St Luke's 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 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 remained good.

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

However, the service was in breach of regulation of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for good governance.

This service scored 71 (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 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 Trustwide ‘Our Vision, Objectives and Values’ poster was displayed in all areas and staff were able to point out the information displayed on the wall. There was an individual clinical service unit strategy derived from this. Leaders were able to outline the strategy. However, staff did not provide a detailed account of the priority initiatives for the service that were outlined in the strategy. We were not assured the senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Leaders told us that staff had opportunities to contribute to discussions about the strategy for their service. We were not provided with any detail regarding specifically focussed sessions, however, staff were able to articulate the areas that they felt required development within the service and were forward thinking. These areas aligned with the views of the leadership team.

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 a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Staff told us their immediate line managers and senior managers on site understood the context in which care was delivered. We heard mixed views about the visibility of the trust executive leadership team. Some staff felt that as St Luke's Hospital was a smaller site there was less visibility of executive leaders whilst some staff reported visits had increased.

We heard there had been a clinical lead role within the senior leadership team until January 2025. This role had become vacant and some staff felt this had left uncertainty around some elements of leadership such as the wider strategic priorities. However, leaders explained how strategic oversight had been maintained with input of a different nature to the previous role, ensuring ongoing multi-disciplinary leadership.

Senior leaders supported staff to take on additional roles and responsibilities when needs arose within the service settings. Staff were supported to enhance their skills.

Department leaders were visible in the service and approachable for patients and staff. Leaders operated with an open-door policy and were responsive.

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

The trust had a freedom to speak up process in place for all staff. We did not see any evidence of this displayed for staff to easily access.

There had been no freedom to speak up concerns raised in the past year in outpatients. Staff told us they did not feel they had needed to formally raise any concerns and would feel comfortable to approach managers if needed.

Managers encouraged feedback from staff to support making improvements. For example, staff had identified a quiet room for patients would be beneficial in the adult outpatient department and a space for this had been created.

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.

There was a trust wide equality, diversity and inclusion strategy.

A range of policies reviewed included equality impact assessments. There were equality and diversity champions within the service.

Staff told us there were flexible working arrangements to support them to manage personal circumstances such as caring roles and health issues.

The trust reviewed clinical service units and undertook equality monitoring of staff groups. This enabled the trust to consider whether the diversity of the staff group was also representative of the patient group. Staff within the outpatient services felt there was diversity at the team level. The scorecard for June 2025 reflected this. The trust benchmarked themselves against the Office of National Statistics data for population.

The trust had an identified equality, diversity and inclusion action plan in place to promote localised action plans within each clinical service unit. However, we did not see evidence of a specific outpatient action plan.

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.

Multiple clinical service units worked within the outpatient department. Each clinical service unit (CSU) had its own recognised governance structure. Staff within the CSU’s were aware of the relevant structures. The outpatient department teams worked closely with the clinical service units and saw themselves as enablers.

There was a trust wide framework for quality and safety meeting agendas at departmental leadership level. We saw this was followed by outpatient leadership teams. These meetings fed into the wider trust governance structures. There was evidence of sharing learning from incidents recorded in the meeting minutes for senior leaders. We also reviewed service area meetings for the adult outpatient team. We did not see evidence of team meetings where information was cascaded to staff within the adult out patient department. However, staff told us that information regarding incidents and complaints would get discussed during huddles.

Staff understood the arrangements for working with other teams, both within the outpatient areas and externally, to meet the needs of the patients.

There was a risk register in place for outpatients and each individual clinical service unit managed their own risks. We saw that risks had review dates identified and were closed when the risk was no longer current. We saw that risks were referenced within departmental leadership meetings. Staff told us that security was a concern within the building and staff sickness was high. We did not see an open risk relating to these or detailed risk assessments and mitigations for reducing the risks. Fire risk assessments lacked clarity regarding mitigations put in place.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. However, some staff told us they did not always receive feedback.

Staff and leaders were all able to identify the same risk concerns.

There was a trust wide emergency preparedness plan.

Systems were in place to collect data from outpatient clinics that were not over-burdensome for frontline staff.

Staff had access to the equipment needed to do their work. However, there was inconsistency in the use of patient record keeping systems as some teams used paper notes whilst others used electronic patient records. Where paper notes were used they were specific to specialism, for example, therapies. This meant there was a risk that some information could be missed or not shared appropriately when using differing systems. For example, safeguarding concerns were recorded electronically whilst some teams used paper notes for clinical interventions recordings. We did not see evidence of a risk assessment to mitigate these risks.

Information governance systems included confidentiality of patient records. The trust had met the standards required for data security and protection when completing the recognised Data Security and Self-assessment Toolkit.

Leaders had access to information to support them with their management role including patient feedback and staffing. A recent staffing review had taken place. We saw that a staffing review had recently been completed and submitted as part of the wider trust safer staffing establishment review. Whilst this review recognised high sickness and absence with potential for impact on care quality it was not felt that a request for a staffing uplift was necessary by the team.

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.

There was a trust wide engagement strategy. The strategy emphasised the importance of engaging with people on an individual basis and through partnerships with groups such as Healthwatch.

We heard about engagement with other providers in the local community. Engagement with others was supportive in sharing positive practices and also in learning from others to improve services, for example engaging with a local private clinic to look at management of Did Not attend (DNA) rates.

There were some effective joined up practices with other local NHS trusts to support seamless care provision. For example, partnership arrangements supporting children’s services.

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.

Staff were supported to develop opportunities for improvements and innovation and this led to changes in care delivery. For example, the physiotherapy outpatient department had developed The Wait Well Initiative whilst the children’s services had focussed on developing quality pathways to improve the autism assessment wait times for the trust’s autism assessment service. Dieticians had led the way in promoting early management of coeliac disease.

Staff had opportunities to participate in research. Staff also encouraged patient involvement in research with a range of studies being recruited for through the outpatient department. Dieticians had led the way in promoting early management of coeliac disease. The work was shared widely through publication of an article in a national journal.

Staff used quality improvement methods and knew how to apply them.

At the time of inspection the outpatient departments did not participate in internal accreditation schemes, however, the trusts ward accreditation model was being developed for use within outpatients departments with a plan to roll this out.