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 previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. This is the first assessment for this service. This key question has been rated good. This means people’s needs were met through good organisation and delivery.

There was a shared vision, strategy and culture. Staff were committed to their work and responsive to the needs of patients. There was a focus on patient safety and care. There was confidence in leadership and staff felt supported by managers. There were processes in place to support staff who required reasonable adjustments. Staff enjoyed working in the service and worked well together as a team. Management had a visible presence at the service.

There was a shared direction and culture throughout the service and an emphasis was placed on continuous improvement of the service and best practice. Leaders 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 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 focus for all staff and leaders was on the needs of patients receiving care.

The service was part of ‘The Ramsay Way.’ This was a set of purpose, mission, values and purpose which staff were knowledgeable about.

Staff told us they felt respected, supported and valued. We spoke with leaders who promoted a team ethos of caring for patients with dignity and respect.

We observed positive interactions between all members of staff regardless of seniority.

There was a clear sense of teamwork, and everyone spoke highly of their colleagues. When talking with staff it was clear that their priority was focussing on the needs of the patients they cared for.

Score: 3

Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in and around the hospital. They supported staff to develop their skills and take on more senior roles.

Staff told us they were encouraged to speak up and discuss their concerns openly. When staff had raised concerns, staff felt the management team were capable of taking appropriate action. Staff felt confident they could raise concerns or risks openly.

Leaders engaged with staff and used staff survey results to explore issues and discuss solutions and improvements.

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 was a policy that encouraged and enabled individuals to voice concerns about safety issues without fear of reprisal. It emphasised a culture where speaking up was seen as a positive action that contributed 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 2 members of staff on site who were the Freedom to Speak up Guardians. However, when we spoke with the 2 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 96% 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 outpatients department was well led. Staff felt supported and were able to develop to improve their practice. There was evidence of an open and supportive culture.

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 acted on information concerning risk, performance and outcomes, and shared information securely with other professionals as appropriate.

Leaders operated effective governance processes throughout the service and with partner organisations.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

The service had a risk register specifically for the outpatients department.

Senior staff and executives were present and visible daily in the outpatients department.

Score: 3

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for patients

The service worked with local health care partners to ensure there was a good understanding of local needs and improve the care they provided. These included both local GPs and local hospitals and supported the GPs alliance.

The service had transfer protocols in place with the local NHS hospital.

The service operated as part of a network of Ramsay hospitals. There were regular meetings between the different hospitals across the country. These meetings were utilised to share information and learning as a result of serious incidents and or complaints.

Information about patient's treatment and care needs were obtained from relevant sources before clinic appointments to enable the service to meet the patient's individual needs. Information was shared with GP's and other community services as appropriate to improve the continuity of care for the patient. The electronic patient record enabled timely access to information and diagnostic test results during consultation which contributed to patients making informed decisions about their care and treatment.

Score: 3

The service was committed to continuous learning, innovation and improvement in order to be more efficient and improve outcomes for patients.

Staff told us that information was sent by email but also followed up face to face in team meetings.

Staff described a culture of learning and of opportunities to develop their knowledge and skills.

There was a Ramsay Apprenticeship Scheme, which staff were encouraged to join if they wanted to further their career qualifications. The apprenticeship scheme was a structured program that combined on-the-job training with off-the-job learning, allowing staff to work and still be paid while gaining significant skills and qualifications in a specific job role.

Staff were encouraged to participate in learning and continuous improvement, for example one staff health care assistant had undertaken an immediate life support course, whilst another staff member had undertaken an acute mental health management course.

The service had a patent participation group which identified issues that could be improved within the service. For example, during the meeting in December 2024 the meeting identified low seating in the outpatient department and a low sofa in the corridor, which the service removed. A room was also identified for confidential discussions on the first floor if all of the clinic rooms were full on the ground floor.