Mount Gould 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 leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This key question has been rated good. This meant there was a positive culture with capable leaders. Governance processes were robust.

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 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 service worked under the trust’s vision and values with a clinical strategy. The clinical strategy for the trust’s diagnostic imaging service had a core priority including to extend the provision of X-ray services in the local area.

Leaders and staff told us values were embedded in training and were built into appraisals. This ensured everyone knew what was expected.

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.

There was a clear management and leadership structure with clear lines of responsibility and accountability. The service had processes to ensure staff were recruited fairly and for roles in which they were competent. There was a process for leaders to meet and discuss issues and cascade information back down to staff in the service. The minutes from governance meetings showed leaders were knowledgeable about the issues and priorities in their services.

Leaders and staff told us they were well supported to perform their roles. They felt listened to and concerns were taken seriously.

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

The service had a Freedom to Speak Up process supported by an up-to-date policy and named Freedom to Speak Up Guardians. The service’s policy provided information on how to raise concerns internally and external to the service. Staff knew how to access support and raise concerns.

Staff told us they felt free to speak up and share concerns about the service. They said there were a number of ways to do this in confidence.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had training in equality and diversity. Staff understood the need to give everyone the same rights and opportunities and to value and respect people's differences. Recruitment practices were inclusive. The provider recruited staff through a range of processes.

Staff told us they had equal access to ongoing professional development. Opportunities to develop were advertised and staff completed an expression of interest.

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

The governance and management structure of the service was part of the trust’s wider structure. This meant that management, risks and planning of the service included all of the trust’s diagnostic services.

There was a clear management structure. Leaders and staff understood their roles and responsibilities. Leaders monitored the quality and safety of the service and identified where actions should be taken. Risks were monitored and reviewed. There was a clear reporting structure, from the service to the trust’s board, with various meetings reviewing the quality and safety of the service. The service held specific meetings relating to the provision of ionising radiation services.

There were processes to monitor performance of external contracted support services. Information was kept secure between referrer, the service and the third-party provider reporting on X-ray images.

There were capital investment plans across the trust’s diagnostic imaging services that included equipment at the Mount Gould Hospital. Leaders encouraged staff to report concerns, incidents, and breakdowns to support decision making on capital investments.

The service had business continuity plans should the service be impacted by certain events.

Leaders told us the service at Mount Gould Hospital was useful for the trust’s overall service provision, as the service was accessible and people who used the service provided positive feedback.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The service worked with the other locations from which the trust provided diagnostic imaging. Staff had systems and processes to share information. The trust’s management processes enabled concerns to be investigated and learnings to be shared via meetings.

Leaders told us they were planning to make improvements connecting with people using imaging services. There were plans to set up a patient experience group.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff actively contributed to safe and effective practice.

The service worked with the trust’s locations to make improvements to the service. The provider was trialling changes to service provision at another location that reduced the waiting list for X-rays across all services.