Good Hope 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.

This is not the first assessment for this service but is the first time the service has been rated. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Most governance processes were effective and staff were passionate about driving improvements, innovation and research in the service. Staff worked collaboratively with key external agencies and partners. However, despite staff stating there was a positive culture at the time of our inspection, staff survey results and an anonymous contact after the inspection raised concerns over this and the use of the freedom to speak up service.

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. However, some areas of the 2025 NHS Staff Survey showed some concerns around culture and teamwork.

Staff were generally aware of the trust’s strategic aim to always put the needs and care of people first and to “build healthier lives”. There was a vision and values which underpinned the strategy and staff training included understanding the trust strategy. Staff were also aware of the trust’s 3 values, ‘kind, connected and bold’ and tried to ensure they embodied these values at all times. The trust had implemented awards based around the values which all staff could be nominated for.

The service had an imaging clinical service strategy which was launched in 2025. This provided staff with information around the short-term priorities. These included introducing the new imaging system and maximising the productivity and utilisation of all the modalities at the service. There was also a 5-year plan of priorities for the service which followed the trust priorities ‘our patients, our people, our potential, our place and our performance’, known as “the 5 Ps”.

Staff and leaders demonstrated a positive, compassionate and listening culture to promote trust and understanding between them and people using their service. They were committed to doing the best for their patients, keeping them safe, and treating them with kindness. Staff were mostly kind and caring about each other and worked in a warm, friendly, and respectful atmosphere. However, just before and after our onsite inspection, we were contacted by 2 members of staff to raise concerns over the culture within the service and how they had been treated as a result of raising their concerns.

Staff at all levels had a well-developed understanding of equality, diversity and human rights and they prioritised safe, high quality and compassionate care. At the time of our onsite inspection, there were no concerns raised within the service about any types of bullying, harassment, or discriminative behaviours. Staff survey results from 2025 showed there had been an overall improvement in staff having negative experiences. However, within team-working there had been an overall decline in how staff felt the team worked together. The areas within this which indicated the most decline was in relation to how disagreements were dealt with, staff enjoying working with their team, and the team meeting to discuss team effectiveness. These areas indicated there were some areas of concerns within the culture of the service. The service shared details around actions they were taking to improve the way staff felt about team working. However, this focused on appraisals which was not necessarily raised as a concern and therefore might not address the issues which led staff to respond negatively.

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 experience and capability to run the services well and support their staff. They were visible and led by example. They were aware of the issues facing the service with rising demand and the complexity of patient needs. Staff were enabled by their leaders to develop and learn in their roles. Leaders had the skills to be aware of any examples of poor culture that might affect people’s care and experience or have a detrimental impact on staff. Senior staff told us they would address this as needed. However, the staff survey results indicated not all staff agreed with this.

Staff feedback at the time of our inspection was largely positive. Staff within mammography were especially positive about their manager and how capable and compassionate they were. However, the results of the 2025 NHS Staff Survey showed line management within the service as a whole at this location was the metric which had the largest deterioration from the previous year (decline from a positive experience from 56.8% to 51.6%) as well as the largest deviation from the trust average (13.1% deviation from (worse than) the trust average). In addition to line management showing a significant decline, compassionate leadership had also decline from a positive experience of 60% in the previous year to 56.5% in the most current survey. This also showed a deviation of 11.2% from (worse than) the trust average. Despite staff telling the inspection team they felt supported by their immediate managers and that they believed their managers cared about their wellbeing, the responses from the staff survey indicated not all staff shared this view. Additional information showed all line managers had completed the ‘welcome to leadership programme’ as well all having completed the ‘how we behave matters training’.

Staff did not always feel they could speak up and that their voice would be heard or actions taken to resolve their concerns.

Not all staff felt they could speak up according to the wider survey results. Despite staff telling the inspection team they had no concerns about speaking up, results from the most recent staff survey showed less than half of the staff felt comfortable raising concerns (49.4% which was a decline of 3.6% from the previous year). In addition to this, only 37.7% of staff felt confident the trust would address any concerns raised. This was only slightly below the trust average but demonstrated that despite the trust implementing measures to improve the culture around speaking up

After the onsite inspection, we received feedback from an anonymous source who had raised concerns over the lack of support when contacting the Freedom to Speak Up team.

Nevertheless, staff who spoke directly with us felt confident and able to speak up without fear of detriment. They were aware of the Freedom to Speak Up Guardian service and their representatives, but each said they would probably contact their own manager in the first instance. Staff said they felt confident in their managers to listen and to act where possible. However, those we spoke with said they would not hesitate to contact more senior leaders, the Speak Up team, or the Care Quality Commission if they felt they had not been heard.

When something went wrong, patients received a sincere and timely apology and were informed of any actions being taken to prevent the same happening again. Staff were open and honest with patients in their care and gave them and their families an apology and a full explanation if things went wrong.

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

There was a diverse workforce which was representative of the local population. Most staff lived locally and saw Good Hope Hospital as their own hospital and said this meant it was valued by them. They wanted it to be a great place to work and receive treatment. A number of staff told us they had been unsure about working at the hospital. However, all had been pleasantly surprised with how welcoming and supportive staff were.

Policies and procedures in relation to the workforce were drafted in accordance with employment law, but also to reduce or eradicate discrimination and bias to achieve a fair culture for all staff. This included fair and proportionate recruitment policies and flexible working practices. Staff were able to take public holidays on different days when, for example, it enabled them to join in with religious or cultural events. They were able to request flexible working arrangements to fit in with caring or other responsibilities.

