked in partnerships with the wider system including local NHS trust and the integrated care board (ICB), enabling leaders to have a better understanding of the wider population and community needs.

The hospital also builds relationships with other external stakeholders. Free Continuing Personal Development (CPD) events were put on for General Practitioners (GPs) and other Allied Health Practitioners (AHP) to engage in learning and training to help improve skills and knowledge. These sessions include lectures from consultants and hands on development of practical skills. Example of these sessions include a joint injection workshop and electrocardiogram (ECG) interpretation.
Patient forums and feedback took place enabling direct feedback to leaders to help develop the service. Senior leaders were accessible to patients and staff on walkabouts through the hospital. Photographs introducing the senior leadership team were displayed within the hospital and departments.

Further details on partnerships and communities can be found on the surgery report.

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.
The physiotherapy outpatient’s department had a Joint school. This is a programme that has been developed for patients that are planning to have surgery. The programme provided patients with pre- and post-operative information and exercises to improve outcomes following surgery. Patients met face to face as a group enabling them to share experiences.
Plans were in place to expand cardiology within the outpatient department and introduce blood testing for children from 5-18 years old.
The service demonstrated a strong commitment to continuous learning. This together with audit data, was driving improvements to ensure patient needs were met.
Further details on learning, improvement and innovation can be found in the surgery report.