St Anthony's 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 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 clear strategic direction that aligned with both local and organisational priorities. Staff and leaders were aware of the Spire Healthcare strategy, Making a Positive Difference in People’s Lives Through Outstanding Personalised Care (2025-2027), and the hospital’s local objectives for 2026. These included improving patient safety, developing the workforce, enhancing patient, colleague and consultant experiences, and promoting continuous quality improvement. Despite past leadership issues and the impact on the overall organisational culture. Staff understood the service vision and objectives and demonstrated a shared commitment to delivering safe, high-quality care. Leaders provided assurances that they had worked to promote a positive and supportive culture, and staff felt able to contribute to the ongoing development of the service.

Leaders described how the hospital’s values and improvement priorities were translated into action through local plans that identified objectives, timescales and individual responsibilities. These strategies helped shape service development and informed the hospital’s day-to-day work.

Staff and leaders spoke positively about the hospital culture, frequently describing a strong "family feel" and shared commitment to delivering high-quality care. Leaders recognised that the hospital was continuing to integrate with the wider Spire organisation and align local governance arrangements with organisational frameworks. They told us they were working to promote an open and inclusive culture, particularly following previous periods where staff engagement had been less effective. Overall, current leaders were compassionate, visible and supportive. They worked to promote an inclusive culture, encouraged staff development and maintained effective oversight of services during a period of leadership.

Staff told us they felt supported to develop their skills, undertake training and assume additional responsibilities. Leaders listened to staff views and encouraged them to provide feedback and suggestions for improvement. We observed opportunities for staff to share feedback and contribute ideas about service development. Such as staff surveys, anonymous suggestion boxes and a recently launched staff-led staff forum.

We saw staff working collaboratively across professional groups to deliver coordinated patient care. Staff spoke positively about current and future service developments, including plans to expand services for children and young people. Leaders also described opportunities for staff to work collaboratively across the wider Spire organisation, supporting shared learning, innovation and career development.

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 hospital's senior leadership team was based on site and was visible, approachable and accessible to staff. The hospital had experienced leadership instability, with 5 hospital directors in post over the previous 18 months. Despite this, the leadership maintained visibility through regular departmental visits and an open-door approach, promoting an inclusive culture, supporting staff development and maintaining oversight of services during this period of leadership transition. Arrangements were in place to ensure managerial support was available to OPD staff during OPD opening hours.

Staff spoke positively about the current leadership team and described leaders as open and supportive. They were working to promote a culture that recognised and respected the individual needs and preferences of both patients and staff. Whilst some leaders described challenges associated with previous leadership arrangements and periods of leadership change, they told us the current leadership team had improved engagement and visibility.

In the absence of a substantive Head of OPD, day-to-day leadership of the OPD and Pre-Operative Assessment (POA) services had been provided by clinical leads, supported by another Head of Department and a member of the senior leadership team. Staff told us these arrangements had provided continuity and support. Daily departmental meetings enabled leaders to discuss staffing, patient care, operational issues, learning and service developments. These meetings were also used to recognise staff achievements and promote teamwork.

Leaders demonstrated a commitment to workforce development. They described talent mapping and succession planning processes designed to identify and support future leaders and provide development opportunities for staff interested in management roles.

Staff told us they felt well supported by the OPD leadership team and were looking forward to the appointment of a substantive Head of Department, who had recently joined the organisation and would provide additional clinical and managerial leadership.

The hospital also recognised and celebrated staff contributions through a range of initiatives, including staff awards, recognition programmes and social events.

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 hospital's senior leadership team was based on site and was visible, approachable and accessible to staff. The hospital had experienced leadership instability, with 5 hospital directors in post over the previous 18 months. Despite this, the leadership maintained visibility through regular departmental visits and an open-door approach, promoting an inclusive culture, supporting staff development and maintaining oversight of services during this period of leadership transition. Arrangements were in place to ensure managerial support was available to OPD staff during OPD opening hours.

Staff spoke positively about the current leadership team and described leaders as open and supportive. They were working to promote a culture that recognised and respected the individual needs and preferences of both patients and staff. Whilst some leaders described challenges associated with previous leadership arrangements and periods of leadership change, they told us the current leadership team had improved engagement and visibility.

