The Westbourne Centre

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.

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.

Staff demonstrated a clear understanding of the service's priorities and were able to explain how their individual roles contributed to achieving these objectives. They remained focused on delivering person-centred care and consistently placed the needs of people using the service at the centre of their practice.

Equality, diversity and inclusion were actively promoted throughout the service, and staff were supported to develop their knowledge, skills and career progression opportunities. The service fostered an open and positive culture, where staff felt empowered to raise concerns, provide feedback and contribute ideas for improvement without fear of reprisal. People using the service, as well as their relatives and carers, were also encouraged to share their views and experiences.

Staff consistently told us they felt respected, supported and valued by both leaders and colleagues. They spoke positively about the leadership culture, describing it as inclusive, approachable and supportive. Relationships across all levels of the organisation were positive, with evidence of effective teamwork, collaboration and mutual respect.

Staff also spoke positively about the future direction of the service and demonstrated engagement with planned developments and improvements. Individual and team achievements were recognised and celebrated, and staff reported regularly receiving appreciation and acknowledgement for their contributions. This helped to promote high levels of morale and engagement, while supporting a positive and inclusive working culture throughout the service.

The service was led by individuals who understood the context in which care, treatment and support were delivered and who embodied the culture and values of both the workforce and organisation. Leaders demonstrated the skills, knowledge, experience and credibility required to lead effectively. They acted with integrity, openness and honesty and recognised the impact their behaviours and leadership had on people's outcomes and experiences.

Leaders had a clear understanding of the challenges and priorities facing the service and maintained oversight through regular engagement with staff and departmental teams. They were visible and approachable, and staff told us they felt comfortable raising concerns, discussing issues and seeking support when needed.

A positive and inclusive culture was evident throughout the service. Staff consistently told us they felt listened to, valued and supported. Feedback from staff was actively used to inform improvement initiatives, including actions to strengthen communication between departments, enhance shared learning and further promote an open and transparent culture.

Leaders supported staff to develop their skills and progress their careers. Appraisal and supervision processes were used effectively to identify learning and development needs, and opportunities were available for training, mentoring and leadership development. The service had also taken steps to identify and nurture future leaders, supporting staff to develop into more senior positions and ensuring succession planning for the future.

The service promoted a culture of openness, learning and continuous improvement. Staff had opportunities to contribute to service development through shared learning forums and multidisciplinary meetings, helping to ensure they felt heard, involved and able to influence positive change. Incidents, complaints and concerns were managed appropriately, with learning shared across teams to improve practice and support high-quality care. Staff told us concerns were taken seriously and that there was a clear organisational commitment to learning, improvement and the delivery of safe, effective and person-centred care.

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

Staff and leaders demonstrated openness, honesty and transparency in their day-to-day practice. Staff were encouraged to raise concerns, share ideas and contribute to service improvement. The culture promoted psychological safety, enabling staff to feel confident that their views would be listened to and acted upon.

Staff told us they felt able to raise concerns and were confident they would be supported to do so without fear of negative consequences. When concerns were raised, leaders responded appropriately, investigating matters sensitively and maintaining confidentiality. Local and senior leaders, including those at provider level, were informed of serious concerns raised through whistleblowing processes where appropriate. Risk registers and management reports included analysis of concerns, trends over time and associated action plans to support learning and improvement.

Patients, families and carers were provided with clear information about how to raise concerns or complaints and what to expect from the investigation process. Staff were encouraged to respond promptly to concerns and complaints with a view to achieving early resolution wherever possible. Robust policies and procedures were in place to support the management, investigation and learning from complaints and concerns.

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

Leaders promoted equality, diversity and inclusion and took steps to address potential inequalities affecting staff with protected characteristics. Recruitment, promotion and development opportunities were advertised through transparent processes, helping to ensure fair access for all staff. Staff told us they had opportunities to apply for additional roles, projects and learning opportunities.

The service had measures in place to prevent and address bullying, harassment and discrimination. Staff understood how to raise concerns and told us they felt confident any concerns would be taken seriously and acted upon appropriately. Staff told us people were treated fairly and with respect.

Leaders encouraged staff to share feedback and used this to support continuous improvement. Staff described a positive and inclusive culture where they felt listened to, valued and able to contribute to the development of the service.

