Orthopaedics and Spine Specialist 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

Leaders ran services well using performance and quality systems focused on the needs and outcomes of patients receiving care. Staff were clear about their roles and accountabilities; the service engaged well with patients and was committed to consistently reviewing and improving services. Staff told us they could raise concerns to leaders and felt they were heard and valued. However, the service did not maintain its records or actions in relation to the Medical Advisory Committee (MAC) and we have requested an action pan from the service to ensure compliance.

This service scored 54 (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.

Leaders and staff, we spoke with told us the service did not have a named freedom to speak up guardian due to the small size of the service. The service had appropriate up-to-date processes and policies in place to enable staff to raise concerns internally and externally regarding any aspect of the service. Leaders encouraged empowering staff to drive improvement, to report incidents and raise concerns. We were given examples of the leadership team responding to concerns raised by staff within the service and these were managed appropriately. Staff we spoke with told us they were valued and felt listened to by leaders and were confident that their voices would be heard.

We reviewed information that showed leaders investigated concerns sensitively and confidentially, and lessons were shared and acted on. When something did go wrong, the service provided a sincere and timely apology and people were told about any actions being taken to prevent the same happening again.

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.

Leaders we spoke with explained the governance processes within the service and how these were used to monitor quality and performance, recognise areas for development and aim for improvements. Leaders implemented relevant quality frameworks, recognised standards, best practices, or equivalents to improve equity in experience and outcomes for people using services. Leaders freely shared quality outcomes and service performance measures with commissioners and external stakeholders to encourage external scrutiny and challenge. The on-site assessment identified that whilst staff were aware of the faults, and leaders had taken action to resolve these, there was a lack of process and governance to ensure the faults were reported and managed effectively.

Although the service had established processes for auditing, and reporting on quality, including external review, the service did not have a quorate medical advisory committee (MAC) and did not keep up-to-date records of MAC meetings. This meant we were not assured that the MAC was operating effectively to provide oversight of audit, quality, and safe practices. The service’s MAC consisted of the service’s medical director, registered manager, and the clinical lead nurse. The MAC was designed to have oversight of service quality, service updates and quality improvement. At the time of our onsite assessment the MAC had no external participant due to the loss of a long-standing external advisor. As well, leaders told us they had not held a MAC since 2020. The leadership team were in the process of recruiting an external participant to support the MAC. Leaders understood the importance of external oversight regarding MAC activities, for example recruitment oversight, practicing privileges and external scrutiny for quality indicators. Information we reviewed during our assessment showed the service consistently submitted data or notifications are to external organisations as required.

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.