St Peter's Hospital

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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

We assessed 2 quality statements from this key question. The scores for our assessment have been combined with scores based on the key question ratings from the last inspection. Though the assessment of these quality statements indicated some areas of concern, our overall rating for Well-led remains good.

There was a defined management structure with clear lines of accountability within the division. Staff felt respected, supported, and valued by their local managers. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service. However, staff expressed concerns of the lack of an open safety culture within the trust and told us safety was not always a top priority. Some staff said they did not feel confident to raise concerns and felt this was adversely affecting the work of the division. A number of senior staff expressed worry about a lack of a clear vision and organisational strategy to guide priorities.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff within the division felt respected, supported, and valued by their local leadership and professional colleagues. We found staff were focused on the needs of patients but felt constrained by staff resources and other factors such as high bed occupancy rates. The service had a clearly developed leadership structure, with a triumvirate of medical, nursing and operational leads. Staff told us senior divisional leaders were visible and approachable, but this was not the same with senior trust leaders. We found there had been significant recent change in the trust leadership and the trust was responding to an independent review commissioned by the chairperson. We acknowledge that further planned interventions were being progressed by the trust. AS the trust received and carried out their factual response using a word document copy of the report they have seen the and responded to the correct version with all the text in the right place . The need to make the change does not relate in anyway to the factual accuracy process. i have already provided you with the text which is in the wrong place in this activity. I have shared here a copy of the report the trust received. We are asking for an error we have made to be corrected

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The trust had a governance structure for the division, covering risk, quality, performance and finance. Staff could access policies and procedures. Managers stated they held regular meetings with staff, during which they discussed clinical concerns and emerging risks. We saw examples of meeting records where actions arising from these meetings were shared with staff. Staff took patient confidentiality and information security seriously. We found examples of trust policies relating to consent, mental capacity and DoLS that were not versioned and staff information had not been updated.However, managers demonstrated that that MCA and Delirium policies were in the process of being ratified and were due to be approved at the appropriate committee shortly after the inspection visit. The trust also confirmed policies were labelled with version numbers.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.