Glenfield 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

At our last inspection we rated this key question good. At this assessment we did not rate this key question as it was a focused inspection where we only looked at specific specialities. The rating for well led has remained as good. There was an area within the service where more focused work was needed to improve the culture amongst a minority of staff. Specialties we assessed 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.

However, there was 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. Specialities we assessed 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. They valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Specialties we assessed understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They focused on continuous learning, innovation and improvement across the organisation and local system.

We found 1 breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to governance.

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 which specialities we assessed were generally aligned with. 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, there was a speciality where more focused work was needed to improve the culture.

There was a shared direction within the wider service which specialities we assessed were aligned with. University Hospitals of Leicester NHS Trust set out 5 strategic goals to be delivered from 2024 to 2027. These included delivering high quality care for all, being a great place to work, embedding partnerships for impact, to provide research and education excellence and to be financially sustainable. Each Clinical Management Group (CMG) was expected to create an annual delivery plan outlining how they intended to deliver these strategic objectives. We reviewed the delivery plans for 4 CMGs which oversaw surgical services and specialities at Glenfield Hospital. The delivery plans were up to date and demonstrated how they were delivering the shared strategic objectives locally and within specialities based at Glenfield Hospital.

The delivery plans also outlined how they were driving improvements across 10 key deliverable targets set by the trust. We saw these targets were linked to some areas of concern we identified during our site assessment. For example, how they intended to deliver referral to treatment targets and reducing cancellations to improve clinic and theatre list utilisation.

Staff were not able to describe the strategic objectives but were able to tell us about the primary goals of their service. Managers had some awareness of the strategic objectives in relation to their area of work.

The trust had recently developed a group working model with local NHS trusts in a neighbouring county. The local objectives for specialities referred to this collaborative model. They set out how they intended to align services and increase referrals into specialist services from these neighbouring trusts. Staff working within specialities showed us how they implemented processes to improve referrals and admissions from local district general hospitals.

The trust implemented a continuous improvement culture strategy 2025-28 which was designed to structure patient-centred care and staff development in a framework of quality improvement. The strategy was aligned with the trust’s values and goals and service delivery plans and included the patient voice.

Staff and leaders ensured any risks to delivering the strategy, including relevant local factors, were understood and had an action plan to address them. They monitored and reviewed progress against delivery of the strategy and relevant delivery plans.

Service leaders promoted the staff survey to staff and there were improvement priority actions plans in place for each CMG which oversaw services at Glenfield Hospital. There had been an increase in the number of staff completing the survey in 2024, compared to 2023. The results varied across the CMGs and specialities. There were areas of positive improvement since 2023. For example, in theatres staff reported feeling valued by their immediate line manager. There were also areas for improvement, and plans to address them had been developed. Managers met with staff to go through the results and sought more detailed feedback from staff on areas of improvement. They worked collaboratively with staff to identify the top 3 priority improvement areas and had agreed actions to improve. For example, the ITAPS action plan for theatres had 3 priority areas including: empowering staff to feel they can speak up, recognition of good work and increasing development opportunities.

Most staff were very proud to work at Glenfield hospital. They valued the experiences they gained and were proud to work with leading experts within each speciality. Staff felt they were able to contribute ideas to improving services offered. Most staff considered they had good working relationships with their colleagues, managers and colleagues of differing roles. For example, nursing staff in general felt they had good relationships with medical staff and medical staff in general spoke highly of the nursing team at Glenfield Hospital.

However, within the cardiac surgical speciality, leaders had not been effective in driving cultural change and improving interpersonal relationships within the team. The cultural concerns related to a small minority of staff resulting in poor interpersonal relationships and behaviour which had impacted staff working within a speciality. The concerns dated back to 2016. Over time action had been taken by the trust to improve the culture, but these actions had not led to sustained improvement. In March and August 2024, further concerns were raised about the behaviour of a minority of staff within this service. The trust commissioned an independent review in April 2024 which showed there to be significant concerns with the culture, resulting in 32 recommendations. A detailed action plan was being worked through by the service at the time of our assessment.

