St Hugh's Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we did not rate effective. At this assessment the rating was good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence people and communities had the best possible outcomes because their needs were assessed. We checked people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff promptly identified and assessed any needs outpatients had using a pre-admission questionnaire. They identified and assessed patient’s pain using recognised tools. Staff gave pain relief in line with individual needs and best practice.

People could access pain support soon after requesting it. They could access same day or week appointments.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up to date policies to plan and deliver high-quality care according to best practice and national guidance. For example, they completed the World Health Organisation’s (WHO) surgical safety checklist for flexible cystoscopy outpatients.

Managers and clinical specialists identified changes to national guidance. Leads provided assurance national guidance such as the getting it right first time (GIRFT) for perioperative assessment services was followed. They ensured GIRFT was referenced, actively implemented, monitored and used to drive continuous improvement. OPD undertook patient initiated follow up in some specialities. This gave patients more autonomy and let them contact clinical teams when their condition or symptoms changed. Leads were working towards rolling this out to further specialities.

The service demonstrated compliance with relevant national guidance and best practice. This was done through embedded policies, pathways, and routine clinical practice across pre-operative assessment and surgical care.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary team (MDT) meetings to discuss outpatients and improve their care. Since early 2025 OPD had daily ad-hoc huddles to address any staff issues. OPD leads had created suspended time in all staff calendars for them to attend huddles. They could relay personal or medical information or request help from colleagues. For example, the pre-operative assessment nurses could ask for support if they had a full patient list. Huddles were immediately after the hospital’s ‘ten at 10’ meeting. OPD lead and specialist nurses attended to pass on any information, policies or updates. All staff received notes of huddle discussions.

OPD leads and staff could feed into their hospitals networking forum for provider updates. These formed the provider trust’s daily information.

Consultants, nurses and support staff worked together to care for patients and provide effective clinical care. Preoperative assessment (POA) staff assessed all outpatients against their hospital admission criteria. Pre-operative and OPD staff worked well and effectively together and appreciated each other’s roles. For example, to offer and run Saturday outpatient clinics.

Nursing and support staff were flexible and could mostly cover each other’s clinics. The department had nurse-led clinics such as urogynaecology in response to identified outpatient needs.

We spoke to all staff groups in the department. Most nursing staff felt very supported and welcomed in clinic. They had a structured induction process into OPD. A student nurse felt part of the team as they were well mentored by staff. They had established competencies and maintained a record of outcomes. Managers and colleagues considered registered staff’s preferred or individual working styles once roster shifts were covered.

However, the department had a lack of nursing presence or oversight. Senior and registered staff worked in the office behind reception. Lower and non-registered grade staff told us they were left to effectively run the department. This meant there was disconnect and more disparity between staff’s teamworking relations and experience based on their grade.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff assessed patient health at every appointment. They provided support for people’s individual needs.

OPD submitted data to the NHS’s patient reported outcome measures (PROMs) programme. We saw the department’s discharge reported patient outcomes for 2025. Of a 231-patient total, 75%+ reported improved outcomes. 88.8% of these outpatients reported their discharge status as treatment complete.

Staff encouraged patients to complete their pre-operative PROM questionnaires at initial consultation, or before they attended pre-operative assessment.

Staff prepared pre-operative rooms for the following day. This avoided delays for morning patients due to equipment searches.

The service displayed relevant information promoting health, wellbeing and outpatient support in waiting and reception areas. For example, there was penicillin allergy, bladder cancer and urinary incontinence information outside the urology gynaecological clinic. Another area displayed smoking cessation, better sleep and exercising with osteoarthritis and loneliness support information.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and they met both clinical expectations and people’s expectations themselves.

Staff conducted monthly clinical audits. Departmental monthly health and safety audits for October, November and December 2025 all met compliance with no actions for improvement. The safe handling of sharps audit for December 2025 achieved 100% compliance. Other audits included documentation standards, safeguarding, infection prevention and control, consent, and patient experience. All monthly audits, except for three, undertaken in OPD during 2025 achieved 67% or more compliance. The department’s fridge temperature checks audit scored the lowest, as staff had not completed or checked the dates in four of the 12 monthly audits.

