Weymouth 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 assessed 1 quality statement in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas showed good practice since the last inspection, our rating for the key question remains good. Staff and leaders had clear responsibilities, roles, systems of accountability and good governance.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. For example, the provider had a patient transfer out agreement with a local independent healthcare organisation for patients requiring treatment in an Intensive Treatment Unit (ITU). Weekly ‘hot topics’ took place to discuss items such as medicine optimisation, freedom to speak up, safeguarding, consent and sustainability. Information was also shared with staff through newsletters. Information shared included: • A controlled drugs newsletter from NHS England. • Weekly newsletter with local and corporate updates All staff were committed to continually learning and improving services. We were shown in-house training videos delivered online for medicine optimisation and the CQC’s single assessment framework. The theatre manager told us that they had regular one-to-one meetings with their line manager. Staff also had performance development review meetings, where they agreed objectives and further training to complete. Staff appraisals for colleagues who worked on the wards were up-to-date. Staff had monthly meetings with ward managers, nurses and healthcare assistants, where staff were able to discuss openly any concerns, thoughts and suggestions. The last staff survey was conducted in May 2023 and had a total of 54 responses. Findings included increased pressure at work, a lack of personal development, unhappy with salary package and lack of internal communications. We reviewed the actions taken from this survey which showed that each finding had mitigations in place, for example the service promoted company benefits to all staff which included subsidised lunches, discount card, cycle to work scheme and private medical insurance.

Governance reporting frameworks were in place. The risk register was reviewed regularly, including at executive level. The top 3 risks were not having an ITU, returning to theatre and a lack of blood products. A service level agreement (SLA) with a local hospital provided ITU care and blood transfusions. There was a strategy for investigating incidents. All staff could contribute to an investigation. There were committees for oversight of risk, quality and clinical experiences of the services. Meetings were well attended, had set agendas, and included items such as CQC updates and practising privileges. Corporate policies were in date and had review dates. Changes made to the policies were easily identified. Policies observed included: • Adult safeguarding policy • Central Alerts System policy • Cyber Security Policy Cyber security arrangements included encryption for devices. Lessons were learned and shared from another provider who had recently experienced a cyber security breach. Senior staff completed a gap analysis of the Independent Healthcare Provider Network key principles. This included working with resident doctors to ensure high quality care, monitoring patient safety, clinical quality and encouraging continuous improvement, supporting resident doctors and whole practice appraisal. A policy was being developed for Patient Safety Incident Response Framework (PSIRF). The provider submitted data to the Private Healthcare Information Network (PHIN). Complaints were reviewed at governance meetings that the ward manager attended and could be escalated to the Independent Sector Complaints Adjudication Service (ISCAS). The audit schedule stated frequency and individual responsibility. There were 3 business continuity plans to cope with unexpected events. The service followed nationally recommended actions following a high-profile case at another provider. Such as promoting FTSU, whistleblowing and reviewing the Fit & Proper Person Framework.

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.