The New Foscote 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.

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.

We scored the service as 3. 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 provider had a vision and a set of values underpinned by a comprehensive strategy. The strategy encompassed 6 main areas, such as quality and safety, patient experience, and finance and investment. Each area had its own set of key performance indicators (KPIs) and targets, and the provider continuously reviewed the progress against these.

Leaders told us they brought in an external consultancy to help create the set of values and behaviours and involved every staff member in this process. The hospital displayed posters of the values across its site. All new members of staff joining the hospital learnt about the provider’s values and behaviours during their induction.

Staff knew about and understood the values and behaviours and told us awards linked to these. We heard one staff member received “2 awards for being approachable”.

We felt the endoscopy service’s culture was one of mutual respect and dedication. Team members valued each other and their colleagues outside of their team. They all worked together to provide safe, high quality and compassionate care.

The endoscopy team, and the workforce, was diverse and reflected the patient base. Leaders understood the different needs of their staff and made allowances; for example, they encouraged staff to take their annual leave in one period of time to visit their families abroad. On staff member explained how supportive the team had been when they had arrived new to the country: “there are a lot of difficult cultures working in the hospital and everyone is really supportive, like a family. I have never worked in an organisation that is so supportive. I was new to this country and so very anxious, but they have made me feel welcome and allowed me to train in endoscopy and this has been done in a manner that was kind and feedback is given in a way that is kind and allows me to improve my practice.”

The provider’s recruitment policy included a section on equality, diversity and inclusion. This clearly outlined they never excluded candidates with disabilities and they ensured reasonable adjustments could be put in place to accommodate any staff with specific needs.

Staff at all levels described a positive and inclusive culture. We did not hear from any staff about inequality or different treatment due to their personal circumstances. Staff felt they could speak openly and honestly to any of their colleagues and leaders without fear of repercussions. We observed meetings and general interactions and felt communication was based on mutual respect and understanding.

The provider supported staff wellbeing and had a wellbeing strategy in place, which set out key objectives for the year. They offered additional benefits, including a day off for staff birthdays, private health insurance with 24-hour access to physical and mental‑health support, an employee assistance programme and financial and pension advice through a bank. One team member told us the hospital was “very supportive and that you get a free annual leave day for your birthday”.

We scored the service as 3. 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 at all levels described an organisation run by inclusive and compassionate leaders. Everybody knew who made up the executive team and regularly spoke with them. Leaders were visible across the organisation, and we felt an atmosphere of inclusivity and a flat hierarchy. Staff felt leaders were visible and described the organisation as “like a family hospital”.

We met many leaders of the organisation and the endoscopy service and felt they all had the experience, capacity, capability and integrity to manage the services and deliver the organisation’s vision.

The leader of the endoscopy team knew and understood the service they managed. They led by example and modelled inclusive and compassionate behaviours. Conversely, the leader described their team as supportive and said “I feel I’m lucky here – as I have an extremely supportive team who care about the patients and are all motivated. I always encourage them to ask questions.”

At all levels throughout the endoscopy team, we heard resoundingly positive feedback about leaders. Everybody felt listened to and able to raise anything they wanted to. This reached from within the team to the leadership of the organisation as a whole. Leaders had an open-door policy and encouraged staff to be open and transparent.

The provider had a formal succession plan document. This included a succession matrix of key roles, both managerial and clinical. It meant the provider was prepared for sudden changes in leadership roles and could fill posts quickly. Each leadership role had a designated deputy who could step into the leadership role if required. The provider had a development framework in place to ensure staff had access to training for senior roles.

Consultants with practising privileges worked at The New Foscote Hospital (these are independent medical specialists authorised to work within private hospitals, whilst often performing NHS work alongside their private practice). The governance team had responsibility for monitoring the consultants’ performance. Together with the medical director and the director of nursing, consultants could be terminated if they did not perform well or if staff or patients raised concerns about them.