At the time of our site assessment, we found these cultural concerns were still present. Many staff working in this service described uncivil and unprofessional behaviours from a minority of staff which impacted their wellbeing. For example, some staff told us they feared reporting these concerns, there was a fear of challenging decision making, a higher-than-average staff turnover and difficulties developing surgical skills as a result of the culture. The concerns mostly impacted staff working in theatres. Doctors in training reported some cultural improvements and acknowledged their learning experience varied depending on the specialty. Staff working on surgical wards considered improvements in behaviours from a minority, but there was still a fear culture amongst more junior staff of different roles in not feeling confident to escalate concerns. These behaviours were not fully in alignment with the trust strategic objective to make it a great place to work and to embed research and education excellence.

Following our site assessment, we shared these concerns with the trust who took immediate action to address this. The concerns were taken to the responsible officer advisory group and as a result, the trust commissioned an externally-led investigation under their raising concerns policy to address the cultural concerns. Trust leaders met with staff and outlined expectations of behaviours and provided staff with the theatre code of conduct policy. Staff impacted by incivility and poor behaviour were given an apology on behalf of the trust who met with them to hear and encourage concerns to be shared. Management support was increased in the department, and the guardian service undertook some focused sessions with staff. The trust had a wider action plan with medium and longer terms actions to continue to drive cultural improvements and sustain these improvements overtime.

Specialties we assessed 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. The surgical services at Glenfield Hospital were managed by 4 different CMGs. The CMGs worked across multiple sites to oversee areas of specialism across the trust. Each CMG was led by a clinical director, a head of nursing and head of operations. The leaders of the CMGs were knowledgeable about their services, the risks and overall performance. Leaders recognised they had a large portfolio, therefore delegated to a team of local site managers for each service they led. A team of matrons supported the nursing staff; head of services led the clinical services and general managers oversaw operations. They reported into the CMG leadership teams.

Leaders were generally visible and approachable for patients and staff. Most staff knew who the CMG leaders were, however, feedback about their visibility was variable. Matrons supported the head of nursing and staff knew who they were and generally staff felt supported by them. Nursing staff felt their local leaders including ward leaders and team leaders across all areas on wards and in theatres to be very visible and supportive. Clinical staff we spoke to knew who the clinical leads were and generally considered them to be visible and supportive when required.

Clinical leads within specialities were generally well respected by medical staff and nursing staff. They generally engaged the team and involved them in decision making. They worked well with the nursing team to make improvements to processes.

Leadership was sustained through safe, effective and inclusive recruitment and succession planning. Training was available to managers and leaders and those we spoke to during our site assessment had completed it. Leadership development opportunities were available, including opportunities for staff to progress. For example, there was a yearlong clinical leadership programme for specialist nurses and ward leaders. A band 6 deputy sister development programme was also available as well as a monthly workshop for staff to develop leadership skills. Staff from Black Minority Ethnic (BME) backgrounds were also encouraged to develop leadership skills and apply for managerial and leadership positions as part of the developing diverse leadership programme. Most staff we spoke to considered there were opportunities for them to develop new skills which included within their area of specialism as well as leadership. Staff in general felt the leadership teams invested in them and there were opportunities to develop management skills.

Leaders were generally visible and approachable for patients and staff. Patients we spoke to knew who was in charge on the wards and who was looking after them. We observed ward leaders walking round and talking to patients. Matrons undertook monthly audits which included talking to patients about the care they were receiving.

