Kings Norton 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 rated well led as good. The hospital director was new in post at the time of our visit in September 2024. Since our visit systems have improved to ensure they are effective. At the time of our visit staff gave mixed feedback about managers visibility and the culture of the service in the context of equality, diversity and inclusion. Since then, we have seen evidence that this has improved. The Freedom to Speak Up Guardian visits the hospital regularly and provides an opportunity for staff to give feedback on how the service can be improved. The governance systems were effective in assessing and identifying risks to people who used the service and ensuring improvements were made to the quality of care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with 23 staff about the shared vision and strategy of the service. 16 of those staff were aware of the values of the organisation and how their role helped in achieving them. However, 7 staff felt they were not involved in the shared vision and strategy of the service and reported that the values could be developed further.

There was a monthly staff newsletter which all staff had access to. This included praise for individual staff and teams and an employee of the month award.

The provider collaborative identified the hospital as an ‘isolated’ provider within the city and felt they would benefit from closer relationships with other providers to support with shared learning and potential for peer reviews. The hospital was the only hospital of the providers services based in Birmingham. The medical director is an Executive Committee member of the Royal College of Psychiatrists West Midlands Division. Psychologists were part of the British Psychological Society.

Following our onsite assessment visit we raised immediate concerns with the provider about medicines management and risk assessments. The provider put systems in place to improve and acted to address these concerns.

At the time of our visit leaders at every level were not always visible. Staff said ward managers were visible, approachable and listened to them. However, staff had mixed feedback about the visibility of leaders above ward manager level. Some staff welcomed the breakfast meetings that the hospital director had started but others said the hospital director & matron were not as visible on the wards as they would expect. Some staff felt they were not included, managers were not approachable, and their views were not listened to. Other staff were confident the culture had improved since the new hospital director started. Following our visit we saw evidence that this had improved and managers were more visible.

Managers were able to access appropriate support and development in their role. Some staff said managers gave them opportunities to do further training and develop in their role. This included physical health observations and phlebotomy training for support workers.

Managers recognised that the programme for internationally educated nurses (IEN) within the organisation had not been delivered well to support nurses and there had been changes in the expectations from the Nursing and Midwifery Council (NMC) which had not been well communicated to nurses. They had put in place additional support to address this. We reviewed the programme and expectations and if the changes made are followed and embedded then improvements should be made to the experience for these nurses. Since our visit with the support all the internationally educated nurses had achieved their competencies.

Managers had provided opportunities for staff to meet with them including breakfast meetings and coffee mornings. Managers had a rota to visit the wards out of hours and increase their visibility on the wards.

At the time of our visit the culture of speaking up was not developed in the service. Some staff were not aware of the Freedom to Speak Up Guardian within the organisation. However, some staff spoke with their managers if they had concerns and said they would address these. Other staff did know how to contact the Guardian and did so when needed to. Since our visit the manager provided evidence to show this had improved. They said that the provider communicated through the intranet, group wide email and the Echo well-being app the role and availability of the Freedom to Speak Up Guardian. At the hospital they highlight the availability through clinical governance and on signage throughout the site, including in the staff room and the wards. The Freedom to Speak Up Guardian regularly visits the hospital.

The provider had employed a Freedom to Speak up Guardian since April 2024. There were contact numbers for the Guardian displayed on the wards. The Guardian attended all staff inductions to make them aware of the process. They planned to build up a network of ‘Champions’ at each of the providers locations to improve accessibility further and a culture of speaking up.

At the time of our visit staff had mixed feedback about how managers acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Some staff thought the diverse workforce worked well together and people’s diversity was valued. However, most staff thought improvement was needed. Staff could not give examples of celebrations of diversity at the hospital and some improvement was needed to engage with staff with protected characteristics to ensure their views were listened to and heard.

However, there was a prayer room available for staff and people who used the service. There were improvements to the food and menus were more reflective of people’s cultural backgrounds.

Since our visit the manager provided evidence to show examples of development and promotion of staff from all ethnic backgrounds in the past 8 months, including in senior nursing positions. They also provided examples of celebrations of diversity at the hospital with specific examples of initiatives around Eid, Ramadan, Easter and Christmas.

