Sturdee Community Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal a legal regulation in relation to good governance (regulation 17).

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We received mixed responses from staff regarding leaders at the service. Many staff we spoke with felt the most recent change in the leadership team was positive and had improved the culture at the service, However, some staff felt afraid to raise concerns in fear of retribution or bullying. CQC received a number of anonymous concerns before and after our site visit regarding bullying and harassment of staff. These were investigated by the hospital director but not substantiated. We were concerned there was a disconnection between the leadership and management team and other staff resulting in some staff feeling disempowered and not listened to and unable to raise concerns without fear.

Culture and values were discussed in team meetings. The provider was aware of these culture concerns and had included them on the hospital risk register along with action plans for improvement.

Leaders did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience to lead effectively.

There had been a change in leadership including a new hospital director/registered manager. Most staff we spoke with told us these changes were positive and resulted in an improved staff morale and patient care. However, some staff continued to feel they were not always listened to and described a bullying culture. These concerns had been ongoing at the service for a number of years with previous changes of leadership and management failing to bring about the required improvements.

The registered manager acknowledged these issues and concerns and had developed a hospital improvement plan. The registered manager was new in post (3 months) and had plans in place to make changes towards improvement. This included addressing concerns identified with the environment, safe working practices and other issues identified within patient and staff survey responses.

Actions the leadership team were taking to improve included, an increased visibility of leaders and managers within the service, promotion of an ‘open door policy and increased focus on encouraging staff to ‘speak up’ about their concerns.

Many staff we spoke with felt the service had improved. A staff member said “Senior staff are present, supportive, with open door policy. They have created a culture of openness. The new hospital director has lightened the mood of the hospital in a positive way.”

However, at the time of our inspection, we were not assured the leadership team had achieved full and robust oversight of the service. Staff teams were not fully working together with mutual trust and respect in order to improve patient care, treatment and support.

People did not always feel they could speak up and that their voice would be heard.

The provider had a process and named person (freedom to speak up guardian) for staff who wished to speak up about any concerns they had. This was discussed in team meetings and staff were encouraged to speak up and given a number of pathway options to raise concerns.

We received mixed feedback from staff we spoke with. Some did not feel confident their concerns would be listened to or handled in a confidential way. Other staff told us of improvements to this process since the new leadership team had been established.

Patients and carers had opportunities to give feedback on the service. However, some patients and staff did not feel confident doing so and did not feel their concerns would be listed to or acted upon. We (CQC) had received and continued to receive anonymous complaints about this issue and ongoing concerns about patient care. Therefore, processes for speaking up may not be effective at the service.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The providers most recent staff survey results (January 2025) was responded to by 53 staff members (approximately 50% of the staff team). Sixteen staff reported they were ‘very unsatisfied’ and 7 staff ‘unsatisfied’ when asked to rate the organisations protection of its employees from discrimination. Twenty staff said they were very unsatisfied or unsatisfied when asked to rate the level of consideration given to equality and diversity in the service.

These themes and concerns were also identified in many of the anonymous concerns sent directly to CQC.

The provider was taking action to address these concerns and felt improvements had been made since this survey. A further staff survey had taken place in May 2025 but unfortunately the results of this survey had not yet been published.

Actions the provider had taken to make improvements included, meeting with staff more regularly to listen to and understand their experience and carrying out staff wellbeing reviews, in particular after an incident.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Clinical audits and clinical governance meetings took place. The provider had a rolling programme of audits to take place each month. Meeting minutes and audit results showed the provider had identified shortfalls regarding incomplete documentation following the use of rapid tranquilisation, incomplete documentation for consent to receive medicines prescribed and infection control/cleanliness. However, action taken had not been sufficient to make the necessary changes and improvements.

Governance processes were not always working effectively to identify areas that needed improvement. The provider did not have clear oversight of the risks we identified during this inspection. Staff feeling stressed, in particular when assigned enhanced observations for prolonged periods of time was not in line with the providers own policy. There were several risks in the premises and environment and although the provider took immediate action when we pointed these out, the premises were ‘tired’ and in need of improvement. Increased focus, scrutiny and oversight of infection prevention and control, fire safety, environmental risks, patient and staff experience and management of medicines was required.

The provider had a risk register but this did not include all risks present in the service. The date the risk had been identified was not recorded. Action plans were not robust and did not include enough information about what action required to reduce or remove the risk. This concern had been identified in the providers previous 2 CQC inspection reports.

There was a clear leadership and management structure in place. Staff and managers had access to information to support them with their role both internally and from the wider organisation.

The service had plans about how to respond to emergencies and disruptions to business continuity.

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

Patients, relatives and staff could meet with members of the provider’s senior leadership to give feedback. There were a range of opportunities including staff meetings, daily safety meetings and staff supervision. Patients and their relatives (where appropriate) were invited to multidisciplinary meetings at least once a month. A relative told us they received fortnightly update phone calls from staff and was able to attend meetings via video call because they lived far away.

The provider submitted notifications to CQC about events and incidents they were required to so we could monitor safety at the service.

There was good evidence in records and through speaking to patients and staff that staff collaborated with external stakeholders to identify new or innovative ideas to achieve better outcomes for patients.

The provider sent us feedback they received following an integrated care board quality assurance visit which was positive and described how small achievable goals had been effective in building a patient’s confidence and motivation.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had been in breach of regulations for the previous 2 CQC inspections and were in breach of regulations at this inspection. Changes to management and leadership had not been effective in levering the necessary improvements. A new registered manager was in place at this inspection and was again working towards achieving compliance and improving patient care.

There was a small fire at the service cause by a tumble dryer earlier in the year. Despite this we found shortfalls in fire safety including a missing fire extinguisher (outside the laundry) and not all staff having access to fire fighting equipment.

There was continued and ongoing culture concerns regarding harassment and bullying within staff teams. There was a lack of a consistent approach for measuring outcomes and impact for patients and a delay in publishing the most recent staff survey results completed in May 2025.

The psychology team was experienced and well-resourced, they used innovative approaches to meet individual patient needs and promote recover.

Staff achievements were recognised within team meetings.