Specialties we assessed generally fostered a positive culture where people felt they could speak up and their voice would be heard. However, further work was required to address the culture amongst a minority of staff within theatres.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promote the value of doing so. In general, staff were confident their voices would be heard. There was a Freedom to Speak Up Guardian (FTSUG) service who had access to the executive team. Most staff knew about the service and how to contact them. The FTSUG were not direct employees of the trust which meant they were independent of the trust management teams. Members from the FTSUG team attended governance meetings and provided feedback to the board on themes and concerns raised. From June 2024 to May 2025, 10 concerns had been raised in relation to surgery at Glenfield Hospital. These concerns were logged and rated based on level of concern. We saw evidence the guardian service acted and escalated the concerns where appropriate and in agreement with the person raising the concern. We spoke to FTSUG staff as part of our assessment. They told us that the senior leadership team responded to issues raised. They considered the board were open and interested in the feedback provided.

There was a culture of speaking up, where staff actively raised concerns. However, it was recognised that some relationships within theatres needed further work. A small number of staff had demonstrated poor behaviour that did not reflect the trust values, and this had adversely impacted the wider clinical teams in 1 surgical speciality. Service leaders had taken some actions to address this and were continuing to work to embed a culture where all staff could speak up and raise concerns without fear. FTSUG staff recognised they needed to continue to promote the service to staff working in theatres and trust leaders told us this work had started following our site assessment.

Staff mostly described an open, transparent and supportive culture. We observed ward rounds and found all staff actively contributed to them and were listened to. We observed positive and open communication between nursing staff, doctors in training and registrars on most wards we visited. Within theatres, staff were overwhelmingly complimentary about the support and encouragement they received from the team leaders. They considered their team leaders would listen to them and deal with any concerns they had to the best of their ability.

The trust scored above the benchmark median average in all nine of the survey themes in the 2024 staff survey. Additionally, the trust’s scores remained the same or improved on the 2023 results on all nine survey themes. This included measures looking at staff engagement, team working and staff morale. Action plans were in place outlining how they intended to improve for 2025.

There was a proactive shared decision-making council within theatres and ward areas. This was well promoted across specialities we assessed. A newsletter was produced demonstrating activities of the council and to seek ideas for future staff engagement and improvements. Staff were given opportunities to give suggestions on making the service better. For example, they raised funds to produce heart shaped cushions to enhance physical comfort for breast cancer patients. They also organised international workers celebration events to showcase the value of international staff.

Under the Freedom of Information (FOI) Act 2000, people had the right to request access to information held by the trust. Information was available on the trust’s website and patients were able to send a FOI request to the trust by completing an online form.

Specialities we assessed valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Managers used Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES) information to drive improvements with workforce equality, diversity and inclusion across surgical services. The most recent trust wide WRES and WDES data for 2024 shows variable performance. For example, the WRES showed further work was required to improve the number of Black Minority Ethnic (BME) staff members being appointed into senior roles. BME staff also reported higher levels of discrimination and reduced confidence in career progression. However, there was a high representation of Asian staff in professional scientific and technical roles and a high proportion of black staff within student roles.

WDES data showed disabled staff were positively represented in non-clinical roles and senior non-clinical positions, however, were underrepresented in clinical and medical roles. Disabled staff were represented at senior non-clinical roles which was a positive improvement in comparison to previous years. Positive experiences were reported on equal opportunities in career progression, promotions and making reasonable adjustments.

A trust wide action plan to improve equality in the workforce had been embedded within the surgical services and was used to inform the surgical services annual delivery plans. For example, at Glenfield Hospital we saw the developing diverse leadership programme was embedded to increase uptake of BME staff in management and more senior positions.

Leaders took action to improve where there were any disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. For example, staff told us leaders had previously listened to feedback that staff from BME backgrounds did not consider they were supported to progress into leadership positions. At the time of our site visit, staff from ethnic minority group backgrounds felt this had significantly improved and they were given fair opportunities for progression.

Managers within surgical services undertook overseas recruitment campaigns for doctors and nurses. They recruited staff to reflect the culturally diverse communities they served. Managers recognised the impact this had on improving the experience for patients in terms of having staff who understand local culture and languages of local communities.

