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.

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's 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. 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 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 patient's and their communities.

The hospital had a vision for what it wanted to achieve and a strategy to turn it into action.

The 2025/26 Spire Norwich Hospital Strategy was developed in line with Spire Group’s ‘five pillars’ which have become Spire Norwich Hospital’s strategic priorities: Driving hospital performance, building on quality, investing in workforce, championing sustainability, expanding proposition.

The healthcare quality strategy 2025-2027 for Spire Healthcare defines the areas of priority work such as patient safety, patient experience and engagement, clinical effectiveness and outcomes and quality improvement.

This was then reflected in the local clinical strategy focusing on patient safety and quality, individualised personal care, increased efficiency and developing clinical services.

The strategy was supported by a detailed action plan aligned to the priorities. For example, for performance to aim for 80% theatre utilisation. For expanding proposition- to achieve Joint Advisory Group (JAG) accreditation for endoscopy and introduce a urodynamics nurse led service.

In the 2025 staff survey only 22.9% of theatre staff and 38.5% of ward staff felt there was strategic alignment. However, the hospital had an action plan to implement the strategy including increasing staff engagement.

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

In a CQC staff survey, 59% of staff overall and 65% of surgery staff felt strongly or somewhat in agreement that managers provided effective support, supervision and opportunity for development.

Relationships between staff of all grades were positive, with strong teamwork and collaboration.

Team and individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

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.

The theatre manager and the ward manager were accountable to the deputy director of clinical services who then reported to the director of clinical services. The director of clinical services managed the pre-operative assessment manager, outpatient manager, imaging and diagnostics manager, physiotherapy manager, specialist nurses, governance manager and resident doctors.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attend the wards and departments to assess for themselves how the service was running.

Staff felt that managers, would take action to address concerns, for 59% of staff overall and 50% surgery staff, either strongly or somewhat strongly in agreement, according to the CQC staff survey.

The service fostered a generally positive culture where patients felt they could speak up and their voice would be heard.

The hospital had a Raising concerns policy. We were informed that staff can raise a concern by several methods. A concern could be raised to a relevant person, a quality improvement suggestion, or a concern related to risk, wrongdoing, or poor practice through the Freedom to Speak Up (FTSU) team. The hospital had a FTSU guardian and is supported by FTSU ambassadors. The FTSU guardian was well advertised on clearly laid out noticeboards.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas. The service had recently introduced 6 FTSU anonymous concern boxes which were locked and only accessible to the FTSU guardian. These were introduced after a concern was raised about the anonymity of using the electronic reporting system. In addition, the corporate concerns officer attended the hospital in May 2025 to provide a session to all heads of departments on the importance of “Speak up, Listen up”. These initiatives gave an opportunity for their voices to be heard. In the CQC staff survey 65% of staff for surgery and pre-operative assessment felt they strongly agree or somewhat agree that they could be confident raising concerns with managers or through the FTSU process without fear.

We examined evidence when FTSU issues had been raised and the actions taken to address these. In total there were 6 instances across the hospital during the period February 2025 and February 2026.

An example of action following a concern raised related to quality improvement and FTSU was a revision of information given to patients before their operation to make it clearer.

When concerns were raised, leaders investigated sensitively and confidentially. The local senior management team received a report on FTSU providing assurance and update on issues raised.

Staff received an update on FTSU issues in the staff newsletter distributed by email allowing feedback of FTSU actions.

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.

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 equality, diversity and inclusion through the Equality of Opportunity Policy and a local Equality, Diversity, and Inclusion (EDI) strategy and training which set expectations for fair treatment and respect at work.

The hospital had a dedicated EDI staff forum and EDI champions. EDI champions represent all areas of the hospital including theatres and wards.

Leaders acted to improve where there are any disparities in the experience of staff with protected equality characteristics.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff told us they had opportunities to apply for development opportunities.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. Staff felt people were treated fairly and that they would be able to report behaviour or attitudes which were negative in style. In the CQC staff survey 90% of staff in theatres and pre-operative assessment areas felt that the service takes action to address bullying and harassment. However, only 45% staff felt that the service places a strong emphasis on the health and wellbeing of staff. Also, 80% of staff in surgery and pre-operative assessment felt staff were treated fairly and EDI work was actively promoted.

Staff had access to support services such as an occupational health advisory service. This ensured staff and managers had access to expert advice to ensure all staff with disabilities were offered reasonable adjustments to support them to carry out their roles well.

There was an overseas resourcing policy supported by a policy for induction of new starters and recruitment and retention policy.

Wellbeing services for staff included Mental health first aiders, an employee assistance programme for counselling and information services and a digital health and wellbeing app.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on information about risk, performance and outcomes, and shared this with others when appropriate.

The service and hospital operated effective governance processes through various committees and on-site activities. There was a ward to board integrated quality governance assurance process. The local integrated quality governance structure fed into the corporate clinical governance and safety committee. The local structure had several subgroups e.g. Point of Care Testing and other groups e.g. patient experience which were accountable to the main local committee.

We reviewed the minutes of the last 3 hospital safety, quality and risk committee and associated departmental meetings e.g. theatres, ward. There was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the corporate committee when relevant. Performance indicator data was analysed and where improvements were needed action plans were developed to make this happen.

There was a medical advisory committee (MAC) led by a chair and supported by the service leadership which included approval of practicing privileges and review of clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them.

The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required. Patient identifiable information was handled correctly.

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 policy.

We reviewed several 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.

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

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, the hospital was represented at monthly Integrated Care Board (ICB) meetings to share quality and governance data with local NHS and ICB partners.

There was also a local risk assessment tool for the transfer of unplanned emergency patients which has been approved by local NHS partners.

We also saw evidence of working with a local NHS provider to provide assurance that patients received the correct Venous Thromboembolism (VTE) prophylaxis when discharged after unplanned transfer. This example demonstrates partnership working to improve patient safety. In addition, there was evidence of joint working with the ICB to manage the priority of NHS admissions activity for the financial year 2025-2026.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contribute 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. We looked at evidence from the weekly “Friday feedback” newsletters where successes were celebrated, learning and important feedback was circulated.

This also included quality improvement work that had been undertaken. There had recently been a quality improvement week across the organisation.

Several staff we spoke with had a good understanding of quality improvement methods and had been trained in this area of work. We were told about some of the areas of work which they had focused on, which included a project that was being undertaken after noticing that patients were inadvertently becoming unwell after surgery. The project was looking at reducing the risk of post-operative complications in patients following various types of surgery. This demonstrated a good example of identifying a clinical problem and putting a plan in place to rectify the problem.

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 how the hospital had been nominated for a Thrombosis UK award in 2025 and had achieved Venous thromboembolism (VTE) exemplar status. Also, research had been carried out on lumbar decompressive surgery.

Staff and leaders were committed to excellence that centred on the patient experience. Where they saw a need, they worked together to find a solution, for example a joint school had been introduced as a quality improvement project. A face-to-face group meeting with therapy staff was introduced rather than a phone call as part of a pre-operative assessment with patients to improve the patient experience and reduce length of stay.