Frimley Park 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

At our last assessment we rated this key question outstanding. At this assessment the rating has remained outstanding.

We assessed six quality statements. 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.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff.

There was a clear system of governance and risk management based around delivering safe and good quality care and treatment. The department was prepared for emergencies and major incidents and worked with others as part of a multiagency response.

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.

There was a good safety culture where events were investigated, and learning was embedded to promote good practice. Staff said raising concerns was encouraged and valued.

Staff and leaders demonstrated a positive and compassionate culture with a focus on learning and improvement. The trust values of \"Committed to Excellence, Working Together and Facing the Future\" were displayed around the trust and department. We saw staff lived these values. We heard staff describe the culture as "all one team" and "all are our patients". We saw numerous examples of this whilst on site.

Leaders fostered a culture of promoting of equality, diversity and human rights to prioritise safe, high quality compassionate care. All but one of the Workforce NHS Workforce Race Equality Standard (WRES) Survey 2023 questions on Black, Asian and Minority Ethnic (BAME) staff experience scored better than the acute trust average.

Leaders had an inspiring shared purpose and strive to deliver and motivated staff to succeed. There were high levels of satisfaction across all staff, despite the challenges they faced. Staff told us that they would bring a family member to be treated in the department.

Staff were helpful, welcoming and professional in their communication with each other, patients and their relatives. Leaders described a positive and compassionate culture. Staff and leaders embodied a positive, compassionate, listening culture. We saw that this culture promoted trust and understanding between staff, leaders and people using the service and was focused on learning and improvement.

There was a shared vision and a set of values amongst staff and leaders. The Emergency Department (ED) vision was ‘Together we will deliver quality emergency care to our patients. Driven by our commitments to excellence, compassion and safety'. Staff were aware of the vision and had been involvement in the development of it.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. Strategies and plans were fully aligned with plans in the wider health economy, and there was a demonstrated commitment to system-wide collaboration and leadership. For example, working with system partners on alternative pathways to avoid ED attendances.

Leaders ensured that the vision, values, and strategy were developed through a structured planning process in collaboration with people who used the service, staff, and external partners. Frimley Health NHS Foundation trust had developed a final draft of its five-year strategy, Frimley Health 2030, aimed at delivering compassionate, effective, and modern healthcare, enhancing patient experiences, and reshaping how healthcare is delivered. We saw that a people who used the service, staff, and external partners had been involved in developing the strategy in a variety of ways including focus groups, surveys and online feedback.

The service was aware of the projected increase in the local population and the pockets of deprivation. The trust was working with the Integrated Care Service (ICS) and other partners to develop a strategy to manage these demands. The trust had access to several community hospitals which allowed them to increase the flow through the hospital. Services in the community had been developed to support people in their own homes.

A Safety-II inspired approach to learn from every day work was starting to become embedded. Senior leaders demonstrated a culture of learning from all patient safety events, not just those that resulted in harm. Safety-II focuses on understanding why most healthcare delivery processes are successful and how they are performed correctly in high-performing units rather than why they fail.

There was a strong organisational commitment and effective action towards ensuring that there was equality and inclusion across the workforce. Staff told us that they were "one team" across the whole hospital and challenges were tackled together.

The national staff survey demonstrated year on year improvement in all categories. The trust's WRES National Staff Survey 2023 showed BAME staff density had grown over the past 5 years, from 36.39% in 2019 to 48.41% in 2024. There was an improving picture within all pay bands.

There were processes to support staff and promote their positive wellbeing. Staff we spoke to felt proud to work in the service. Multiple staff told us they had worked at Frimley Park Hospital for several years. Several staff stated the reason for remaining was due to the positive work culture. Data provided by the trust showed that the staff turnover rate was consistently below 10% for the previous 12 months, this was lower than the trust's overall turnover rate.

There was compassionate, inclusive and effective leadership at all levels. Leaders demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There was a deeply embedded system of leadership development and succession planning, which aimed to ensure that the leadership represented the diversity of the workforce.

There was a triumvirate leadership structure at departmental and directorate level with medical, nursing and operational leads in place. There were clear reporting structures and key roles were supported by deputies or associate roles to support succession planning. Staff understood the reporting structures and leaders understood their key roles and responsibilities.

