Pilgrim 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 looked for evidence that service had capable and compassionate leadership and governance assured high-quality, person-centred care.

At our last inspection we rated this key question good. On this inspection we found some areas that required improvement, however, as we only looked at a small number of quality statements. Therefore, the rating has remained good. This meant that governance did not always assure high-quality, person-centred care, however, the service had capable, compassionate and inclusive leaders.

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.

We did not look at Shared direction and culture during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We scored the service as 3. 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 services they managed. They could explain clearly how the teams were working to provide high quality care. Staff were supported to develop their skills and take on more senior roles.

Staff and patients told us that ward managers and matrons were visible and approachable. It was clear who was in charge of the shift, and staff roles were clearly displayed in the entrance to wards and clinical areas. Some staff told us that senior leaders above matron level were not always visible in ward areas. Most staff told us they felt the leadership culture of the wards was good. Most staff felt that they were valued and respected and that leaders were inclusive. Leaders told us how they addressed poor care and gave examples of the process.

Across the wards we visited leaders engaged with staff, understood the difficulties and challenges staff faced and engaged and motivated them to provide high quality care. However, in the discharge lounge staff felt that issues in relation to patient suitability and medical coverage that they raised had not been properly addressed despite being raised consistently over a long period of time.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders and staff understood their roles and responsibilities. Staff knew where their individual wards sat within the governance structures. Wards 6A, 6B, 7A, 7B and 8A sat within the medicine division, under various specialities. The discharge lounge sat within the corporate division. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

There were issues raised in relation to the suitability of patients for the discharge lounge and medical coverage of patients. Staff had raised this issue consistently, and it had not been properly addressed despite being raised over a long period of time. The discharge lounge sat outside the medicine division. After these issues were raised as part of inspection feedback the Trust provided the reviewed inclusion/exclusion criteria as part of the evidence request. We were also provided with a standard operating procedure (SOP), which also came into place on 20 February 2026.

Local leaders did not have access to a clear framework of what must be discussed at a ward or team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. As part of inspection process we requested 6 months’ worth of team meeting minutes and they were completed inconsistently and when completed, had differing topics that were discussed. The trust told us that ‘some teams have found it difficult to have regular formal team meetings, therefore they have adapted ways in which the information can be disseminated to the teams,’ There was some evidence of learning from incidents being shared and disseminated in the meeting minutes we reviewed. We also saw information disseminated in newsletters. The trust told us information was also shared via closed online chats and safety huddles.

Quality and performance was overseen within the divisions. Wards 6A, 6B, 7A, 7B and 8A, were part of the medicine sub-specialties of older people’s medicine, gastroenterology and respiratory. As above the discharge lounge was in a separate division. As part of the data request we reviewed governance meeting minutes where governance reports were discussed alongside other areas. The agenda also included incidents and complaints, morbidity and mortality, operational performance, staff, audits, policies and staffing. There were also governance updates from the individual specialities within these meetings. Actions were clearly assigned and monitored as part of this process.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. As part of this inspection process, we reviewed monthly matrons’ audits in relation to MCA and DoLS, medicines, risk assessments and documentation (including falls, tissue viability, nutrition and hydration). We also reviewed the safeguarding teams audits of MCA and DoLS practice and the pharmacy teams audit of controlled drugs. Leaders and teams used these audits to manage performance and improve safety by actioning results.

Staff and leaders could identify relevant risks and issues within their services. However, the risk registers provided as part of the data request were limited and did not accurately reflect the risks in the services we saw and what staff told us. The relevant risks were mostly in relation to consultant staffing levels within the specialities. For example, the risks in relation to the inclusion/exclusion criteria and medical cover in the discharge lounge were not on the risk register but leaders were aware of these issues. The risks in the risk register had named staff members responsible and had evidence that they were regularly reviewed.

Systems were in place to keep data secure, accurate, and accessible. There were clear policies for managing digital and paper records, including retention and disposal. Systems were secure and patient identifiable information was handled correctly. Staff completed mandatory information governance training. Information systems were integrated and secure. Data and notifications were consistently submitted to external organisations as required.

We did not look at Partnerships and communities during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Learning, improvement and innovation during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.