Spire Portsmouth 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 at 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 people 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 we spoke to had awareness of how their work contributed to achieving targets.

Staff were focused on the needs of patients receiving care, and there was an open culture where patients, their families and carers as well as staff could raise concerns without fear. The service promoted equality and diversity in daily work and provided opportunities for career development. Staff told us that recent learning sessions had developed their knowledge and skills and they spoke positively about the impact on their professional development.

Most staff felt respected, supported and valued. Staff told us the leadership culture was positive and senior leaders were visible. Relationships between staff of all grades were positive, with strong teamwork and collaboration. This meant staff were better able to work together to meet people’s needs.

Staff achievements were recognised and celebrated. Staff were thanked for their work and positive feedback was shared with them, helping them to feel proud of the work they did.

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.

The service was led by an imaging manager, who staff described as accessible and approachable. They oversaw the running of the diagnostic imaging service and provided leadership for staff, as well as clinical oversight of the scans.

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. Most staff felt the leaders supported them to develop their skills and take on more senior roles, which supported their professional development. Leaders attended the service to assess for themselves how the service was running and had knowledge of risks.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. When things went wrong, leaders acted with integrity and were open and honest with patients. We saw actions had been taken in response to concerns.

At the time of our inspection, staff survey results had recently been shared with leaders. They were clear about the actions they needed to address and were in the process of developing action plans.

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.

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. The service had a Freedom to Speak Up Guardian (FTSUG) and 4 ambassadors across different specialties. The hospital director met monthly with the FTSUG to discuss areas of concerns. The FTSUG felt supported by the hospital director and was given time to carry out duties.

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. Staff completed speak up training as part of their mandatory training and induction. The service clearly displayed information about how to raise a concern. Monthly drop-in sessions were advertised to staff so concerns could be discussed face to face with the FTSUG. The service had processes where staff could raise concerns anonymously, as well as face to face or by email.

When concerns were raised, leaders investigated sensitively and confidentially. The local senior leadership and provider level were made aware when whistleblowers had raised serious concerns. Risk registers and management reports contained analysis of concerns over time and associated action plans.

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.

Leaders had taken 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 project work, new roles and to undertake external studies through an open application process.

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.

Leaders promoted an inclusive culture where differences were valued, and staff told us they felt supported and able to raise concerns without fear of discrimination. Leaders told us they were committed to the Workforce Race Equality Standards (WRES) and the Workforce Disability Equality Standards (WDES), by monitoring workforce data and feedback to understand staff’s experiences.

There was an Equality and Inclusion strategy to support diversity within the workforce. Information was gathered through staff engagement surveys and used to identify themes or areas of attention. Equality, diversity and inclusion networks, such as an LGBT+ network and a Race Equality network had been set up to support staff.

Reasonable adjustments were made to support staff needs, and flexible working arrangements helped promote wellbeing and retention. Equality and diversity training was mandatory and regularly refreshed, enabling staff to deliver person-centred care to a diverse patient population.

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 operated effective governance processes through various committees and on-site activities. For example, there was a quarterly Health and Safety committee with various sub-committee’s including Radiation Protection. All staff, including those within diagnostic imaging, attended weekly hospital Rapid Response meetings. There was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the provider. The organisation carried out Excellence in Care Delivery performance reviews to assess the quality of the care provided.

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. The MAC met every quarter to advise the Hospital Director and Director of Clinical Services with input from different consultant specialties. Quality and risk issues were discussed, including complaints, incidents and audits. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Medical physics support was provided by the hosting NHS trust. Staff were clear on who their radiation protection advisor and medical physics expert were and could describe how to contact them. We saw evidence in incident logs of the medical physics experts’ input in incidents involving radiation or requiring advice.

Leaders ensured radiation incidents were fed into risk management structures, and they notified relevant organisations for accidental and unintended radiation exposure. Staff were able to describe learning from recent incidents and risks.

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. Staff and managers were able to suggest ideas for improvement and be involved in the development of the service. 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.

Locally, the diagnostic imaging department had a schedule of regular audits, including the ‘Pause and Check’ audit, hand hygiene audits and medication storage. The imaging manager told us they are involved in monitoring and improving outcomes, and they were able to identify improvements needed to ensure positive outcomes. For example, there were plans to audit the quality of reports generated by clinicians on diagnostic images to ensure this is carried out consistently.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared via Friday Feedback meetings and quarterly departmental team meetings. Staff confirmed that information and learning was shared with them, and they were able to access the information easily.

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. Where required, there was expert input from Medical Physics Experts or Radiation Protection Advisors.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were submitted to external organisations as required. The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

The service had a business continuity plan which would be put into operation in the event of an unexpected disruption to the service, this included a short-term disruption plan. We found there were risk assessments for the down time of the scanners.

Most risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations or bring to resolution. However, there were some areas where governance oversight had not been as effective as possible. For example, some staff told us there was not always regular opportunity to have a 1:1 with their manager, which could limit their professional development and the oversight of their performance. Sharps equipment was found in an unlocked cupboard near to patient areas which had been not identified by staff. This meant some patients could be at risk due to the unsecure storage of these items.

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 at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, radiologists working within the service attended Radiology Events and Learning Meetings (REALM) at a local NHS trust. These allow radiologists to engage in peer-review to improve their knowledge and skills.

Leaders worked with other Spire organisations to share learning and best practice. As part of the service’s patient engagement and experience framework, a quarterly Patient Experience Group was used to identify themes, trends and actions needed to improve services. An action plan was created from the outcomes of the recent group meeting, and this was due to be reviewed in July 2026. For example, the group identified the service needed to ensure patients were always given ‘next step’ cards to ensure patients had the information they needed following their procedures.

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 were committed to continually learning and improving services. There were processes for learning when things went wrong or to learn from good practice, either locally or nationally. For example, learning was shared with the service from other Spire organisations. Within the service, staff took part in Friday Feedback sessions which helped with learning from incidents and discussing feedback on the service. Staff told us they received weekly emails with updates and information.

Some staff and leaders we spoke with had a good understanding of quality improvement methods and had been involved in this area of work. This included using patient feedback data to target specific areas within the service that could improve. The imaging manager regularly reviewed the data and was able to have a good understanding of performance.

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 improvement and we heard about the Driving Clinical Excellence programme which had been available to staff. Staff reported positive experiences and we heard how this had supported their professional development.

Staff and leaders were committed to good quality care that centred on the patient experience. Teams worked together to find a solution to improve the care and treatment people received. For example, the service produced a new patient information leaflet for patients to be given when booking their appointment to improve communication around charges. We also heard how a step being used for an x-ray machine was identified as being too small, causing difficulty for some patients. This was improved with a new step and handrails which helped patients feel safer when having the procedure.