Leaders demonstrated how they worked as part of a multidisciplinary team within the service and how they worked with external stakeholders, such as the local and regional commissioners, integrated care boards and local NHS ambulance and mental health trusts. Stakeholders such as local NHS ambulance and mental health trusts told us they worked collaboratively with the urgent and emergency services. They said they worked well together and there was regular engagement to review performance and identify improvements to services.

Medical and nursing staff and leaders understood the key risks to the department. They had deep understanding of issues, challenges and priorities in their service, and beyond. Leaders were able to explain the improvement actions being undertaken to improve capacity and patient flow in the department. For example, plans to ensure that the Same Day Emergency Centre was utilised to the maximise to alleviate pressure on the ED.

Staff told us the departmental leads and senior managers were approachable, visible and provided them with good support. There was support to the team from senior leaders in the trust, including the Chief Executive Officer and Chief of Midwifery and Nursing, who were regularly seen in the department. The Chief of Midwifery and Nursing held regular focus groups with staff this helped to create an atmosphere where staff felt respected, heard, and an understanding of their experiences and perspective.

Nursing staff were extremely positive about the matrons. Staff described how the matrons promoted excellent teamwork and effective communication. There was a culture of knowledge sharing and mutual respect.

All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning for the future. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

Staff and leaders actively promoted staff empowerment to drive improvement. The culture supported staff to speak up without fear of detriment. Leaders encouraged staff to raise concerns and promoted the value of doing so. Staff told us that they felt comfortable to raise any concerns and were confident that their voices would be heard and demonstrable action taken.

Call 4 concern was available to staff, patients and those close to them to raise concerns and we saw that these were listened to and addressed by the team.

The service had established Freedom to Speak up arrangements. Information about the guardian and how to contact them was available the internet. Whilst not all staff knew the name of the trust’s Freedom to Speak Up Guardian, they knew how to raise a concern.

The number of contacts to the Freedom to speak up service was increasing as was the complexity of issues raised. The Freedom to speak up team raised several challenges due to the pressures on the hospital. This included a reduced champion and ambassador network and the reduction in their duties, lack of infrastructure and investment. The trust had recently invested in further posts to support the development of the service. Anonymous concerns were at 12% which was slightly higher than the national average.

Patients knew how to make a complaint or raise concerns. The service clearly displayed information about how to raise a complaint.

Managers investigated complaints, identified themes and shared feedback with staff. Learning from these was used to improve the service. Staff understood the policy on complaints were able to give examples of learning from complaints.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed Duty of Candour was completed appropriately.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Assessment findings

Governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes. Governance was used to learn, improve and innovate.

Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, were clearly set out, understood and effective. Staff were clear about their roles and accountabilities.

Audits undertaken included clinical effectiveness and compliance with guidance from the National Institute of Health and Care Excellence (NICE). The service was also complying with the 3 audits commissioned each year by the Royal College of Emergency Medicine, which included the administration of time-critical medicines.

The service had policies and procedures for escalation and care of patients in non-designated areas, to mitigate the main risks from crowding. The hospital had processes to monitor performance and quality against national targets and standards.

Data systems enabled a good oversight of performance as evident in meeting minutes and in our discussions with staff.

The trust had an effective digital system for logging risks that linked directly to the incident reporting system. Leaders tracked the risks in the ED effectively using this and had oversight of the risks and their mitigations.

There were monthly emergency medicine clinical governance meetings. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Changes had been made when needed to improve the service. Good practice was recognised and celebrated.

There was a joint site assurance meeting 3 times a day. We observed a meeting chaired by the Deputy Chief Operations Officer the focus of the call outlined was to increase capacity and flow in the hospitals, to improve ED capacity and focus on facilitating safe transfers or discharges for patients. The call provided updates from both hospital sites across directorates on staffing, bed capacity and site team updates around discharges and the use of escalation beds. There were updates from estates, infection prevention and control, pharmacy, pathology, psychiatric liaison and community services.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. For example, staff told us how they had recently reviewed the Local Safety Standards for Invasive Procedures (LocSSIPs) for the insertion of chest drains in non-traumatic chest injuries. This resulted in a change to the LocSSIP, associated check list and standardised equipment pack. This was based on national guidance and best practice. A LocSSIP is a written Standard Operating Procedure that sets out the critical safety and quality steps required for invasive procedures.

