Practice Plus Group Hospital - Emersons Green

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 there was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of people who used services and wider communities. We checked leaders proactively supported staff and collaborated with partners to deliver care, which was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We previously rated well led as good. At this assessment this has stayed the same.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of regulation 17 for good governance as the oversight of information in key documents such as the local rules for X-ray and patient information for some CT scans required improving.

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.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. We scored the service as 3. The evidence showed a good standard. 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 service had a realistic vision and strategy for achieving the priorities and delivering good quality sustainable care. For example, the service embraced diversity and had a zero-tolerance approach to poor behaviours in the workplace.

Managers were aware of a national shortage of some staffing groups and planned their staffing to mitigate these risks. They were actively engaged in additional training to extend some roles. Managers were liaising with universities to encourage suitably qualified staff to seek employment at the hospital.

Staff felt supported, respected and valued which was reflected in the 2025 staff survey results. All imaging staff we spoke with felt positive and proud to work in the organisation. Staff we spoke with told us the culture and communication in the imaging department was supportive and collaborative.

The culture was centred on the needs and experience of people who used services. The service demonstrated an inclusive and non-discriminatory person-centred approach, ingrained in the values of the service. This was evident in everyday interactions with staff, people who used the service and the public. People felt respected, listened to and safe, and services were designed around what matters most to communities served.

Staff were proud of the service and consistently reported high levels of engagement, pride and trust in local leadership. They reported the service was an inclusive, supportive and empowering place to work. Staff felt alignment with and ownership of the service’s culture, vision and values. There was also a strong emphasis on the safety and well-being of staff with multiple newsletters, events, awards and support programs open to staff.

Managers gave us examples of support provided to staff on an individual and personal level which took a holistic view of each staff members’ individual needs and disabilities.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. We scored the service as 3. The evidence showed a good standard. 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.

Leaders had the skills, knowledge, experience and integrity they needed. They understood the challenges to quality and sustainability, and could identify the actions needed to address them, such as identifying changing needs in the workforce.

The provider ensured all staff underwent appropriate checks as required by Schedule 3 of the HSCA 2008 (Regulated Activities) Regulations 2014. This was carried out before staff began their employment with the service for both permanent and agency staff. We reviewed 3 sets of records and saw all required information was captured.

Safety was promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks. We viewed 3 personnel files and saw evidence of appropriate Disclosure and Barring Service (DBS) checks relevant to the role of the staff member.

Leaders understood challenges for the service and were visible to staff.

The management structure ensured there was senior support and specialist advice for staff when they needed it.

Leaders acted where behaviours or performance fell below expected standards, irrespective of seniority or role. The radiology service manager had an open-door policy and staff reported feeling safe to raise concerns or ideas to them.

There were clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and the leadership strategy included succession planning and staff development.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

2. We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voices would be heard.

Staff did not always feel they could speak up without fear of retribution. Staff knew who the freedom to speak up champions and guardians (FTSUG) were and how to contact them. Freedom to speak up champions had attended additional training to support their role. Staff were confident in raising concerns with line managers and felt supported by them but were hesitant to engage with other nominated freedom to speak up staff.

In the 12 months prior to our assessment, there had been no cases raised with the freedom to speak up team about Emerson’s Green Hospital. The FTSUG presented an annual report to the leadership board.

Staff contributed to staff surveys, and some felt action was taken in response. For example, in response to feedback in the 2025 staff survey, leaders had developed and compiled a comprehensive action plan, based on feedback from staff.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were actively engaged so their views were reflected in the planning and delivery of services and in shaping the culture.

Staff felt supported, respected and valued at service level. Most felt positive and proud to work in the organisation.

There was an emphasis on the safety and well-being of staff. There were monthly staff team meetings where operational issues were discussed alongside staff achievements and feedback.

The service met its statutory responsibilities for the health and safety of staff. Steps were taken to support staff, and wellbeing was supported through resources, rest, and cultivating a positive work environment. There was sensitive and non-discriminatory support for those who were struggling at work, which had a positive impact on the care they delivered to people.

Staff worked as a team and shared responsibility for providing good, safe care and resolving issues together.