We scored the service as 3. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had 3 Freedom to Speak Up (FTSU) Guardians. Leaders told us they saw these as “very serious posts and we take it seriously”. They chose to have 3 Freedom to Speak Up Guardians to ensure every member of staff felt comfortable to speak up; Freedom to Speak Up Guardians were of different genders and seniority. Staff voted colleagues into the role of Freedom to Speak Up Guardian.

Leaders encouraged staff to speak up. They welcomed feedback and saw it as an opportunity to listen and improve. Staff knew who to approach and they understood the role of the Freedom to Speak Up Guardians. However, we heard staff mostly felt comfortable speaking with their own line managers and did not feel the need to take issues to the Freedom to Speak Up Guardians. None of the staff in the endoscopy team had raised concerns with the Freedom to Speak Up Guardians.

The Freedom to Speak Up role included training, which was done in-house but aligned with the National Guardian’s Office training. The guardians sought advice from the National Guardian’s Office if needed.

The provider also had a rolling online staff survey, which had been built by an external company. Any member of staff could access this and leave anonymous feedback in real time. This then allowed for real time actions. At certain points in the year, the provider themed the feedback so they could gather trends. For example, staff left feedback to say they wanted to have an area for staff to go during their breaks. The provider created this space following feedback and staff now had access to a staff room.

We scored the service as 3. 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.

The provider valued diversity in their workforce. They produced a diversity report, which monitored gender, disability, and diversity across the workforce. The senior leadership team was made up of 4 males and 6 females. The remainder of the workforce was one third male and 2 thirds female. Staff voluntarily completed forms to indicate whether they considered themselves to have a disability. Multiple staff reported themselves as being neurodiverse. The provider employed people from a wide range of different ethnic backgrounds. Out of 102 employees, 88 had disclosed their ethnicity; for example, Asian, Black African, Chinese, Latino, and White British.

The provider had a flexible working policy outlining eligibility criteria and the process for applying. The provider invited staff to apply for flexible working arrangements if needed. Staff had to complete an application form and give reasons for requesting flexible working. Examples included requests to work less hours due to caring responsibilities; or more hours when life circumstances changed. Leaders considered each application and took up to 3 months to make the decision whether to accept or reject the application.

The provider put reasonable adjustments in place to support staff. These included access to occupational health and confidential counselling services. These arrangements supported staff to remain healthy at work and helped reduce barriers for those experiencing physical or mental health concerns.

The provider had a wellbeing strategy for 2026 with 3 key objectives: promote existing physical health initiatives, launch financial wellbeing partner, and promote existing emotional wellbeing benefits. Staff accessed a campaign calendar, which listed key events throughout the year, with additional wellbeing focus sessions. For example, we saw sessions called ‘time to talk’, healthy habits sessions, and supporting mental health sessions. Staff accessed an external occupational health service who visited the hospital once a month.

Staff had not witnessed any disrespectful, discriminatory or abusive behaviour from colleagues or patients. They said they felt confident they could report poor behaviours to their manager and that appropriate action would be taken.

We scored the service as 3. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The provider had clear and effective overall governance, management and accountability arrangements. All levels of governance and management functioned effectively and interacted with each other appropriately. The provider had clear lines of accountability and staff knew who to report to. We reviewed the governance structure, which clearly outlined the reporting structure and core responsibilities of each part of governance; for example, the director of governance reported to the senior leadership team and had direct links with the medical advisory committee. Governance sub-committees reported to the director of governance, for example, the infection, prevention and control committee, or the medicines management committee.

Staff understood their roles and responsibilities. Each service had its own local governance structure, feeding into the clinical governance committee. Information coming from the executive board used the same routes to feed information back to governance and the local structures.

Meetings took place at senior and local levels. Each meeting had standard agenda items and staff minuted the meeting. In the senior leadership team meeting, the agenda included discussions relating to all areas of the business, for example, finance, human resources, nursing, learning and development. The clinical governance meetings dealt with items such as complaints, audits, compliments, and patient surveys.