Staff with disabilities and those with individual circumstances were offered reasonable adjustments to support them in their roles. For example, leaders supported a staff member to move into a more flexible role to help them balance their parenting responsibilities, enabling them to remain in employment and continue to develop within the organisation.

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 about risk, performance and outcomes, and shared this with others when appropriate.

The service maintained a risk register which was regularly reviewed through governance processes. Risks were assessed using a risk scoring matrix, with the highest-rated risk relating to failure of the theatre air handling unit (AHU), which could lead to unsafe theatre temperatures and disruption to surgical activity. The service had mitigation and monitoring measures in place to reduce the impact on patient care and service delivery.

A Medical Advisory Committee, chaired by a consultant and supported by senior leaders, met regularly to review clinical governance, consultant practising privileges, incidents, complaints, audit findings, policy updates and service developments. Decisions and actions were documented and reviewed at subsequent meetings to ensure accountability and oversight.

Leaders used quality, safety and performance data to monitor services and support decision-making. Clinical incidents, complaints, safeguarding concerns, safety alerts and operational performance were reviewed regularly through governance processes. The service also participated in regular contract review meetings with the Integrated Care Board to monitor performance and contractual compliance.

The service maintained a comprehensive audit programme. In May 2026, leaders reported that 46 audits had been completed with an overall compliance rate of 97.6%, with no red-rated audits identified. Audit findings informed quality improvement activities and action plans where required.

Leaders maintained oversight of current and emerging risks through formal risk management processes. Risk registers demonstrated that risks were identified, assessed and regularly reviewed, with mitigating actions in place where required. Governance records also evidenced ongoing improvements to clinical pathways, diagnostic result management, implant traceability and patient safety systems.

Information governance arrangements were effective. Information systems were secure, data quality and reporting requirements were monitored, and there had been no reported data breaches. Patient information was managed appropriately.

Leaders had a clear strategic focus on clinical quality, workforce development, operational efficiency and sustainable growth. Workforce sustainability was supported through training, professional development and competency monitoring. Staffing was reported as stable with no significant recruitment gaps identified, and the service achieved Gold ANTT Accreditation in 2026.

Financial and operational performance was monitored through internal and external governance arrangements. Business continuity and major incident plans were in place, and policies were regularly reviewed to ensure they remained aligned with national guidance and regulatory requirements.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for patients. Staff always shared information and learning with partners and collaborated for improvement.

Leaders and staff worked with local organisations, healthcare partners and representative groups to support community engagement and health and wellbeing initiatives.

The service had established partnerships with organisations including Edgbaston Golf Club and Edgbaston Archery Lawn Tennis Society. Through these partnerships, staff delivered cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training. Attendees told the service the training increased their confidence in responding to emergency situations. Leaders used feedback from these events when planning future community engagement activities.

Leaders maintained regular engagement with healthcare partners, including Birmingham and Solihull Integrated Care Board (ICB), through quality, performance and contract review meetings. They also worked with primary care colleagues to support joined-up working across services.

Staff and leaders engaged with representative groups, including Armed Forces and Disability Neurodiversity People Resource Groups. This helped the organisation maintain links with veterans, serving personnel, military families, disabled people and neurodiverse communities. The organisation held Veteran Aware accreditation and had achieved the Armed Forces Covenant Gold Award.

Patients, visitors and members of the local community contributed to a community photography project, with selected images displayed throughout the hospital. Staff told us the initiative strengthened links with local groups and schools.

Staff also participated in charitable, educational and volunteering activities within the local community.

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 patients. Staff actively contributed to safe, effective practice and research.

Staff were committed to learning and improving services. Learning from training, service developments and good practice was shared across teams through a range of communication and governance processes, supporting a culture of continuous improvement.

Staff demonstrated a good understanding of service improvement and were supported to develop their skills and undertake additional responsibilities. For example, several nurses had completed Professional Nurse Advocate training, which supported reflective practice, staff wellbeing and professional development.

Leaders encouraged innovation and staff involvement in service development. This included the introduction of an anaesthetic review clinic to support patients through the pre-assessment pathway. Leaders also described plans to establish patient engagement forums to gather feedback and inform future service improvements.

Staff and leaders were committed to delivering high-quality, patient-centred care. A staff-led newsletter provided an innovative platform for sharing learning, recognising achievements, promoting wellbeing and encouraging engagement across the service.