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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

Outstanding: This meant the service was consistently very well managed and well-led. Leaders and the inclusive culture they created always promoted high-quality, person-centred care.

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.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 4. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of patients and their communities. Leaders proactively identified areas for improvement and took decisive actions to support staff inclusively.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Leaders ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision, values and strategic goals and how their role helped in achieving them.

Leaders promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff said they trusted the local leadership teams and mostly felt able to raise concerns with them. Most staff felt respected and valued by their colleagues and the leadership team within the trust. There was a strong sense of teamwork which encouraged candour, openness and honesty. Staff said this helped them cope with additional pressures when they were very busy.

The culture within the service was centred on the needs and experience of patients. A few staff said they felt ‘tired’ but were being supported. All staff said the service operated in an open, friendly and inclusive manner. There was a ‘no-blame’ approach used with respect to complaints, incidents, and errors. They all told us they enjoyed working there. We saw very positive professional interactions between staff in the service and highly effective communication with patients.

Staff were very proud of their hospital and team. 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 local plans. Staff spoke highly of their colleagues and how supportive they were. Some staff described their team as “like a family”. Team and Individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

Local leaders were proud of their staff at the hospital with a team working and learning culture that they were most proud of. Leaders said that came about through strong interpersonal relationships, strong working commitment and commitment to patient care.
Everyone worked in a very professional manner with a strong emphasis on teamwork.

Local leaders spoke of their ongoing work to strengthen the Clinical Decisions Unit (CDU) such as they had held a listening event with the deputy chief nurse with ongoing meetings since then to ensure staff voices were fully heard. . Leaders provided detailed evidence of how, following discussions regarding the well-being of the team on CDU, further support was highlighted to understand the concerns raised. The aim was to improve staff morale, behaviours and working culture. An outside independent coach was brought in to engage with the staff and listen to them, understanding what matters most, and using this as a platform for staff led improvement. Listening to staff, through planned listening events and hearing their experience of working in a busy admissions unit led to leaders developing some time out days for the Band 6 deputy leaders on CDU. This was the staff group that were most commonly in charge out-of- hours.

Leaders facilitated a time out day for staff, away from the hospital in a nice environment with a lunch provided to help staff feel valued and to recognise their input with an agenda that supported reflection and vision for the future. The first day was well evaluated with excellent engagement from the staff, the second time out day was planned for the October 2026. The Band 6 nursing team on CDU were also included in a 2 day development workshop alongside their Emergency Department colleagues that encouraged team working across the urgent and emergency care pathway. Leaders also adjusted the skill mix for the unit to include increasing Band 7 nursing staff from 3 to 6 to provide more visible leadership. This demonstrated leaders’ commitment to supporting and empowering all staff inclusively.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 4. 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 very effectively. They did so with integrity, openness, honesty, and compassion.

Leaders had a diverse range of experience, skills and abilities to run the service, and they fully understood and managed the priorities and issues the service faced. Leaders were very visible and approachable in the service for patients and staff. Staff felt the leaders supported them very well to develop their skills and take on more senior roles.

The senior management team were present, supportive and clearly knew their staff and their challenges. They were compassionate and kind to each other and to the ward staff. They appeared an experienced and cohesive team working hard for the benefit of all patients, staff and their local community. Leaders had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered, and risks were well managed. Leaders at every level were visible and led by example, modelling inclusive behaviours.

Staff told us that they knew who their senior leaders were. Leaders were continuing to deliver the staff experience improvement plan, which was working to address the key themes identified in both the annual and quarterly surveys and responding to patient and visitor feedback. High-quality leadership was sustained through safe, effective and inclusive recruitment and succession planning.

Leaders were very knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. Senior Leaders empowered staff to create quality improvements through their Leicester Excellence Accreditation Framework (LEAF) programme.

Leaders were alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. They addressed this quickly.

