St Hugh's Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment we rated this key question good. At this assessment the rating remained good. This meant people’s needs were met through good organisation and delivery.

We looked for evidence people and communities were always at the centre of how care was planned and delivered. We checked the health and care needs of people and communities were understood, and they were actively involved in planning care which met these needs. We also looked for evidence people could access care in ways which met their personal circumstances and protected equality characteristics.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Some of the OPD environment was designed or adapted to meet the needs of people living with dementia. We heard the flooring had been selected as it was suitable for people with dementia and staff wore name badges with large lettering.

Staff took a structured approach to identifying and supporting patients with dementia, mental health conditions, or learning disabilities. Staff could add alerts to any patient’s record for future reference. The letter template booking, which staff sent patients, asked them to contact the department if they had any extra needs.

The department had free disabled parking. Staff could reserve patients with limited mobility spaces near to the department.

Managers ensured staff, patients, loved ones and carers could request face to face interpreters when needed. Staff could provide interpreter services, large print or braille materials. We saw the bookings records for outpatients’ interpreters.

Staff met the information and communication needs of patients with a disability or sensory loss. The hospital’s main reception used a hearing loop system for outpatients who were hearing impaired.

Records showed that staff engaged in inclusive discussions with people’s families during the pre‑operative assessment. Documentation showed that relatives were appropriately involved in conversations to support understanding of people’s needs and to assist with planning for their care.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service’s clinics did not always run on time. However, patients were never kept waiting long. Outpatients were prompted to inform reception staff if they had been waiting more than 15 minutes or needed to leave the waiting area.

Administrative staff sent outpatients auto text reminders and confirmation letters about their appointments. If the appointment was in under three weeks, they also rang to confirm.

The service captured the number and percentage of patients who waited over 45 minutes for their appointments. The total number of these patients in the 12 months before our assessment was 335, or 1.61% of the appointments overall. 87 of these were for the same consultant. This amounted to 12.76% of their total appointments. However, another consultant had a higher percentage of their total appointments delayed over 45 minutes, with 15.63%. This meant these two consultants, along with a few others had a significantly higher percentage of delayed appointments than the total. We could not ensure leads acted on this information to improve consultant’s performance.

The outpatients waiting areas displayed screens with each clinic’s waiting times. However, the TV screens in patient areas displaying waiting times froze early during our assessment. No OPD or reception staff noticed this until we made them aware. At the time we left site, it had not been fixed.

We heard one or two consultant clinics could run a bit late. For example, staff told patients with complex needs they would get more consultant time to explain and cover everything. Reception staff would ring patients who were later on the appointment list to adjust times or reschedule if needed.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

We saw examples of translated patient information leaflets, hospital passports to support the needs of people with neurodiversity, interpreter booking processes, and the pre-operative questionnaire. These demonstrated the department’s commitment to accessibility, reasonable adjustments, and reducing health inequalities.

We saw examples of information leaflets on total hip replacement available in Ukrainian.

Staff talked with patients, families and carers in a way they could understand. They used communication aids where necessary. We saw pictorial pain and ‘I want, I am’ charts, staff could use for outpatients who were neurodiverse, less or non-verbal.

Department waiting areas displayed information from the British menopause society. This included national survey results and statistics on women affected by the menopause. Leads told us this encouraged staff and outpatients to speak up and share their symptoms and the impacts.

The service adhered to information governance principles in accordance with UK general data protection regulations (GDPR).

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

People gave positive feedback about the service. NHS Friends and Family Test (FFT) feedback showed outpatients felt respected, listened to, and treated with kindness. Staff collected patient feedback through digital surveys and the FFT results.

However, FFT numbers were low in 2025 and had reduced compared to previous years since the endoscopy service closed. Leads planned to address this and increase response rates.

Healthcare support staff offered outpatients the option of completing surveys on a handheld device after their appointment.