Equality and diversity were promoted within and beyond the organisation. Staff, including those with protected characteristics under the Equality Act, felt they were treated equitably which was reflected in the latest staff survey.

Staff were able to request reasonable adjustments and changes to working arrangements which were considered by managers. Staff reported they had not worked for such a flexible and accommodating manager before.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always ensure all key roles were filled in a timely way, and any associated documentation was kept up to date. 

Not all governance arrangements were clear and effective. Governance systems were reviewed to assess they remained fit for purpose, proportionate and responsive to emerging risks, system changes and population needs. Reviews occurred annually and were overseen internally. However, we saw key documents such as local rules, had not been updated to contain the latest information about the Radiation Protection Advisor. Following our assessment, the service provided updated local rules showing the RPA and RPS had now been updated. 

Staff at all levels were clear about their roles and they understood what they were accountable for, and to whom. Organisational structure charts and governance structure charts were clear and accessible to staff.

Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promoted coordinated, person-centred care. There was a comprehensive structure tor reviewing contracts.

There were a range of committees with specialist responsibilities. For example, the radiation protection committee (RPC) reported incidents and actions to the overarching radiology review management group meeting. Minutes from meetings were detailed and clear with evidence of actions taken. Data showed that last meeting had taken place in 2024, although remote advice and support was available. However, since our inspection the service has scheduled its next RPS meeting for November 2026. 

Leaders were assured of service performance through analysis of quantitative data, qualitative insight, audit, lived experience and external assurance. Focus was on patterns, trends and root causes, rather than isolated metrics, and this intelligence was used to challenge, learn and improve.

There was a systematic programme of clinical and internal audit to monitor quality, and systems to identify where action should be taken. The audits were reviewed at the relevant committee meetings and reported to the overarching governance committees. For example, there was a weekly focus on reporting backlogs, so no reports were delayed.

Risk registers were clear and up to date and there was alignment between the recorded risks and what staff said was ‘on their worry list’. For example, the service clearly recorded the risks around total equipment failure and possible anaphylaxis following contrast administration in both MRI and CT.

Potential risks were considered when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities. For example, the service had undertaken comprehensive risk assessments for each imaging modality to cover loss of power and IT failure which may result in delays in patients receiving either their scan or subsequent report.

The service implemented external alerts such as MHRA or patient safety alerts through regular team meetings which were documented and disseminated to those who were unable to attend. Where serious enough, staff kept written records to confirm which staff had seen the alert or update. For example, following an alert from NHS England the department was moving to an enhanced form of cleaning for the internal ultrasound probes.

Leaders maintained oversight of the governance arrangements for medicines management through use of a third party who prepared and stocked emergency bags. These bags were then subject to regular checks by staff who reported any issues or discrepancies.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. We scored the service as 3. The evidence showed a good standard. 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.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally. All staff knew how to report incidents using the electronic system.

The service reviewed and investigated safety and safeguarding incidents and events when things went wrong. All relevant staff, services, partner organisations and people who used services were involved in these reviews and investigations.

Learning from lessons was shared to make sure action was taken to improve safety. Senior staff and medical physics staff attended dose optimisation meetings where discrepancies from dose audits were discussed, and actions identified.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice, and research.

There was a systematic approach to continuous quality improvement, which leaders understood was key to delivering high-quality care.

Leaders and staff strived for continuous learning, improvement and innovation. For example, the service had developed and expanded the service for ultrasound guided injections, which could now be undertaken by ultrasonographers who had undertaken specialist training.

The service was working towards external accreditation from multiple organisations including Quality Standards for Imaging (QSI) (formerly Imaging Services Accreditation Scheme, ISAS).

The service invested in its people to ensure quality improvement was embedded in the work of all its staff. There was a clear strategy for developing staff capabilities.

Staff were able to allocate time to work together to resolve problems and to review individual and team objectives, processes and performance. This led to improvements in patient care and better working relationships within the service and with partner agencies.

Leaders at local level fostered an open culture of trust, which was honest about challenges and mistakes, and used these as opportunities for learning. Leaders actively listened to staff, monitored and assessed improvement and innovations, and enabled collective problem solving and continuous improvement.