Leaders had a detailed understanding of the services they managed. They could explain very clearly how the teams were working to provide high-quality care. Leaders also understood pressures around staffing in their teams and would work with other wards to avoid unsafe staffing levels at all times. We saw leaders on Ward 20 discuss with other wards how to alleviate their staffing pressures that day. There was also a very organised site meeting held daily whereby any pressures or concerns were addressed effectively at pace.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. We observed examples of feedback displayed on posters on the wards. Patients told us that they felt comfortable raising concerns.

Patients and carers were sometimes involved in decision-making about changes to the service. Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

Staff knew their Freedom to Speak Up (FTSU) Guardian, and how to access them. Staff and felt comfortable to approach the FTSU Guardian.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Quality Statement Score: 4.

We scored the service as 4. The service always valued diversity in their workforce and were proactive in supporting all staff inclusively. They worked towards an inclusive and fair culture by improving equality and equity for everyone who worked for them. Diversity was celebrated.

Staff told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Feedback from staff who we spoke with, and the staff survey told us that the service provided an inclusive environment where people felt valued regardless of their background or identity.

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. Leaders provided examples of how proactively they sought to support staff with diverse needs, making adjustments to working hours, providing support from practise development nurses, and use of different types of equipment to meet individual needs.

Every year the RRCV CMG hosted a cohort of Japanese nursing students who visited the UK to learn more about British health care and the NHS. This visit was led by the Head of Nursing, Deputy and Matrons and Specialist Nurses. The students heard about the specialisms; the care patients receives and the experience of nursing in the Glenfield Hospital. The Head of Nursing described the culture and the aims of the organisation in developing a diverse workforce. This annual visit was well received and has become embedded in the service as a valued experience for these students.

We also noted staff feedback about the trust’s diverse leadership programme, which promoted an inclusive culture within teams, by encouraging staff voice, supporting development opportunities and ensuring that diversity and inclusion remained part of everyday leadership. By recognising and valuing the individuality of both staff and patients, leaders were creating stronger teams, improving engagement and contributing to safer, more person-centred care.

The CMG had a Recruitment and Retention Matron, who was passionate about creating a positive culture where staff members felt valued, supported and empowered to develop their careers. Working collaboratively with the other recruitment leads across the trust, the CMG used staff feedback to improve recruitment, retention, engagement and wellbeing. Through compassionate leadership, inclusive practice and a focus on career development, leaders and the Matron helped create an environment where people wanted to join, stay and grow their careers, enabling the service to retain a skilled and motivated workforce that delivered high-quality patient care.

Information the trust provided showed interventions are monitored to evaluate their impact. For example, leaders collected feedback from all staff including students and reported actions. Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Checking accountability included ongoing review of policies and procedures to tackle structural and institutional discrimination and bias to achieve a fair culture for all. Staff told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

Leaders used proactive ways to engage with and involve staff, with a focus on hearing the voices of staff with protected characteristics.

Staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation. Staff said they were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. There were equality and diversity champions within the service e.g. LGBTQ+, and BAME.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance systems and processes were established and operated effectively by the Clinical Management Group (CMG). Detailed information regarding performance was produced, reviewed at regular governance meetings, and used to monitor effectiveness and progress across services. Each specialty submitted quarterly clinical governance and patient safety reports, which included key quality, safety and performance metrics. In addition, each specialty produced its own quarterly clinical governance and patient safety report, detailing specialty-specific quality, safety and performance indicators. These reports were discussed at specialty management meetings, where areas of good practice and actions for improvement were identified.

Action plans had been developed and implemented in response to incidents. Staff described how learning from incidents was shared within teams through ward huddle meetings.

Minutes from governance meetings clearly outlined performance and safety issues across specialties. Actions required to improve services were identified and monitored appropriately. Local leaders told us that key messages and learning were cascaded throughout staff teams. Each speciality also held monthly quality and safety meetings, and we saw evidence that key themes arising from these meetings were reported and escalated appropriately to divisional board meetings.

We reviewed a sample of divisional board meeting minutes from November 2025 to February 2026. Meetings were attended by relevant leaders and provided oversight of specialty-level risks and performance issues. Meetings were well attended. Risks were clearly documented, and actions to mitigate these risks were identified and monitored. The risk register for the service was comprehensive.