In the absence of a substantive Head of OPD, day-to-day leadership of the OPD and Pre-Operative Assessment (POA) services had been provided by clinical leads, supported by another Head of Department and a member of the senior leadership team. Staff told us these arrangements had provided continuity and support. Daily departmental meetings enabled leaders to discuss staffing, patient care, operational issues, learning and service developments. These meetings were also used to recognise staff achievements and promote teamwork.

Leaders demonstrated a commitment to workforce development. They described talent mapping and succession planning processes designed to identify and support future leaders and provide development opportunities for staff interested in management roles.

Staff told us they felt well supported by the OPD leadership team and were looking forward to the appointment of a substantive Head of Department, who had recently joined the organisation and would provide additional clinical and managerial leadership.

The hospital also recognised and celebrated staff contributions through a range of initiatives, including staff awards, recognition programmes and social events.

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 service had policies and processes in place to promote equality, diversity and inclusion. These included an Equality, Diversity and Inclusion (EDI) policy, mandatory EDI training and access to an EDI Champion who provided support and promoted inclusive working practices.

Training records showed all OPD staff had completed EDI training. Staff demonstrated an awareness of the importance of treating colleagues and patients fairly and with respect.

The provider supported flexible working arrangements where possible. Staff told us leaders were supportive of changes to working patterns to help balance family responsibilities and other personal commitments.

Staff described a positive and inclusive culture within both the OPD and wider hospital. They told us they felt respected, valued and treated fairly. Staff described strong working relationships and a sense of belonging within the organisation.

The hospital promoted inclusion and staff engagement through a range of activities, including charity events, departmental and hospital-wide social activities, and staff recognition schemes, including awards. These initiatives helped foster positive teamwork and a sense of community.

We observed a culturally diverse workforce within the OPD and wider hospital. Overall, the service demonstrated a commitment to equality, diversity and inclusion and had systems in place to support a fair and inclusive working environment.

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. Although some governance processes and workforce development arrangements required further embedding following a prolonged leadership vacancy.

The service had clear governance arrangements and lines of accountability to support the safe and effective delivery of OPD services. A newly appointed Head of OPD had commenced employment during the week of our assessment. Prior to this, the absence of a substantive departmental lead, the clinical leads had required additional support from senior leaders for the running of services, which had affected some staff development processes, including continuity of appraisals and unification of some departmental systems. For example, we observed minor differences in the information sharing systems observed within the OPD and POA, such as the use of the quality boards, which meant there was not a department-wide unified approach.

Structured governance and management systems enabled leaders to oversee service safety, improvements and quality. These included daily departmental and hospital-wide huddles, weekly senior leadership meetings, bi-monthly heads of department meetings that review governance and risk, and quarterly Safety, Quality and Risk Committee meetings. These forums were used to review patient safety, staffing, operational performance, incidents, risks and service developments.

A medical advisory committee (MAC), supported by senior leaders, provided oversight of practising privileges and clinical governance. The committee reviewed applications for practising privileges, assessed the suitability of new consultants, monitored individual doctors' clinical outcomes and practice, and provided advice on clinical quality and safety matters. Processes were in place to manage any performance concerns, including the review or removal of practising privileges and referral to relevant professional bodies where required.

The service operated a comprehensive programme of monthly, quarterly, and annual audits. Audit compliance was monitored through departmental dashboards, which generated alerts when activities were overdue. Leaders used audit findings to monitor performance, identify areas for improvement and provide assurance through governance processes.

Managers and staff understood their roles, responsibilities and accountability. Risks were identified, monitored and escalated through departmental and hospital risk registers. We reviewed risks relating to the OPD and saw that appropriate action plans and mitigating measures were in place. Staff reported incidents appropriately, and leaders used incident investigations to identify learning and improve practice.

The service demonstrated effective oversight of quality and safety. We saw quality and safety information clearly displayed within the OPD, including audit performance, staffing information and incident themes. However, equivalent governance information was not displayed as consistently within the POA area, reducing the visibility of performance information across the wider service.

