Victoria Infirmary

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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.

We last inspected the service, in 2014 in combination with diagnostics and with the other location. 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.

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 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.

Staff knew and understood the provider’s vision and values and how they were applied in their day to day work.

The trusts vision was: “To inspire hope and provide unparalleled care for the people and communities of Cheshire, helping them to enjoy life to the fullest. Their values were: “we put you first”, “we strive for more”, “we respect you” and “we work together”. The trust mission, objectives and values were displayed and visible to staff and patients.

Staff had the opportunity to contribute to discussions about the future strategy for their service. Staff were involved where changes were happening in the service.

Staff could explain how they were working to deliver high quality care.

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 and experience to perform their roles.

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

Immediate line managers were visible in the service and approachable for patients and staff, however senior managers were based at the trust’s other hospital site. Staff we spoke with told us that managers had been less visible but recognised support from the matron who was covering for an interim period.

There was a general manager who was based at the service who was a direct point of contact for staff undertaking daily site walk rounds and attending weekly safety huddles.

Leadership development opportunities were available, including opportunities for staff to undertake additional training for their personal development.

Staff, we spoke with told us they felt supported and listened to.

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

Patients and those close to them had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Managers and staff had access to the feedback from patients, those close to them and staff and used it to make improvements.

The trust had policies and procedures in place to support staff to speak up formally and staff were able to raise concerns either in person or anonymously. There was a freedom to speak up guardian; and champions throughout the trust who were accessible to staff. Staff told us that they were aware of the freedom to speak up process, and we saw information and contacts displayed for staff who wished to raise concerns.

Freedom to Speak Up Week in November 2025 was used as an important opportunity to reinforce an open, supportive culture at the hospital and to launch the Trust’s Freedom to Speak Up Strategy 2025–2027.

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 able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. There were a number of staff, both registered and clinical support workers who worked part-time hours.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

Leaders monitored diversity of staff to ensure it was representative of the local population. The trust collected data as part of the workforce race equality standard (WRES) and workforce disability equality standard (WDES), however this was reported at trust level.

Feedback from staff was encouraged in the NHS annual survey and quarterly pulse surveys. One of the outcomes from surveys was the launch of ‘VIN Voice’ where staff could share their views anonymously including raising concerns but also celebrating colleagues. This has led to “you said, we did” actions by managers.

The monthly newsletter ‘VINews’, for the location was used to share any updates with staff such as available training and surveys. Face to face engagement had taken place including CQC awareness and FTSU activities.

Recognition awards took place such as “you made a difference” and “because you matter” as well as team awards and celebration of long service or retirements.

Events were held throughout the year including charity events.

The evidence showed a good standard. 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.

There was a clear structure and set agendas for scheduled meetings to ensure that essential information, such as learning from incidents and complaints was shared and discussed. This included the trust wide bi-monthly divisional quality and safety group (DQSG) that had representation from senior managers across the division. At these meetings agenda items included risk, quality, patient feedback, safety and any updates. A divisional integrated governance report was produced monthly that covered both outpatient departments for the trust. This included any update of risks in the departments, incidents across sites, patient feedback, clinic utilisation, staffing, training compliance and audits.

Monthly management meetings for the hospital were held with attendance from heads of departments. At these meetings updates regarding activity, incidents, improvement work and celebration of staff were shared. However, due to capacity issues representation by the service had been poor, therefore alternative weekly informal meetings had taken place between the general manager and the matron to ensure key messages were shared.

Staff had implemented recommendations from reviews of incidents and complaints.

Staff understood the arrangements for working with other teams, both within the provider and external to meet the needs of the patients.

Staff maintained and had access to the local risk register. Staff could escalate concerns when required.

Managers were sighted on the top risks for the service that included ventilation of outpatient procedure rooms as well as capacity. There were mitigations in place and actions were reviewed in governance meetings.

Staff had access to the equipment and information technology needed to do their work, however, we observed that multiple electronic systems were in use depending on the speciality. We were concerned that important information such as allergies or time-critical medicines recorded in one system may not be available elsewhere. We escalated our concerns whilst on site and were provided with details of actions taken to mitigate risks.

Team managers had access to information to support them with their management role. This included information, on a divisional dashboard, on the performance of the service and staffing. This reported monthly data as well as cumulative over the year for planned and actual activity.

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.

The service was working closely with the community teams as part of an integrated trust. We saw that the outpatient areas were shared with other teams which worked well.

Access to sufficient car parking had been raised by patients, visitors and staff. There were plans in progress to improve the situation. There had been 2 public events held to share proposed plans and discuss with the local community as well as stakeholders.

PLACE audits had taken place and included patient representatives.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

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.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery.

There was a focus on improvement and a trust wide poster displayed how to progress an idea.

An unwell patient pack for patients who become unwell within outpatient’s department areas had been developed. The pack included: a medical or surgical proforma, intravenous (IV) prescription, prescription charts, sepsis screening sheet and vital signs chart.