Spire South Bank 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

Leaders and staff knew the service’s local vision, aims and objectives and understood how their service aligned with this. There was a culture based on speaking up, listening, learning and trust.

Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment.

Staff understood their roles and responsibilities.

Leaders had sound oversight of the quality of service being delivered through effective governance and risk management systems.

Staff with protected characteristics felt supported.

There was a culture of continuous improvement with staff able to contribute ideas through a quality improvement programme.

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.

This is the first assessment for this service. This key question has been rated good. This meant patient’s needs were met through good organisation and delivery.

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 patient 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 spoken with had awareness of how their work contributed to achieving targets.

The outpatient department had a positive, inclusive and patient-centered culture supported by clear organisational values and effective leadership. Staff understood the service's vision and objectives and demonstrated a shared commitment to delivering safe, high-quality and compassionate care.

The department's objectives aligned with the wider organisational strategy and focused on providing exceptional patient experience, clinical excellence and continuous quality improvement. Staff we spoke with understood how their individual roles contributed to achieving these aims and were able to describe the behaviours and values expected within the service.

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. Staff felt motivated about the future and planned changes for the service. 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 within the outpatient department demonstrated the skills, experience and behaviours required to deliver safe, effective and compassionate care. Leaders were visible, approachable and actively engaged with staff, patients and wider teams to support high standards of service delivery.

The outpatient service had clear leadership arrangements, with defined roles and responsibilities. Leaders understood the needs and challenges of the service and used their knowledge of outpatient care, patient experience and operational performance to drive improvement. They worked collaboratively with consultants, nursing teams, administrative staff and corporate colleagues to ensure care was coordinated and responsive to patient needs.

Leaders promoted a compassionate and inclusive culture where staff felt respected, valued and supported. Staff told us managers were approachable and listened to their views. They felt confident raising concerns, reporting incidents and suggesting improvements, knowing these would be considered fairly and without fear of blame.

Leaders demonstrated a commitment to equality, diversity and inclusion. They ensured that patients and staff were treated with dignity, respect and fairness and that individual needs were recognised. Reasonable adjustments were considered for both patients and staff where required, and leaders promoted an environment where diversity of background, experience and opinion was valued.

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

The outpatient department promoted an open and transparent culture where staff felt able to raise concerns, provide feedback and suggest improvements without fear of negative consequences. Leaders recognised that listening to staff was essential to maintaining patient safety, improving quality and supporting a positive working environment.

The service had Freedom to Speak up Guardians and ambassadors within the hospital. Staff were confident that any issues raised would be listened to and addressed.

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.

Leaders demonstrated behaviours consistent with an open and learning culture. They welcomed challenge, responded constructively to feedback and ensured staff felt valued and respected. This supported a positive environment where staff were empowered to speak up and contribute to improving outpatient services.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

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

The service promoted equality, diversity and inclusion (EDI) within the workforce and fostered a culture where staff were treated fairly, respectfully and with dignity. Leaders recognised the importance of having a diverse workforce and ensured that equality and inclusion were considered in recruitment, development, support and retention of staff.

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 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. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

Staff with disabilities were offered reasonable adjustments to support them to carry out their roles well. For example, the department considered the needs of staff with protected characteristics and made reasonable adjustments where required. Staff had access to appropriate support, including occupational health advice and workplace adjustments, to enable them to perform their roles effectively.

The service had processes in place to support fair recruitment and selection practices, ensuring appointments were based on skills, experience and suitability for the role. Staff had access to opportunities for learning, development and career progression, with performance reviews and appraisals used to identify individual training needs and support professional growth.

Mandatory training records demonstrated that staff completed equality, diversity and inclusion training. Staff understood their responsibilities to provide inclusive care to patients and to maintain a respectful working environment for colleagues. Leaders monitored compliance with training requirements and addressed any gaps appropriately.

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 outpatient department had effective governance and management systems in place to support the delivery of safe, high-quality and sustainable services. There were clear lines of accountability and defined roles and responsibilities across the outpatient service. Leaders worked collaboratively with clinical and operational teams to ensure that risks, performance issues and opportunities for improvement were identified, reviewed and acted upon. Staff understood their responsibilities and how their roles contributed to maintaining safe and effective patient care.

