All Saints 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

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 good. 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.

Governance processes did not always operate effectively, and performance and risk were not always managed well or with appropriate oversight. There were processes that had been implemented which had not been reviewed to ensure that they were embedded effectively. The service had further work to do to ensure the culture of the service was improved.

However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff generally felt respected, supported and valued.

The service was in breach of regulation due to issues around governance processes.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had some ongoing cultural issues that had historically been a challenge for the service. Managers were aware of these issues and had taken actions to address them, although staff still raised this as an issue during the assessment.

Managers and staff identified that the culture of the service could be challenging and that work was ongoing to ensure that all staff felt supported and included. The key challenge for the service was between deaf and hearing staff, who both expressed frustrations about how each group communicated and interacted with each other, along with the different expectations of people. Managers were aware of this issue and had undertaken some pieces of work around culture in the service. This included an independent review of the culture of the service, staff and patient focus groups, a review of the service’s model of care and a “down tools week” in which sessions and training was delivered to staff, including discussions around the culture and shared direction of the service. Managers had identified some actions that could be taken to improve the culture within the service and gathered staff feedback on these proposals.

Staff generally spoke positively about their work and the service. Staff were passionate about their roles.

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 and experience to perform their roles. The leadership team at the service was relatively new and was still developing within their roles.

The Registered Manager had started in post around 12 months prior to the assessment. Staff gave positive feedback about the Registered Manager and the work that they had undertaken since joining the service.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders had been reviewing the service and assessing areas in which improvements could be made. Leaders were open about some of the challenges that they faced and were passionate about providing high quality care and treatment to the patients.

Leaders were visible in the service and approachable for patients and staff.

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

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The service had recently conducted the patient survey for 2025. 14 patients across the service responded to the survey. Most questions received positive responses with the most negatively responded to question being “staff ask what I like to do”. Managers had created an action plan based on the results of the survey.

A staff survey had been conducted in 2024 with most questions receiving positive responses. The service had an action plan based on the results of this survey.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. Patients could give feedback in relation to the service through various methods such as community meetings, the patient forum or direct to staff and managers.

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.

At the time of the assessment, the service did not have any specific equality and diversity groups. Managers had made enquiries with staff about any interest in a local inclusivity group. Managers described that the focus for inclusion and diversity needed to include all aspects, as opposed to just having a focus on deafness. However, managers noted that work around equality and diversity within the service was a challenge and still required further work.

The organisation had an inclusivity lead and structures in place regarding equality and diversity.

Staff received training in equality, diversity, inclusion and human rights. At the time of the assessment, the hospital had a 98.6% compliance rate for the mandatory training in diversity, equity and inclusion.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Managers described how they monitored and supported staff that may need additional support.

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

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes.

We reviewed 6 electronic staff records during the on-site inspection and found inconsistent recording of supervision records. 3 of the 6 records did not contain any supervision records. Managers had stated that there were some paper records for supervision which were either scanned on or kept in a separate folder. We reviewed the paper records for 2 of the 3 staff that did not have supervision notes in their electronic file and did not find any paper records for these staff. There was no clear process for ensuring that supervision was being documented correctly and appropriately within the service; or how managers could be assured that supervision was being undertaken in line with their expectations.

The service had implemented a “new starters” checklist. We reviewed the checklists against any agency staff that had worked in the service for the week of the 15 September 2025. For the 20 agency staff listed as having worked in that week, only one had a completed “new staff” induction checklist. This indicated that the process had not been embedded correctly and that staff were not undertaking the checks as manager’s expectations. Managers had not established a process to monitor, review and evaluate this process to ensure that it was robust and appropriately embedded.

The service had processes in place for staff to report maintenance issues however at the time of the assessment the process for the oversight of maintenance issues within the service was not fully robust. Managers noted that each ward had a maintenance book and that staff could also escalate maintenance issues via email which would then be addressed by the maintenance worker. It was not clear how maintenance issues escalated via email were logged and recorded or how managers had oversight or monitoring in relation to these issues and whether the jobs had been completed. Managers explained that they had discussions about ongoing maintenance tasks, including via supervision with the maintenance worker, and implemented a maintenance log following the on-site assessment.

We reviewed the personal emergency evacuation plan (PEEP) folder on Braidwood ward. The folder had PEEPs for 11 of the 12 patients currently admitted to the ward. The patient’s care record was checked and confirmed that a PEEP had been created but not printed and added to the folder. The patient was the newest admission to the ward. Staff would not have had access to this PEEP if an emergency had occurred which required patients to be evacuated from the ward. Managers confirmed that the PEEP had been printed and added to the folder.

The service had a clear governance structure to ensure that information was shared with ward staff and that managers could have oversight of how the wards were performing.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The service had both a local and organisational audit calendar identifying the frequency at which audits were conducted.

The service had a risk register. Managers were aware of the items on the risk register and relevant the mitigation controls.

Managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

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.

Managers engaged with external stakeholders such as commissioners. Managers reported positive relationships with external stakeholders and partners.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. The service had a patient forum that was held monthly, along with regular community meetings. The Registered Manager advised that they tried to attend the community meetings where possible.

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.

The hospital had undertaken improvement activities in the 12 months prior to the assessment, in particular around improving the culture of the service. This had involved reviewing the previous culture and identifying ways in which this could be addressed. Managers had identified recommendations following this and engaged with staff and patients to get their feedback.

The ward was not participating in any accreditation schemes at the time of the assessment. The Registered Manager identified this as a long-term goal for the service.