The provider had a corporate risk register, which incorporated potential risks from categories such as patient safety, reputation, legal, financial. Each risk had its own reference identification, the date of when it was identified, the impact of the risk and mitigations to reduce it. The risk register identified the person responsible for monitoring risks and putting actions in place.

An area identified on the risk register related to loss of utilities, such as power outages, loss of water, or IT failures. The provider had a comprehensive business continuity framework, which addressed all potential disruptions. For each risk, the provider had created an action card, outlining primary action points in response to a situation. For example, they had action cards for bomb threats, loss of IT systems, lift failure, and loss of staffing.

If a member of staff identified a risk, they emailed the information to the governance team. Governance took all risks to the weekly senior leadership team meeting where they discussed each risk and whether it should be placed on the risk register. Staff in the endoscopy service knew about the risk register and how to escalate risks if needed.

Governance structures included assessment of user satisfaction and complaints, audit of quality management systems and quality improvement. Policies and procedures underwent robust reviews and staff ensured they were up to date and in line with current guidance. We saw management of equipment was systematic and staff knew who to go to if they encountered any problems. We saw records of equipment checks which took place at the beginning of each day.

The provider had current indemnity and public liability insurance and ensured consultants with practising privileges had appropriate levels of professional indemnity insurance. We saw the electronic record system where all information about consultants was held.

We scored the service as 4. The service clearly understood and carried out their duty to collaborate and work in partnership. They always share information and learning with partners and collaborate for improvement.

One of the provider’s 5 values was ‘community’. The provider had a strong commitment to working collaboratively with system partners, such as the Integrated Care Board (ICB), local GPs and NHS providers. This ensured they aligned their services to those they partnered with and ensured they knew and understood the population they served. They used these networks to identify and share new or innovative ideas which could lead to better outcomes.

The hospital employed a dedicated GP Liaison Officer. This ensured both the hospital and the local GP practices understood each other’s roles and services, their referral pathways and patient groups. The hospital provided training to local physiotherapists. This helped to strengthen referrals to endoscopy and other services.

The provider had robust links to the local NHS trust and held several regular meetings with them. This is where they shared learning and best practice to continuously improve their services. Consultants with practising privileges working at the hospital, facilitated learning sessions for clinical staff.

The New Foscote Hospital had links with universities. They facilitated student placements and took part in recruitment events at the universities. The provider supported their own staff to gain a Master of Business Administration (MBA), which they fully funded.

The provider had strong relationships with their suppliers, including robust governance processes. Representatives from suppliers came to the hospital to teach staff how to use their products. This ensured staff learnt the appropriate use of medical equipment first hand.

The provider sponsored a local football club and several local grassroot sports teams.

We scored the service as 3. 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.

One of the provider’s 5 values was ‘innovation’ and it was apparent they strove to commit to continuous learning and improvement. The provider fostered an environment in which they listened to both staff and patients and made changes as a result. For example, following patient feedback the service added air conditioning to patient rooms and improved their patient communication by providing it in different formats.

The provider currently worked towards their Joint Advisory Group (JAG) in endoscopy. The aim of achieving the JAG accreditation standards was to define a high-quality, safe and appropriate endoscopy service, delivered by a highly trained, highly supported and highly motivated workforce. The service expected to be inspected by JAG assessors in October 2026.

The provider undertook the development of in-house sterile services due to risks identified using external services. This took time and a lot of planning to overcome practical challenges; the outcome meant the provider now had improved turnaround times, cost efficiencies, and better quality and integrity of endoscopic equipment.

Leaders listened to staff ideas and had the willingness to improve. Staff told us they felt comfortable contributing to and proposing new solutions. For example, the endoscopy lead changed the way the service collected patient feedback. Previously patients received a form to take home, which they completed and posted back to the hospital. The service now provided a QR code for patients to give feedback online. As a result, patient feedback had increased.