The trust held monthly Safety Investigation Review Group and Patient Safety Steering Group meetings. We reviewed meeting minutes which showed good multidisciplinary attendance, a set agenda was followed and action tracker with owners and timescales.

Information held about patients was mostly secure and protected. Staff were part of the emergency preparedness network, and they had the strategies and guidance to respond to major incidents.

The trust had made a commitment to reduce operational carbon emissions to net zero by 2040, and last year published their Green Plan 2022-2025- ‘Building a greener Frimley Health'. Examples of the trust reducing the harm from carbon emissions and environmental degradation include: The launch of an electronic patient record - reducing the need for paper, the use of electric cars for staff needing to travel between sites, the increased use of dry powder inhalers in respiratory medicine, recycling of plastic such as oxygen masks and tubing and inhalers and making the endoscopy service greener buy reducing emissions from the medical gases used. The trust monitors it's carbon emissions and have achieved reductions in the use of oil, electricity and business travel year on year since 2014. This is a reduction of 24% in carbon emissions.

Staff told us they felt listened to and heard by the relevant stakeholders and external partners. They were supported by clinical partners. For example, there was a good partnership with the local NHS mental health trust providing support to patients with mental ill health in the ED and staff said they were responsive and supportive.

As a combined acute and community services provider, the trust worked in partnership with the local system. This included a local community trust, the local ambulance trust, GPs and the integrated care board (ICB).

There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the people. There were learning events scheduled for after the winter period with system partners to identify what worked well and areas for improvement for the next winter period.

Staff reported positive relationships with the local police force and Urgent Treatment Centre (UTC) which was co located but run by a different NHS trust.

The trust worked in partnership with the ICB and local GPs. For example, trying increase shared care uptake. Shared care is a particular form of the transfer of clinical responsibility between different healthcare partners.

There was a fully embedded and systematic approach to improvement, which makes consistent use of a recognised quality improvement (QI) methodology. The trust used a quality improvement methodology Frimley FX based on Lean methodology. They trained staff and expertise was marked using a series of "belts" like that used in martial arts. Each belt represented a distinct set of skills, responsibilities, and contributions to achieving quality improvement initiatives. Over 2700 staff had undertaken foundation level `White Belt' training so they could identify opportunities for improvement and use plan-do-study-act cycles to test changes and improvements. There were over 600 `yellow belts' who were trained in `Frimley Excellence' with its foundations in A3 thinking to deliver larger scale improvements, and over 60 staff trained to the `Green Belt' level meaning they are working to coach and grow improvement capacity across the organisation to tackle the biggest challenges. A3 thinking is getting the problem, analysis, corrective actions, the action plan down on a single sheet of A3 paper. We saw that staff who had undergone the training and managed quality improvement initiatives had different coloured lanyards to represent the belt colours.

Innovation was celebrated. Improvement methods and skills were available and used across the organisation, and staff were empowered to lead and deliver change. For example, following a patient safety incident when there was a delay to the diagnosis of a stroke, it was noted that neurological examination documentation was incomplete based upon these findings, it was felt a proforma for neurological examination would support clinical staff to document thoroughly and efficiently. A proforma in the electronic patient record was created. This was promoted at induction, via email, at board rounds and via the educational electronic group chats. Following introduction of the proforma a reaudit was completed which showed a marked improvement in documentation and evidenced the efficacy and uptake of the proforma. This was now used as regular practice and promoted at each induction for new starters. A neurological exam evaluates brain and nervous system functioning.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff. Staff were supported to prioritise time to develop their skills around improvement and innovation.

The trust introduced a Care Quality Programme (CQP) to support a trust-wide focus on ensuring continuous improvement. The CQP is a quality assurance tool of over 200 questions bringing safety and quality together in a specific timeframe. Wards were awarded bronze, silver or gold status.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation.

There was a consultant Quality Improvement (QI) lead. The department amalgamated all improvement work, for example, relating to patients attending with exacerbation of asthma, into trust wide committees such as mortality and morbidity meetings, QI meetings and patient safety committees. Effectiveness was monitored through scheduled audit cycles. We saw there was Quality Improvement plans to address areas for improvement.