St Anthony's 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

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 patients 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 Good. At this assessment the rating has remained Good.

This meant patient’s needs were met through good organisation and delivery. 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 patients 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.

The hospital strategy was to raise awareness of the hospital locally, enhance customer, colleague and consultant experience, develop minor operations, and improve patient retentions. It also focused on growing complex surgery volumes, increase speed of access and expand robotic assisted surgery and NHS growth.

The hospital and service 2026 clinical strategy included patient safety, developing workforce, celebrating excellence and enhancing professional pride, building a culture of continuous quality improvement, deliver outstanding care, and multidisciplinary team working.

Staff we spoke with were aware of the service vision and goals and had awareness of how their work contributed to achieving targets.

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.

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. For example, the staff ‘best awards’ were introduced in November 2025 to celebrate staff bravery, excellence, safety, and ‘team player.

The reason for our inspection was partly in response to significant cultural concerns. However, we found that this was being effectively addressed by leaders. To further improve the culture of the service and hospital, senior leaders carried out some cultural work between November 2025 and May 2026. This included introducing LGBTQ+ champions, equality diversity and inclusion (EDI) champions, fund raising events throughout the year, townhall staff session with senior management for staff to share their thoughts and opinions. Leaders also held bimonthly colleague forum known as the ‘Voice’, which was a protected time for staff with free lunch for staff to air their views.

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 patients 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.

The hospital strategy was to raise awareness of the hospital locally, enhance customer, colleague and consultant experience, develop minor operations, and improve patient retentions. It also focused on growing complex surgery volumes, increase speed of access and expand robotic assisted surgery and NHS growth.

The hospital and service 2026 clinical strategy included patient safety, developing workforce, celebrating excellence and enhancing professional pride, building a culture of continuous quality improvement, deliver outstanding care, and multidisciplinary team working.

Staff we spoke with were aware of the service vision and goals and had awareness of how their work contributed to achieving targets.

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.

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. For example, the staff ‘best awards’ were introduced in November 2025 to celebrate staff bravery, excellence, safety, and ‘team player.

The reason for our inspection was partly in response to significant cultural concerns. However, we found that this was being effectively addressed by leaders. To further improve the culture of the service and hospital, senior leaders carried out some cultural work between November 2025 and May 2026. This included introducing LGBTQ+ champions, equality diversity and inclusion (EDI) champions, fund raising events throughout the year, townhall staff session with senior management for staff to share their thoughts and opinions. Leaders also held bimonthly colleague forum known as the ‘Voice’, which was a protected time for staff with free lunch for staff to air their views.

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

Staff and leaders promoted a culture of openness, honesty and transparency. Staff told us they felt able to raise concerns and share ideas and were confident they would be supported to do so without fear of detriment.

Resident Medical Officers (RMOs) described positive working relationships with consultants and told us they felt able to raise concerns. There were established processes to support RMOs to escalate issues, and leaders described that these were reviewed and acted upon. When concerns were raised by staff, leaders investigated sensitively and confidentially. Serious concerns raised by whistleblowers were escalated to both the local and provider-level leadership teams.

Risk registers and management reports contained analysis of concerns over time and associated action plans.

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. There were policies to support the complaints process.

Freedom to Speak Up arrangements (FTSU) were in place. The service had designated FTSU Guardians, and leaders told us that speak-up processes were promoted through mandatory training, emails and staff meetings and was supported by a FTSU policy.

From June 2025 to June 2026, the service received 4 freedom to speak up concerns relating to theatre staff concerning communication and staff behaviours.

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

Leaders acted to improve where there were any disparities in the experience of staff with protected equality characteristics in line with their equality and inclusion strategy.

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 new roles, take part in improvement projects 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 and caring responsibilities were offered reasonable adjustments such as flexible working arrangements to support them to carry out their roles well.

The hospital supported various staff equality networks and staff we spoke with were aware of the available staff networks. This included LGBTQ+ and Race Equality networks. The hospital had 5 mental health first aiders. The service had organised several events to celebrate EDI which include celebrating the race equality week, pride month, International Women’s Day, black history month and speak up months.

The service did not always have clear governance and accountability arrangements to ensure risks were shared with appropriate people in a timely manner. However, staff and leaders understood their roles and responsibilities and used information about risks, performance and outcomes to support decision-making.

The service reported a never event to CQC a day before our onsite assessment, this was 6 weeks after the incident occurred. The provider did not notify CQC without delay, as required. We also noted that it took the service 7 days to complete and submit a patient safety incident report to their central governance team to review and classify the incident. This delay prevented CQC from receiving timely information to assess potential risks, monitor the provider's response, and exercise its regulatory oversight effectively. This is a breach of the provider's statutory duty to submit notifications without delay in accordance with the relevant notification requirements. These delays indicated weaknesses in governance processes for escalating and reporting serious incidents and did not provide assurance that never events were consistently identified, escalated and reported in line with national guidance. The delays also did not provide assurance that leaders had effective oversight of incident reporting processes or that statutory notification requirements were consistently met.

