Woodthorpe 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 people 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.

However, there was some confusion from staff concerning the role of The Freedom to Speak up Guardian.

This was the first assessment of this assessment service group. This key question has been rated good. This meant there was good service leadership and governance. Leaders and the culture they created assured the delivery of high-quality care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 3

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 endoscopy team was part of the surgical division within the service. Leaders could talk to us about the clear vision they had for the service and the ways in which they wanted to expand and improve services. Leaders told us they listened to staff and there were regular team meetings and an open-door policy. Leaders told us staff were involved in decision making when the service was making changes. It was evident that leaders knew staff and spent time in the different areas of the hospital.

Staff we spoke to were positive about prioritising safe, high quality, compassionate care. Staff told us they felt leaders understood the services being provided and the challenges to providing high quality care. Staff told us there was a positive and open culture and they could raise any concerns they had.

Both leaders and staff had an understanding on equity, equality and human rights, diversity and inclusion. This was made clear throughout their work.

Score: 3

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.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance there was a defined leadership and governance structure with clinical, nursing and managerial lead roles.

Leaders across all the different areas of the service were competent in and understood their roles. The service had an embedded recruitment process that ensure leaders met Fit and Proper Persons (FPPR) guidelines.

Staff told us that leaders at a hospital level and at department level were visible, accessible and supportive. Leaders told us that they had an open-door policy for staff to come and get support.

Score: 2

The service fostered a positive culture where staff felt they could speak up and their voice would be heard. However, processes in place to enable staff to speak up were not robust.

The service did not have any Freedom to speak up Guardians (FTSUG) on site and did not follow the FTSUG process. Instead, the service had a Speaking up Safety code. This is a policy that encourages and enables individuals, in healthcare settings, to voice concerns about safety issues without fear of reprisal. It emphasises a culture where speaking up is seen as a positive action that contributes to patient and worker safety and improved care.

There was a process for staff to follow if they wanted to use the Speaking up Safety code, however staff were not knowledgeable about this or who to contact. At the first site visit, there were no posters on site to provide information about the freedom to speak up process however the corporate Freedom to Speak up lead was mentioned on a poster of leaders. Between the two site visits, a poster had been added to which explained to the process for staff to follow.

During our assessment, we spoke to staff to ask about who they would speak to if they had a concern. Staff told us of two members of staff on site who were the Freedom to Speak up Guardians. However, when we spoke with the two named members of staff, both stated they were not Freedom to Speak up Guardians but were instead mental health first aiders.

We spoke with the corporate person involved with the Speaking up Safety code after our assessment. They agreed that staff were 'confused' about the process, with staff referring to mental health first aiders as FTSUG's and would ensure the correct information was provided to staff.

Speaking up for safety, was part of mandatory training for all staff. At the time of our assessment the training compliance was 100% for staff against the hospital target of 90%.

Staff who we spoke to told us the culture within the service supported them to speak up and report any issues or concerns to their managers. Staff told us they felt confident to escalate matters if they felt their concerns were not being responded to.

We requested data after our assessment on the on the number of Freedom to Speak up enquires received with actions, outcomes, themes and trends for the period April 2024 to April 2025. However, we did not receive any information. The service told us there had been no Freedom to Speak up enquires during this time.

Score: 3

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

Training was available for all staff in equality, human rights and workplace diversity. This was a mandatory requirement. We saw the compliance rate of 100% for staff. The service had a policy in place for equity, diversity and inclusion.

Staff and leaders told us and we saw that there was a diverse workforce with a positive sense of inclusion. The service made workplace adjustments where necessary. The service had posters, information and awareness sessions shared with all staff covering a wide range of events.

The service carried out activities to improve workforce equality, diversity and inclusion. The service had a faith room on site, which was designed by staff. The service was part of the Workfit scheme which provided employment opportunities for people with Down’s syndrome.

Score: 3

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 the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Endoscopy care sat in the theatres subcommittee within the overall hospital governance structure. This group fed into the overall hospital governance structure and would feed into hospital wide groups such as patient safety, clinical governance and infection prevention and control. The service had an Endoscopy lead in place.

The service had regular team meetings. The meetings had a clear agenda in place with accreditations, training, safety, equipment, incidents, audits and new guidance were discussed. Meeting minutes were shared with staff who could not attend.

The service had its own risks within the theatres risk register. All the risks had individual risk scores in place, and they were marked as open, closed on ongoing. Each risk had a named owner and actions that had been or were being done to manage and reduce the risk to patients.

The service had a performance dashboard in place which aligned with theatres which could look at monthly performance including areas such as patient safety, patient experience, clinical effectiveness and training. The most recent data provided by the trust was positive, with all scored areas being green.

Score: 3

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

The service operated as part of a network of Ramsay hospitals, there were regular meetings between the different hospitals across the country. They utilised these meetings to share information and learning that has come from either incidents or complaints.

Leaders told us they had a positive relationship with both local GPs and local hospitals. The service supported the GPs alliance. The service had transfer protocols in place with the local NHS hospital.

Score: 3

The service focused on continuous learning, innovation and improvement across the organisation. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe and effective practice.

The service demonstrated that staff engaged in continuous learning and improvement. For example, all endoscopy staff had attended a 360 Reprocessing cycle session specific to endoscopy and aseptic non touch technique (ANTT) training.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance the leadership team and workforce engaged in innovation, sharing quality improvements, and research other endoscopy services.