The hospital used the Patient Safety Incident Response Framework (PSIRF) to support learning from incidents and identify themes, trends and opportunities for improvement. Patient Reported Outcome Measures (PROMs) and other performance information were used to monitor the effectiveness of care and help support service development.

Processes were in place to ensure compliance with external reporting requirements. Leaders submitted information to the Private Healthcare Information Network (PHIN), Care Quality Commission and other relevant bodies. Mortality and morbidity reviews were undertaken through the Spire group’s central governance arrangements rather than locally. Although information regarding deaths reviewed through the provider's mortality review process was shared and we were assured that all reported deaths underwent a local governance review, including discussion at the local Rapid Response meetings.

Patient information was managed securely. Paper records remained in use, evidence submitted showed this had not resulted in confidentiality concerns or unavailable records. We found consultant documentation audit compliance was 92%, and there had been no reported incidents involving missing patient records. Whilst some elements of documentation were being transferred to electronic systems, there were no improvement plans for a fully electronic OPD record system at the time of this assessment.

Staff had access to the equipment, technology, policies and information required to undertake their roles. Business continuity plans were in place to support the management of service disruption, including fire, flooding and power outages.

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.

The service demonstrated effective partnership working with a range of internal and external partners such as healthcare providers, commissioners, safeguarding agencies and community stakeholders to support coordinated care and positive outcomes for patients.

As part of the wider Spire Healthcare Group, the hospital benefited from shared governance arrangements, operational support, learning opportunities and access to education and development resources.

The hospital maintained formal partnerships with external providers where required. For example, pathology services were supplemented through contractual arrangements with an external provider, and policies with clear protocols were in place to support transfers to local NHS hospitals when patients required additional care.

POA staff told us they worked closely with GPs and other healthcare professionals to support smooth patient pathways, particularly for patients accessing elective surgery through NHS-funded pathways. NHS patients were treated by consultants working within the hospital, many of whom also practised within local NHS services, supporting continuity of care and professional collaboration.

The service had established relationships with external safeguarding partners, including the local children's safeguarding partnership and local authority safeguarding teams. Staff described positive working relationships with these organisations, which supported effective information sharing and safeguarding oversight.

Leaders also maintained regular engagement with NHS commissioners and worked with NHS partner organisations through contractual arrangements. Leaders told us the hospital engaged with local healthcare professionals to share information, promote services and strengthen professional networks within the community.

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 and effective practice.

Leaders and staff demonstrated a commitment to learning, innovation and continuous improvement. Service developments, staff development opportunities and investment in new ways of working supported the ongoing delivery of high-quality care.

Staff told us they were encouraged to develop their knowledge, skills and competencies, and were supported to take on additional responsibilities. Clinical leads described how they had developed leadership and management skills whilst providing support across both the OPD and POA services during a prolonged vacancy in the Head of OPD role.

Staff had opportunities to develop specialist skills relevant to their roles. Competency frameworks and localised teaching sessions supported learning and development, and staff described sharing knowledge and learning from uncommon conditions and complex patient presentations to improve care delivery. A staff member told us they had gained a range of new competencies and responsibilities through their work within the OPD.

The service demonstrated a commitment to service improvement. Since our previous inspection, the OPD had expanded its facilities, including the development of a dedicated minor operations suite providing procedures such as carpal tunnel surgery under local anaesthetic.

Leaders described several initiatives designed to improve patient pathways and experience. These included the introduction of a telephone risk-assessment clinic for patients aged 16 to 17 years to support pathway decisions and reduce unnecessary contacts, as well as the development of a "one-stop assessment" approach to improve the pre-operative assessment journey. A dedicated staff area had also been created to support staff wellbeing and performance.

Plans were in place to further develop services for children and young people, including the introduction of day surgery pathways. Leaders also described ambitions to achieve additional external accreditations to support service quality and continuous improvement.

The hospital showed innovation through the introduction of a robotic surgery programme in 2025. We were told how the programme had expanded its scope beyond its initial remit, demonstrating the organisation's development of new treatment options and enhanced clinical services.