People and their families could also give service feedback. Staff supported them to do this. We saw hip and knee surgery questionnaires available for pre-operative outpatients. There were also accessible patient satisfaction surveys for outpatients who had percutaneous tibial nerve stimulation (PTNS) treatments in the department’s nurse-led urogynaecology clinic. People could score four areas between 1-5 and add extra comments.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Waiting times for outpatient appointments were consistently low and within acceptable limits. Most people were seen on time, with only a small proportion experiencing extended waits. Leads undertook ongoing monitoring of waiting times to ensure patient experience stayed positive. They identified any emerging trends requiring action. TV screens located within both waiting rooms displayed real-time waiting information. This meant people were kept informed and reduced uncertainty during delays.

Clinics were accessible and adaptable to meet people’s needs. We reviewed the OPD’s referral to treatment times (RTTs) by speciality for the six months before our assessment. The speciality with the longest average pathway was gastroenterology with 50.05 weeks. However, the service assumed responsibility for legacy backlogs from the Integrated Care Board, which meant aspects of RTT performance were shaped by wider system factors.

The OPD complied with the Accessible Information Standard and Equality Act 2010. Processes were in place to support compliance. Staff ensured equitable access for people with language needs. Staff confirmed and recorded people’s preferred language and any communication needs on their pre-operative questionnaire. They could extend pre-operative appointments by ten minutes when a translator was required.

Staff flagged any accessibility needs people raised. ODP staff could offer people evening, weekend and telephonic appointments.

The department held dedicated slots for outpatients who needed diagnostic tests. Staff could contact diagnostics directly to confirm availability or expedite urgent requests. Radiology and pathology teams could usually prioritise urgent OPD requests. This meant their results could be available on the same day where possible.

However, delays could occur if lists overran or emergencies arose.

OPD leads supported wider access to treatment within the local healthcare community and in collaboration with the local acute trust, hospital and provider. Staff could liaise with contracted pharmacies to dispense medications.

The hospital offered outpatients access to a portal and online healthcare hub. This allowed people to view, book and change appointments and bookings.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

ODP leads had undertaken quality improvement (QI) plans around the plan, study, do, act (PDSA) cycle. These plans related to patient optimisation and reducing cancellations in August and September 2025. The hospital’s cancellation rates had almost halved in the six months since this work and consistently reduced per quarter. For example, the hospital had 51 cancellations in the fourth quarter of 2024, but only 17 by the fourth quarter of 2025 during our assessment. The work had enhanced efficiency and improved the overall patient journey, reducing anxiety and promoting confidence in the service.

The provider’s waiting list and access policy ensured outpatients had transparent and equitable access to NHS treatment. Bookings team members told us outpatient flow had improved since the OPD rolled out electronic patient records (EPRs). Staff could switch between waiting lists and the bookings system to accommodate people’s needs.

Managers monitored and took action to minimise missed appointments. They ensured patients who did not attend appointments were contacted. OPD receptionists first followed up all did not attend (DNA) appointments. If they were unsuccessful the bookings team tried to contact the patient three times. Staff collated the most common reasons for missed appointments. These were patients forgetting to ring to cancel.

Administrative staff told us they could not always rebook patients into the same clinic, especially at short notice or when clinics were busy. Clinics could also be cancelled if consultants were unavailable. In these cases, staff either added patients to a waiting list or offered an appointment with another suitable specialist.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The provider was progressing work on a new quality approach that outlined the ‘MAGIC - Making A Genuine Impact in Care’ clinical model. Managers undertook internal quality visits across all sites.

Staff supported patients to make informed decisions about their care.

Service improvement plans (SIPs) had actions, arising from immediate areas of focus. Leads planned to create a quality insights group to share useful information and updates for staff.

Staff could access funds for new equipment if they could justify clinical need. They could purchase orders for repairs using a secure login portal. Staff were trained to report faulty or missing equipment immediately through hospital reporting systems, and by emailing hospital facilities.

Managers could request additional resources to ensure or promote the quality of care and treatment.