The service had processes to monitor recruitment records and ensure required checks remained up to date. Our review of recruitment and practising privileges records found that most required documentation, including DBS checks where required, were complete and in date. However, in theatres, we found gaps in some surgical first assistants file records. These included missing current competency certificates, professional indemnity arrangements or other workforce assurance records, including evidence of occupational health checks and clearances as required.

As a result, the service was unable to provide immediate assurance that all required credentialing and workforce governance records were complete and up to date for staff working in theatres.

Following the inspection, the provider submitted evidence demonstrating that it held records of occupational health checks, professional indemnity insurance and professional registration for surgical first assistants. However, competency certificates for 2 of the 10 staff were not available and the provider advised it was awaiting copies. This meant we could not be fully assured that all required competency records were maintained and readily available.

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. However, data or notifications were not consistently submitted to external organisations in a prompt manner as required.

The service operated governance processes through various committees and on-site activities. Governance meetings included hospital local governance meetings, exception reports, quarterly and national governance meetings, operational safety quality and risk committees (SQR) and clinical governance and safety committee.

There was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the provider. Performance data was analysed and compared within the provider organisation and where improvements were needed at the location level, action plans were developed to make this happen.

A range of data and information was collected and reviewed through these governance meetings, including clinical indicators, incidents, risks, and quality metrics. This information was discussed at governance meetings, used to benchmark performance across the provider’s hospitals, and informed the development and monitoring of action plans where improvements were needed. Leaders made sure that accurate information was discussed and shared with key staff. Key information on governance was shared with staff through various medium such as newsletters, feedback Fridays bulletin, handovers, daily huddles, team meetings, emails, displayed information boards and new colleague forums.

There was a medical advisory committee (MAC) led by a chair and supported by the service leadership, who were responsible for approving practising privileges, reviewing and advising on suitability of new outcomes, 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 service had 377 doctors with practising privileges and in the last 12 months prior to the assessment had 20 practising privileges withdrawn.

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.

Risks were clearly identified and recorded on a formal risk log, which was used to monitor risks, oversee mitigating actions and track progress towards resolution. The hospital risk register showed that risks were regularly reviewed and had actions in place to manage or reduce these risks. The risk register included a broad range of risks such as equipment, aging pipework, mobile X-ray machines nearing end of life, pager and bleep system, new e-learning system, risk of lost to follow up due to manual entry, and risk of falls of engineers and contractors during refurbishment. 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, which included major incident plans such as fire, flood and power failure.

The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

We reviewed several service level and provider policies and found majority of these were up to date and readily available to staff. However, the service had a few policies relating to human resources which were overdue and being reviewed or review date extended at the time of assessment. 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 service worked with NHS services, a local hospice, and community providers to support continuity of care across different patient pathways. This involved the coordination of referrals, sharing relevant clinical information, and ensuring appropriate pre-operative assessment and post-operative follow-up. Staff engaged with specialist teams, including wellbeing and mental health support services, to provide additional support where required.

Some senior leaders were part of regional networks to understand the needs of the community and the providers’ ambitions.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. For example, the service supported local charities and held tri-annual patient forums. The director of clinical service attended the local safeguarding adults and children board and partnership meetings to ensure strong external partnership working with local safeguarding priorities, understand emerging risk, shared learning and best practice.

The hospital had service level agreements with a range of partners, including local NHS trusts, ambulance services and critical care networks, to support safe transfers, diagnostics and emergency care.

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.

Staff were committed to continually learning and improving services.

There were processes in place to identify and share learning from incidents and good practice at local, organisational and national levels. Several staff we spoke with had a good understanding of quality improvement methods and had been trained in this area of work. 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. We were told about some of the areas of work which they had focused on, which included theatre kit hire, discharge planning and robotic assisted 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 and implement changes.

The service had implemented and invested in robotic technology to support assisted surgery in gynaecology, urology, thoracic and general surgery. At the time of the assessment, the service had completed 113 robotic assisted surgery (RAS). Staff were proud of the implementation and governance around the RAS.

The physiotherapist team delivered a targeted quality improvement (QI) initiative in 2025/2026 to enhance patient outcomes and improve service efficiency. The key achievement included reduced length of stay for hips and knees surgery from 2.52 days to 1.62 days, which was now aligned to national performance of 1.6 days. The QI initiative also improved patient flow and bed utilisation, supported earlier mobilisation and discharge, and strengthened multidisciplinary working. Staff had also undertaken QI projects around post-operative rehabilitation pathway redesign, pelvic health service expansion for gynaecology which have improved patient access, experience and outcomes.

The service introduced follow-up emails after pre-operative assessment to ensure patients had the information needed before admission, helping to minimise delays and improve patient experience. Pre-discharge patient education was also provided to help reduce readmissions

The deputy theatre manager received a hospital award and was recognised for delivering outstanding patient care in the service. The patient experience lead and other nurses had also won a hospital colleagues awards for their dedication to patient care and experience.