There was a framework of what must be discussed at a ward, team or CMG level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

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. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Leaders monitored Deprivation of Liberty (DoLS) and Mental Capacity training compliance via the safeguarding assurance committee. Leadership teams reviewed the deaths of people who were diagnosed with autism and Learning disabilities. This ensured people who were subject to DoLS restrictions or lacked mental capacity were supported in line with their rights. We also saw a robust process for carrying out PLACE audits, with improvements made swiftly when required.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders were open and transparent, and they collaborated with relevant external stakeholders and agencies, such as the integrated care board and local authorities. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care.

Staff and leaders engaged with people, communities and partners to share learning with each other that results in continuous improvements to the service. They used these networks to identify new or innovative ideas that can lead to better outcomes for people. Local leaders spoke of how in the last 12 to 18 months, they had seen a shift in more collaborative working, particularly with ICB colleagues. They also spoke of improvements in the discharge processes, working with local authority colleagues and the impact that the complex discharge nurses were having to ensure patients' needs were being met.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 4. The service robustly focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged the most creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research both regionally and nationally.

Staff and leaders had a good understanding of how to make continuous improvement happen. The approach was consistent and included measuring outcomes and impact to improve patient care. For example, the trust operated an accreditation and assurance programme, Leicester Excellence Assurance Framework (LEAF), which was a programme designed around a quality improvement methodology to allow staff to participate in projects based around a quality and safety aligned to their ward dashboard. Projects had actions, conclusions and review dates so that their implementation could be monitored and progressed. From our conversations with senior leaders, we were assured the trust was actively trying to improve their service.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Staff were supported to prioritise time to develop their skills around improvement and innovation. There was a clear strategy for how to develop these capabilities and staff were consistently encouraged to contribute to improvement initiatives. Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff.

We heard of some excellent initiatives including the student placements of three young people with a learning disability and/or autism.

Consultants spoke highly of their commitment to research with 40 researchers with very high publication numbers, not just in airways diseases, but also in other areas. There was a very good collaboration between the research teams and the clinical teams.

Glenfield was only the 7th Hospital in the UK to achieve the Pathway to Excellence accreditation from the American Nursing Credential Center (ANCC). The Pathway to Excellence program is recognised globally for promoting nursing excellence, instilling a strong sense of professional pride and offers proven strategies to help ensure that the care delivered to patients is of the highest standards. Leaders said that the Pathway to Excellence creates a positive practice environment for all colleagues and supports staff to have a voice and feel listened to.

The Pathway to Excellence can demonstrate improvements in:

• Staff retention and recruitment, reducing reliance on agency staffing and associated costs.
• Workplace culture, leading to improved productivity and reduced sickness absence.
• Clinical outcomes, which contribute to more efficient patient flow and reduced variation in care.

The Inherited Cardiac Conditions Service (ICC service) at Glenfield Hospital was one of 6 pilot sites selected across the UK for the British Heart Foundation and coronial service sudden cardiac death pilot which started in 2021 (due 2020 but deferred due to COVID). The service’s contribution to the success of the pilot project resulted in a national roll-out of this model as standard of care. The service’s participation in this project had resulted in standardised streamlined, holistic and evidenced based care following unexplained sudden cardiac death for both the deceased individuals and their family members across Leicestershire. The project had also resulted in effective high quality cross department partnership between cardiology, clinical genetics, pathology, bereavement services and the coronial services to cater for different aspects of care following sudden cardiac death.

We also noted the notable downward trend in falls in the service, and the improvement was clearly linked to two key changes:

• Implementation and consistent use of sensor devices, supporting early detection and prevention.
• More detailed incident reporting, which enabled appropriate de-escalation of medical collapse cases and improved the accuracy of the service’s falls data.

Communication to the teams to further improve safety was noted as the recurring themes continued to centre around unwitnessed night-time falls in bathrooms. While maintaining patient dignity was essential, we saw actions in place to address this.