OPD audits were shared between all staff, and audit leads were changed yearly. This allowed nursing, support worker, and medical staff to review notes together. This ensured completeness and a focus on continuity of care across the patient pathway.

Staff monitored their effectiveness of care and treatment. Managers and staff participated in the hospital’s audit programme. Managers identified data trends they used to monitor and develop patient outcomes. For example, extracorporeal shockwave therapy outcomes were audited for efficiency over four to six sessions. This is a non-invasive treatment that uses high energy acoustic waves to promote healing, reduce pain and treat various musculoskeletal conditions.

The department contributed to hospital audits in accordance with the corporate clinical audit programme. OPD areas undertook monthly audits to ensure compliance with national guidance. The Head of OPD discussed findings at the monthly Heads of Department (HoD) meetings. This allowed for peer review, shared learning, and identification of themes or risks. The HoD ensured meeting slides were displayed within the department. This made audit outcomes and learning points accessible and transparent for staff, patients and families.

Staff contributed to national audits and compared their performance against national benchmarks where applicable.

We saw the OPD’s performance dashboard which covered the previous 12 months. Managers used a discharge reported patient outcomes dashboard. This allowed staff to review and filter data in real time. This dashboard formed the basis of the speciality reports for the monthly HoD meeting key performance indicators (KPIs).

The department had met its monthly KPIs from July 2025 up to our assessment date.

The department’s vast majority of appointments by speciality were trauma and orthopaedics (70%), gynaecology (12%), general surgery (8%), urology and ophthalmology (both 5%).

OPD was compliant with national surgery safety procedures (NatSSIPs). The provider trust had local policies and procedures in place to support safe invasive practice. Leads had developed local surgery safety procedures (LocSSIPs) for joint injection in the department. These were tailored to the service and specialities provided, and implemented in line with NatSSIPs. This provided assurance national guidance was referenced, actively implemented, monitored, and used to drive continuous improvement.

Staff used audit findings to make improvements and achieve good outcomes for patients. A therapist manager had devised a very comprehensive set of screening tools for outpatients, including some bespoke. For example, a risk assessment to increase arthrofibrosis patients’ knee mobility. These tools captured all their biometric details using a systems approach. Staff aggregated tools together to capture and mitigate the risks to patients.

The service monitored and improved outcomes for outpatients. For example, staff used a patient records audit tool devised by an allied health professional manager. This was based on the chartered society of physiotherapy (CSP) audit tool so it could be peer audited. The manager used their audit compliance tools for staff appraisals and supervision. They provided a feedback narrative when auditing patient notes then shared findings with the team

Therapists managed an outcomes spreadsheet for outpatient’s post-discharge. The best outcomes were for patients who had greater trochanteric pain syndrome. This was a condition that affected the outer side of the hip and thigh.

The service told people about their rights around consent and respected these when delivering person-centered care and treatment.

Staff clearly recorded consent in patient notes. They gained written consent from people when needed. We reviewed five outpatients’ consent forms. Staff had completed agreements to investigation or treatment in all.

The department had completed a quality improvement workpiece related to informed consent. This aimed to ensure patients made decisions based on all available information, including doing nothing in line with informed consent principles such as the Montgomery Rule, and findings from national inquiries such as the Paterson Inquiry. The results were mixed and subject to further review and new auditing. Leads had adopted some improved practice and shared learning points.

OPD relevant staff would attend best interest meetings for their patients when required. Their best interest training was provided by a regional training hub. This helped ensure the best outcomes for patients.

The provider trust’s capacity assessment and best interest decision record complied with the Mental Capacity Act 2005. Their related policy ensured staff empowered and protected vulnerable people unable to make their own decisions.

Patient notes were comprehensive and stored securely on their EPR system. We saw examples of written patient notes where consent was gained for a proposed surgical procedure in the OPD department by a medical staff member.