The 2025 NHS Staff survey showed there had been an improvement in staff feedback around diversity and equality from 28.7% of staff identifying this metric positively to 36.9% on the current staff survey. This result was also slightly higher than the trust average of 34.5%. Although it was acknowledged that the concerns around staff equality and diversity were going in the right direction, the result still identified the service needed to ensure staff felt safe within the workplace from an equality perspective. However, none of the staff we spoke with during our inspection discussed concerns over feeling harassed, bullied or discriminated against.

The service had mostly clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. They mostly acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, there was limited reporting of clinical and other audit metrics.

There was a model for governance and leadership which made the local team accountable for quality and safety. Leaders told us following the implementation of the new hospital structure, group clinical support services (GCSS) which diagnostic imaging was part of, also restructured to follow the site-based model for governance and leadership. However, it was still important there was cross-site oversight to ensure consistency in standards. The service had 2 clinical governance leads for diagnostic imaging, 1 covered only the Queen Elizabeth Hospital Birmingham and the other lead covered the other three district general hospitals, including Good Hope. They were key individuals for advocating for the needs of patients.

All local governance meetings fed into group GCSS board meetings, which subsequently fed up to the trust board and committee meetings. Due to the nature of the service, there were specialised meetings, such as radiation safety meetings which were held outside of the main core committee meetings and fed directly into trust level meetings.

Staff understood their role and responsibilities. Staff regularly attended a number of governance meetings including the quality and safety meeting and the groups compliance and regulatory meeting. The meetings had standardised agendas and covered all pertinent governance points including, but not limited to, incident investigations and those taken to the patient safety incident review group, safety alerts, audits, emerging risks and complaints.

Staff told us they felt they were updated on key governance issues. Some staff told us they attended monthly meetings with their colleagues where key information was discussed and concerns escalated. Other staff told us they kept up to date through reading the service newsletters.

Staff used a system to manage current and future performance and risks to the quality of the service. They took a proportionate approach to managing risk. The risks on the service’s risk register reflected those which staff discussed with us during our inspection. The largest risk identified was around the equipment capital risk. During the inspection, we observed equipment which required updating. However, this relied on constrained finances and staff told us previous plans to replace some imaging equipment had been postponed. Leaders had a plan to manage the succession requirements of the equipment within the department. They prepared business cases and assessments in advance for the next equipment items which required replacing so when funds became available, the leaders were ready to act.

Staff used audit information to effectively monitor and improve quality of care. We reviewed a number of audit reports, most of which had recommendations and actions for the staff to consider. The service had an audit plan for each of the modalities for the next 12 months as well as an audit schedule against the IR(ME)R requirements. Audits were an agenda item on the GCSS’s clinical quality and patient safety meetings. However, the minutes we reviewed did not demonstrate audits were reviewed and discussed. The minutes reflected outstanding audits and details around data collection. The service therefore had insufficient assurance around how audit outcomes were discussed and oversight of the actions recommended were completed.

Staff mostly had access to equipment and information technology needed to do their work. The service had recently updated an area to become a reporting hub which enabled more computers to be provided for staff to use. However, staff told us they still believed there was an imbalance in the numbers of available computers and the demands from the work they had. Staff said the IT and maintenance teams usually responded quickly to any issues with equipment.

There were effective arrangements for the security of patient records, data and files. Information was shared over secure systems. Data was submitted to external organisations as required. Radiation incidents were reported to the Care Quality Commission in line with IR(ME)R regulations.

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

Staff and leaders were open and transparent and collaborated with all relevant internal and external partners and agencies. Senior leaders told us they were involved in the Diagnostic Improvement Pathway Transformation Group which also had members from primary care, community care and staff from the integrated care system working together to develop new or improve new diagnostic imaging pathways.

Staff and leaders engaged with people, communities and partners to share learning with each other. The hospital held bi-monthly patient and public involvement forums where experience was shared and there was an opportunity for co-production of improvements in patient experience.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. Staff discussed examples where this occurred. Breast screening was an example where they worked closely with GPs to ensure patients accessed care and treatment and where referrals were required, this was delivered in a joined-up way. Another example provided was around the new pathway being delivered in relation to self-referral chest X-ray. The introduction of this new pathway supported patients to access chest X-rays in a timely manner which supported earlier diagnosis and treatment.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff and leaders had a good understanding of how to make improvements. The service had conditions placed on their registration following a focused CQC inspection in 2020. After regularly submitting information demonstrating their improvements, the conditions were lifted in 2021. During our inspection we reviewed information related to the delays in reporting of images and found the measures to tackle this had continued to ensure reporting of most images was completed within set key performance indicators (KPI). Where reporting was heading out of KPI, there were processes to outsource the reporting.

Leaders told us about other improvements they were making to the service to ensure a more effective and safe service for patients and staff. One example included radiographers commenting on nasogastric (NG) tube placement to reduce the number of NG tube related incidents and never events. The service was also in the early stages of implementing a new digital imaging platform which would eventually innovate the ways of working by working across organisational boundaries.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work which included research. The service was involved in a number of research and development programmes, although most of the imaging for studies occurred at other sites within the trust. There were clearly defined roles and responsibilities for staff when supporting research studies.