The senior management team identified the need for further promotion of equality, diversity and inclusion in working alongside the freedom to speak up guardian, and created a specific group/ forum for this ‘lets talk about it’. The group hold a quarterly meet up with a specially designed phone QR code questionnaire to provide quantitative data to analyse.

The Freedom to Speak Up Guardian had identified that across the organisation there was a theme where staff from minority ethnic backgrounds felt they were treated differently. From this the provider had set up an international workforce meeting which was face to face. The Guardian also raised this with the providers Equality, Diversity and Inclusion lead and continues to update them with themes if staff continue to feel treated differently. An external provider was currently reviewing the organisations equality, diversity and inclusion strategy which was commissioned by the provider. The provider was working on providing equality, diversity and inclusion groups and networks across the organisation.

Some staff were unsure of governance processes and their roles and responsibilities in these. Some staff were unaware of what was on the risk register and how risks were reduced. The manager told us the risk register is reviewed in the monthly senior managers team meeting and in Clinical Governance meetings, so changes or adjustments can be passed through management streams to all staff.

Staff were aware of how to report maintenance concerns and had access to the system to do this.

Governance processes were effective in identifying and assessing risks to the people who used the service. There were weekly community meetings and a spreadsheet showed what action was taken based on the views expressed by people who used the service.

There were monthly clinical governance meetings which included all managers across the hospital and minutes of these are circulated to all staff.

There was an audit process that had been strengthened recently using an application software programme and staff had been allocated to do these. These included care plans, risk assessments, infection control and the Mental Health Act. These processes needed to develop further to ensure the governance was effective and robust in identifying and assessing risks.

People had access to local community groups with the support of occupational therapists. This included football clubs, boxing clubs and gyms. The hospital had developed links with local colleges, adult education services and organisations that provided work opportunities for people using the service.

Managers collaborated with all relevant external stakeholders and agencies. The matron had taken time to engage with the local authority team and when there were issues with this had sought support from the local integrated care board.

The hospital was isolated from the providers other similar services, so they did not have a local network of peer support. However, the manager told us the hospital was part of a 'seven Hospital' structure across Active Care Group. This meant they received support, networking and learning through forums such as divisional governance, divisional medicines management, fortnightly hospital director meetings which included monthly face to face meet ups. Support is also gained from the providers Head of Nursing, Head of Safeguarding , quality leads and the providers inspectorate team. The hospital also links in closely with the health and safety lead, group procurement, IT and management information, People and Culture team, Risk and Governance department and operations/ managing directors.

The provider collaborative quality team had visited the service and were continuing to monitor the service. They had identified that improvements were needed and were reviewing the providers improvement plan.

Staff and leaders engaged with partners to share learning. The hospital had tried to make links with the local authority safeguarding team to share learning. The medical director was part of the regional Royal College of Psychiatrists network and psychologists were part of the network of the British Psychological Society.

Staff were aware of Safewards interventions, and these were used within the hospital. The hospital had designated Safewards champions. They send calendar invites for virtual meetings to enable the opportunity for wider attendance. Champions attended external workshops and meetings for Safewards and then delivered feedback/ power point to the wider site teams.

Leaders were developing the need for people using the service, their families and carers to be involved in developing and evaluating improvements. The providers employed a person with lived experience as a peer support worker who met with people who used the service. They then fed back to the hospital clinical governance meetings. They said there were positive improvements and they and people using the service were listened to by managers. They said people were starting to feel more involved and communication amongst staff was improving with a willingness to learn.

The hospital had processes in place for learning from incidents and from good practice. Staff were involved in reflective practice.

There was a quality improvement project on meeting people’s physical health needs. Staff had surveyed people to ask if their physical health needs were being met at the hospital. From this they found that some people needed further information and awareness of physical health needs. They discussed these in the ward community meetings, had information on a physical health topic each month on notice boards, made links with a local GP practice and trained support workers in taking blood tests and doing physical health observations.