The service reported information to the Private Healthcare Information Network (PHIN). Intelligence reports were reviewed by service leaders. These reports contained data on PHIN’s existing performance measures, including; patient activity volumes, length of stay, never events, Patient Reported Outcome Measures (PROMs), infections and also data submission levels. The information showed that leaders had oversight of key performance and quality indicators and used this data to monitor the safety, effectiveness and quality of services provided. PHIN data demonstrated the service was actively submitting required information and using benchmarking information to understand performance against wider independent healthcare providers.

There was a medical advisory committee 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. The Medical Advisory Committee (MAC) provided clinical oversight and assurance regarding medical practice within the hospital. The committee reviewed matters including consultant appointments and performance, clinical governance, significant incidents, complaints, clinical audit outcomes, patient safety concerns and areas requiring improvement. The MAC provided a forum for consultants and leaders to discuss clinical risks, share learning and promote consistent standards of care across outpatient services.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared through regular outpatient team meetings, clinical governance meetings, safety huddles and departmental briefings. Key updates relating to patient safety, incidents, complaints, audit findings, risks, performance indicators and service changes were discussed with relevant staff to ensure they understood current priorities and actions required. Minutes and action logs were maintained to support accountability and ensure important information was followed up. Staff told us they felt well informed and had opportunities to ask questions, provide feedback and contribute to service improvements.

The department maintained a comprehensive risk management process. Risks were identified, assessed and recorded on the organisational risk register, with actions, responsible leads and review dates documented. The risk register was regularly reviewed through governance processes to ensure risks were actively managed, mitigations were effective and emerging concerns were escalated appropriately.

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

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

The outpatient department worked collaboratively with internal and external partners to support coordinated, person-centred care and improve outcomes for patients. Leaders recognised the importance of effective partnerships in delivering safe, responsive and sustainable outpatient services.

The service worked closely with consultants, multidisciplinary teams, diagnostic services, primary care providers and other healthcare professionals to ensure patients experienced joined-up care. Communication pathways supported timely sharing of relevant clinical information, referral management and continuity of care between services.

Leaders maintained effective relationships with referring clinicians, including GPs and external healthcare providers. Clinic letters, investigation results and treatment recommendations were communicated appropriately to support ongoing patient management. Where patients required onward referral or additional support, staff worked with relevant services to facilitate appropriate pathways and minimise delays.

The outpatient department engaged with patients and communities through feedback mechanisms including patient surveys, Friends and Family Test responses, compliments and complaints. Patient views were used to understand experiences, identify areas for improvement and inform changes to service delivery. Leaders considered the needs of the local population when planning and developing services.

The service worked collaboratively across the hospital to support safe patient pathways. Outpatient teams liaised with theatres, diagnostics, inpatient services, pharmacy and administrative teams to coordinate care and ensure patients received appropriate support throughout their journey.

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 patient. Staff actively contribute to safe, effective practice and research.

The outpatient department demonstrated a commitment to continuous learning, improvement and innovation. Leaders promoted a culture where staff were encouraged to identify opportunities for improvement, learn from experience and introduce changes that enhanced patient safety, quality and patient experience.

The service used a range of information sources to identify areas for improvement, including clinical audits, incidents, complaints, patient feedback, Friends and Family Test results, staff surveys, performance data and quality indicators. Findings were reviewed through governance processes, and actions were developed, monitored and evaluated to ensure improvements were effective and sustained.

The department used patient and staff feedback to drive service improvements. For example, feedback regarding communication and the patient journey informed changes to appointment information, processes and staff communication methods. The impact of these changes was monitored through ongoing feedback and service reviews.

Leaders supported innovation and encouraged staff to suggest new ways of working. Improvements included reviewing outpatient pathways, streamlining processes, improving coordination between teams and using digital solutions where appropriate to enhance communication and patient access. Changes were assessed to ensure they maintained patient safety and improved outcomes.

Staff told us they were encouraged to share ideas and participate in improvement projects. They felt their suggestions were listened to and that changes were communicated effectively. Leaders recognised staff contributions and supported professional development through training, appraisal and opportunities to enhance skills.

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 improving the outpatient patient journey, reducing delays in clinic flow, improving communication with patients before and after appointments, and enhancing the coordination of care between clinical and administrative teams.