HCA Healthcare UK The Harborne 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.

This is the first assessment for this service. This key question has been rated good. This meant there was good leadership and a culture that created high-quality 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.

All staff on the unit were passionate about their work and responsive to the needs of people. The culture of the unit focused on patient safety and care. It was clear from speaking with staff that they had confidence in leadership, and they reported feeling supported by their teams and managers.

Please see medical report for more details.

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.

Staff felt supported by their managers and that management were regularly present on the unit. There was support available for staff who had been involved in an emotional or difficult situation.

Please see medical report for more details.

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

The hospital had Freedom to Speak Up champions on site who staff were able to contact. A Freedom to Speak Up Guardian is a named person in every hospital who can provide independent support and advice to staff that want to speak up. Staff told us they were aware of the champions and would access them if required.

Please see medical report for more details.

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.

Please see medical report for more details.

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.

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities.

There was an integrated governance framework these included the medical advisory committee (MAC), CLIP (Clinical Learning and Improvement Plan), corporate and local meetings. The weekly CLIP meeting reviewed incident, complaints, audits and activity.

The local governance structure included daily safety huddles to review staffing, patient numbers and patient acuity. Information on any risks, incidents, complaints and concerns was shared with staff on a daily basis.

Monthly staff meetings were held in ICU. Agenda items included, incidents, complaints compliments, training, audits and staffing levels.

The service had a risk register with 2 risks identified. The hospital had not submitted data to the Intensive Care National Audit & Research Centre (ICNARC), which is one of the GPICS recommendations, this was due to low numbers of patients using the ICU facilities. There were plans to commence submitting data in 2026. The other risk related to the provision of consultant intensivist cover due to the imminent changes in the patient pathways and models of care working closer with a local NHS trust. Options were being discussed with the local trust and executive team.

Please see medical report for more details.

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.

Please see medical report for more details.

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 people. Staff actively contribute to safe, effective practice and research.

Leaders told us of potential changes to the ITU service, due to low numbers of activity and patient acuity. Between January and July 2025, 160 patients were admitted to the ICU. Predominately patient care was enhanced care level 1.5, with few patients requiring level 2 and level 3 support.

Leaders were currently in discussion with a local trust and a consultant intensivist group to review patient pathways, models of care and consultant intensivist cover. The medical director and consultants told us they were aware of the proposals and had been involved in discussions with the leadership team. At the time of the inspection the proposed changes were still being finalised.

Where incidents occurred a RECALL investigation would be undertaken within 24 hours. This enabled timely sharing of learning and improvement across the service. Learning from sister hospitals was also shared throughout the service.

Learning and improvement include sharing learning from a pressure ulcer and developing education cards about new processes. When consultants introduced a new procedure staff would attend training sessions.