Managers supported staff with flexible working to meet their individual needs and personal circumstance. Managers recognised international nurses needed extra support to manage family life, therefore ensured rostering reflected staff needs. Staff told us they were able to apply to work flexibly to meet their individual needs. International nurses we spoke to felt supported to book extended leave to return home. They told us they felt comfortable to feedback any concerns to managers who acted to address them. Managers supported international staff socially and outside of work to integrate into a different culture. There was support in place to help people set up bank accounts and find accommodation.

Managers recognised their responsibility to support the mental and emotional wellbeing of their staff. The most recent staff survey demonstrated improvements had been made with flexible working arrangements.

Leaders ensured there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff with protected equality characteristics and those who are excluded or marginalised, or who may be least heard within their service. Most staff we spoke to felt in general leaders provided opportunities for staff to feedback and were listened to. There were opportunities for staff to feedback ideas on improvements to management which were staff led. Celebration days were organised for staff including celebrating internationally trained nursing staff.

Specialties we assessed 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.

There was a complex governance and management structure across the surgical specialties. There were 4 CMGs which had responsibilities over and above the location and the specialities we assessed across the rest of the trust. These CMGs were The Cancer, Haematology, Urology, Gastroenterology and General Surgery (CHUGGS), Intensive care, Theatres, Anaesthesia, Pain and Sleep (ITAPS), Musculoskeletal and Specialist Surgery (MSS) and the Renal Respiratory and Cardiovascular (RRCV) groups. Each CMG had monthly board meetings which provided oversight of quality and safety issues, performance and updates from specialities. They were led by a clinical director, a head of nursing and head of operations. Each surgical speciality was led by a head of service who was the lead consultant and was supported by administrative teams and matrons.

The governance structure generally supported consistent and effective board to ward communication. However, ward level and some clinical meetings often lacked consistency and structure.There was not always an agreed agenda for what must be discussed at a ward, team, clinical management group or speciality level to ensure essential information, such as learning from incidents and complaints, was effectively and consistently shared and discussed. We reviewed meeting minutes for CMG board meetings, ward meetings and consultant meetings. We found the structure and content was inconsistent across the specialities we assessed, and different templates were used. There was lack of alignment between ward to board subject matter in the content of the meetings. Leaders told us following their review of factual accuracy that they shared learning from incidents and complaints routinely through daily ward safety huddles, and ward leaders disseminated incident-related learning to their teams by email.

Incident review meetings took place weekly where all incidents of moderate and above harm were discussed. The meeting provided a rapid assessment of all significant incidents including never events. Where required, staff directed immediate safety actions in addition to tracking and reviewing incident investigations. There was a clear escalation process through the monthly quality and safety meetings and patient safety incident response committees.

All patient deaths were reported to the Medical Examiner (ME). Where there were concerns with the quality of patient care the ME reported these to the clinical director and clinical leads for specialities.

The services we assessed reported into the infection prevention and control board assurance framework which was reviewed at trust board meetings. However, further work was needed to improve governance around Surgical Site Infection (SSI) oversight. An SSI policy was being devised which would lead to formalised reporting to board and meeting structure. However, this was not in place at the time of our site assessment. Reporting of SSI rates and actions was discussed during divisional meetings and informal task and finish groups where work was being undertaken to embed an SSI programme.

Mortality and morbidity (MM) meetings took place but were not consistent across specialities. MM meetings were undertaken and led by each surgical speciality. Following our site visit, we requested MM meeting minutes for each speciality. We reviewed minutes for thoracic, vascular, breast, and cardiac surgery specialities. Renal and hepato-pancreato-biliary minutes were not provided to us at the time of our assessment. However, they were provided by the trust following their review of factual accuracy. We found the format of the meeting minutes varied across each speciality. For example, we found the vascular and thoracic team had clear meeting minutes which documented attendance and provided a summary of each patient discussed. Both specialities demonstrated good attendance from the surgical teams to discuss cases. The breast team produced a detailed report on service activity as well as a detailed overview of specific cases. However, we found the cardiac surgical specialty MM meeting minutes did not have attendees documented and the patient summary was limited. It was unclear which case had been discussed and whether there were any learning or outcomes. Leaders told us following their review of factual accuracy, that attendance was electronically recorded.

