Spire Wellesley 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 reduced health inequalities. At our last assessment we rated this key question as outstanding. At this assessment the rating has changed to 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 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 hospital had a vision for what it wanted to achieve and a strategy to turn it into action.

The 2025/26 Spire Wellesley Hospital Strategy was developed in line with Spire Group’s ‘five pillars’ which have become Spire Wellesley Hospital’s strategic priorities: Make it count, listen up, be a change champion, inspire kindness and respond fast.  

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 reflected 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.  

Leaders recognised and celebrated team and individual achievements and regularly thanked staff for their contributions, reinforcing a positive culture and supporting staff engagement in achieving the organisation's strategic objectives.

Leaders promoted an open and inclusive culture where patients, families, carers and staff could raise concerns without fear. This reflected the priorities of Listen Up and Inspire Kindness and supported continuous learning and improvement. 

Staff understood the organisation's vision and strategic priorities and demonstrated these through their day-to-day practice. Staff remained focused on meeting patients' needs, promoted equality and diversity, and delivered person-centred care in line with the organisation's commitment to patient experience and quality. 

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 understood the challenges and opportunities in which they delivered care, treatment and supported 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 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 service had clear lines of accountability from ward and departmental leaders through to the director of clinical services, providing oversight of service delivery and quality.

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. 

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.

The hospital had a raising concerns policy and a range of mechanisms for staff to speak up. Staff could raise concerns directly with managers, submit quality improvement suggestions, or report risks, wrongdoing or poor practice through the Freedom to Speak Up (FTSU) process. The hospital had an FTSU Guardian supported by FTSU Ambassadors. Information about how to raise concerns and access support was clearly displayed throughout the hospital. 

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas. All staff that we spoke to 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 of detriment.

We reviewed evidence relating to Freedom to Speak Up (FTSU) concerns and the actions taken in response. Between July 2025 and July 2026, four concerns were raised across the hospital.

Leaders investigated concerns sensitively and confidentially and took appropriate action where required. The local senior management team received regular FTSU reports, which provided oversight of concerns raised and assurance regarding actions taken and themes identified.

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 support timely resolution. 

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.

Staff 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.

Leaders took action to identify and address 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 developmental roles.  

Leaders 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.  

Staff had access to support services including occupational health advisory services. This provided staff and managers with expert advice and helped ensure reasonable adjustments were identified and implements to support staff with disabilities in carrying out their roles well.

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

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.

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

Leaders had 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 meeting and associated departmental meetings e.g. theatres, ward. There was a range of information collected, monitored and communicated internally at the relevant committee meetings which was fed upwards to the corporate committee when relevant. Leaders analysed performance indicator data and where improvements were needed, effective action plans were developed.  

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. Leaders tracked performance, and concerns followed a formalised processes, including sharing relevant information with professional bodies as required.

Staff at all levels understood their roles and responsibilities and were clear about their accountabilities. Job descriptions clearly set out expectations and responsibilities. Staff with lead roles for audit and quality monitoring understood their responsibilities and carried out these duties effectively.

Leaders kept information systems integrated and secure. They submitted data and notifications consistently to external organisations as required.  

All staff handled patient identifiable information correctly.

Leaders clearly identified risks and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution.  

Leaders contributed to decision-making to help improve sustainability and improve quality of care.

Leaders used audit processes and their outcomes to assess and maximise the quality of services. 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.

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 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, the hospital was represented at monthly Integrated Care Board (ICB) meetings to share quality and governance data with local NHS and ICB 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 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. They had processes for learning when things went wrong or of good practice, either locally or nationally. Staff used a flash alert email if there had been a major incident or never event.

Staff were involved in quality improvement activities, including a recently held organisational quality improvement week that supported learning and service improvement.

Several leadership 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. 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.

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 room was fully adapted for wheelchair users after patient feedback.