The CMG leadership team had a monthly performance review with the trust executive team. They presented their performance dashboard where the metrics were scrutinised, and actions set to improve performance. Staff told us this was both a challenging and supportive meeting.

The CMG structure sometimes led to challenges. Leaders of the CMGs we spoke to considered there were opportunities for CMGs to interact and collaborate. For example, there were meetings at each level of nursing that crossed over specialities as well as patient safety incident review framework meetings. However, the governance structure at Glenfield Hospital sometimes prevented effective change and improvement, delaying action being taken to address significant issues or concerns. During our site assessment, managers and staff working within the CMGs we spoke to shared examples where the crossover between CMGs caused problems. For example, the CMGs who oversaw surgical specialities were responsible for the budget required to purchase surgical equipment, yet the theatre teams were responsible for ordering and ensuring the equipment was in place. Managers and staff told us this caused conflict and delays in ordering as equipment had to go through a ‘clunky’ process of authorisation. This sometimes led to changes to theatre lists where equipment was not yet ready and delays in patients undergoing surgery. CMGs we spoke to recognised this and was in the process of implementing a centralised budget to reduce the delay in ordering equipment.

Furthermore, managers recognised there was a disconnect between the theatre’s leadership and speciality leadership to effectively address cultural concerns within a speciality. For example, a detailed action plan was in place to address these cultural concerns which was led by the CMG who oversaw the speciality. They considered there had been improvements in the culture. However, the staff working in theatres who were impacted by the cultural concerns still considered the cultural issue were continuing with minimal improvement. Managers of the CMG who oversaw theatres did not always consider if the concerns and impact on theatre staff had been fully addressed as part of the action plan in a timely manner.

Post-operative wound clinics lacked oversight and governance to ensure patients were safe. Ward clinics were available to patients post discharge on wards 26 and 31. Patients attended the clinic for dressing changes and suture removal where they could not be safely done in the community, and wound reviews where there were signs of infection. There was no evidence of a standard operating procedure (SOP) or booking system to ensure these attendances were recorded, and risks and treatment given were documented. For example, there was no option for staff to record pictures of wounds or update records of attendance on the patient record as they were not admitted to the ward. Leaders told us following their factual accuracy review of this report, a formal SOP and digital documentation pathway was being developed to strengthen governance’

Risk registers were in place and monitored at a divisional level through the quality and safety board. Following their factual accuracy review of this report, leaders provided minutes of the RRCV CMG quality and safety highlight report for April 2025 and a risk assurance report for May 2025. This demonstrated the RRCV CMG had a process in place to escalate to the trust board, new risks or concerns, documented actions taken and positive assurance in place, and decisions made to mitigate the risks. However, some risks on the risk register were long standing and did not have a robust plan to reduce the risk. For example, there were 3 risks associated with the quality of the environment within theatres at Glenfield and the lack of capital funds to refurbish. During our site assessment we observed some theatres to be in a poor condition and both managers and staff shared concerns about delays with repairs and lack of refurbishment. During our last inspection in 2022, we identified concerns with the condition of theatres and noted this was on the risk register along with issues about lack of capital investment to refurbish. This meant there was lack of reassessment of the risk or robust actions to mitigate the environmental risks in some theatres which had been a concern for several years.

The risks were generally aligned with the issues staff and managers raised with us during our site assessment. All CMGs had some ‘very high’ and ‘high’ risks. For example, the ‘very high’ risks on the ITAPS risk register related to the theatre estates and high risks related to staffing vacancies and information technology system replacement. Not all staff could tell us what was included on their service risk registers, however they could tell us about areas of risk they faced locally.

In general, the risk registers were in a suitable format, were dated and described the issue, risk, potential consequence, controls in place, preventative measures and assurances. There were actions in place with timescales and ongoing updates.

Management of risk day to day was overseen by site managers. There was a matron of the day allocated to trouble shoot any specific issues such as staffing challenges. In theatres there was an allocated team leader to deal with issues and provide support to all specialities. Theatre briefings took place daily at 8am where they discussed theatre lists and any challenges.

Team managers had access to information to support them with their management role. This included information on the performance of the specialities and services we assessed, staffing and patient care. All managers we spoke to had a good insight into the performance of their area. They underwent regular performance reviews and actions were set to drive improvement. A new accreditation process had been introduced in alignment with the role out of electronic patient records to provide each are with a score for quality and safety. Performance was reviewed by the head of nursing monthly and actions for improvement set.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

At the time of our assessment, the service was in the process of moving over to Electronic Patient Records (EPR). Managers told us they believed the introduction of the EPR would give them greater oversight of the performance of their services.

Specialities we assessed understood their 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 they collaborated with relevant external stakeholders and agencies. For example, they worked with local commissioners and external specialists to improve the service they offered.

Staff and leaders worked in partnership with key partners and organisations to support provision, service development and joined up care. The surgical leadership team was working towards a trust wide strategic objective called ‘Partnerships for impact’. Speciality action plans incorporated how they intended to build partnerships with local district general hospitals to increase referrals into their services.

Specialities we assessed provided specialist surgical procedures to a large area, accepting patients from neighbouring hospitals. Satellite clinics were set up at these hospitals to improve partnership working and to create a collaborative pathway for the patients.

Staff and leaders engaged with partners to share learning with each other that resulted in continuous improvements to the service. They use these networks to identify new or innovative ideas that led to better outcomes for people. For example, clinical leads supported neighbouring trusts with the management of complex cases. The cardiac service was a centre for aortic dissection and took emergencies from across the East Midlands.

Specialities we assessed 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. Staff actively contributed to safe, effective practice and research.

Staff and leaders had a good understanding of how to make improvement happen. Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Shared decision-making councils took place across the services and specialities we assessed. Staff we encouraged to contribute ideas for improvements and presented these to managers. The decision-making councils led on rolling out new ideas to improve the service for staff and patients.

Innovations were taking place across specialities we assessed. There was an active research, development and innovation (RDI) team at Glenfield Hospital. The RDI department had a 5-year research and innovation from 2023 to 2028. This was linked to the trust’s strategy to:

• Embed research into everyday clinical care
• Drive innovation and service improvement
• Support staff retention and development
• Promote equity and inclusion in research
• Strengthen partnerships

University Hospitals Leicester, including Glenfield Hospital, supported a wide-ranging research and development infrastructure. It hosted several bodies within the National Institute for Health and Care Research (NIHR).

Specialties we assessed led on multiple clinical research projects in association with universities and consultant led research. In cardiac services they had commenced a mini aortic arch programme and a mini mitral service. They had also implemented an online cardiac rehabilitation programme and in thoracic surgery, an ion robotic bronchoscope service was launched in September 2024. This service had developed a diagnostic tool designed to improve the early detection and treatment of lung cancer.

Staff working with surgical teams were provided with training, research involvement and working with experts in their field. For example, in thoracic surgery, they had weekly training and education sessions for the multi-disciplinary team to learn. Positive feedback was received from trainees. In vascular surgery, a surgeon was appointed as a clinical lead for vascular science with the physiological science network. The vascular service used innovative practice as part of their medical teaching programme. They used high and low fidelity simulators which enhanced the learning experience and increased attendance at national conferences.

A ward accreditation scheme encouraged a culture of continuous improvement. The scheme aimed to improve the quality of care, staff engagement and patient experienced. Wards were awarded a bronze, silver or gold status following an assessment against a quality framework.