Nuffield Health Brentwood Hospital

Updated 6 January 2026

We assessed Nuffield Health Brentwood Hospital 8 to 9 July 2025. Nuffield Health Brentwood Hospital was registered with CQC in December 2010 to deliver the regulated activities Diagnostic and screen procedures, Family Planning, Surgical Procedures, and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

At this assessment we assessed 4 assessment service groups: surgery, children and young people, diagnostic imaging and outpatients. We assessed 33 quality statements in each assessment service group.

We visited the following areas as part of the assessment: Surgical ward, theatres, recovery, endoscopy, outpatients, children and young people services and radiology.

We found breaches of regulations in relation to good governance within surgery, diagnostic imaging and outpatients.

Updated 9 June 2025

We rated the diagnostic imaging service as good overall. We rated the service as good. We found 1 breach of regulation in relation to governance.

Patient areas were safe, visibly clean, well equipped, well maintained and fit for purpose. The service had high vacancy rates at the time of the assessment and relied on agency staff to maintain some services. Recruitment was in process at the time of the assessment. Staff received training to support safe care and treatment. Staff were knowledgeable about the service and how to report incidents, safeguarding issues and radiation specific concerns. Staff and teams worked well together and treated people with kindness, empathy and compassion. There was evidence of timely access to scans for people.

There were some processes that could be improved in the management of governance and risk. The department risk register was limited in detail and proposed actions to mitigate the risks. There was some innovation with an external provider and joint working with external stakeholders.

Updated 12 June 2025

The outpatient department comprises 25 rooms in total, including 20 consulting rooms and 5 treatment rooms; an Ear, Nose and Throat (ENT) suite, audiology and cardiology testing rooms, and a physiotherapy suite with an adjoining gym.

The hospital’s core service is surgery. Where outpatient arrangements mirrored those in surgery, findings have been reported in the surgery section.

The on-site assessment was unannounced and took place on 8 July 2025. We assessed 33 quality statements across the key questions of safe, effective, caring, responsive and well-led to determine the rating.

During the assessment, we spoke with staff, leaders, service users and stakeholders. We reviewed care records, policies, and other documentation relevant to the service.

We have rated the service as good

The outpatient service was found to provide compassionate and person-centred care. Safeguarding practice was strong, levels of compliance with mandatory training were high, and effective teamwork was evident across clinical areas. Staff were observed to work collaboratively to support continuity of care.

Medicines management was safe and infection prevention and control practice was generally effective.

Shortcomings were noted in relation to record-keeping, cleaning documentation, and risk awareness. Governance and audit processes were not consistently robust, which limited the level of assurance available. Staff engagement and access to development opportunities were variable across different staff groups, and aspects of leadership and transformation planning did not always address concerns raised by frontline staff.

However, further work was required to ensure greater consistency in embedding learning from incidents and in strengthening risk management processes.

We found one breach of the regulations regarding good governance. If we have requested an action plan, this will be requested upon publication of the final report.

Updated 17 June 2025

Date of assessment:8 to 9 July 2025.

We rated services for children and young people as good overall.

The service had a positive learning culture and people could raise concerns. Leaders investigated incidents thoroughly. People were treated with kindness, empathy and compassion. People were protected and kept safe. Staff understood and managed risks. The designated children’s and young person’s lead understood the role of safeguarding and had good local links with local stakeholders. There were effective processes to assess the needs of patients using evidence-based guidance. Staff provided patients with patient-centred care and treatment. Leaders were highly respected, visible and inclusive. Staff felt valued and respected.

However, there was no dedicated waiting area for children and young people. Consultants did not always have sufficient mandatory training.

During the assessment, we spoke with staff, leaders, service users and stakeholders. We reviewed care records, policies, and other documentation relevant to the service. The main service provided by the hospital was surgery. Where the arrangements in children and young peoples’ services mirrored those in surgery, findings have been reported in the surgery section.

Updated 3 June 2025

We rated the service as good. We found 1 breach of regulation in relation to governance.

Patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. The provider had enough staff to ensure people’s safety and meet their needs. Staff received training and appraisals to support safe care and treatment. Patient satisfaction surveys scored 85%. Patient outcome measures data showed patients reported an improvement in health in line with or better than the national average following surgery at Nuffield Health Brentwood. The service reviewed reported safety events and identified lessons learnt to identify and embed good practice. However, they did not always listen to concerns about safety and some staff reported not being trained in incident reporting. The service had not reported any never events or deaths related to surgery. Integrated care records covered the entire patient pathway from pre-operative assessment to discharge and included comprehensive care plans for identified care needs. Where unplanned transfers out occurred, we saw evidence of reviews to learn and prevent future occurrence. The service had clear responsibilities and roles, however there was a lack of accountability and good governance.

Updated 14 June 2017

Outpatient and diagnostic imaging services were a small proportion of hospital activity. The main service was Surgery. Where arrangements were the same, we have reported findings in the Surgery section.

We rated this service as good because:

• Incidents were reported and investigated appropriately and staff could give examples of learning from incidents.
• 100% of staff had received an appraisal and completed mandatory training.
• The imaging department had implemented a pause and check process before every patient examination to ensure the delivering of safe and effective patient care as part of clinical imaging services using ionising radiation.
• There was good multidisciplinary team working and good communication between staff at all levels.
• Staff interactions with patients and visitors were friendly and respectful. Care was given with compassion and dignity.
• Patients could choose appointment times to suit their needs. The diagnostic imaging department provided a walk in x-ray service so that patients could have their x-ray in conjunction with their appointment.
• Complaints and concerns were investigated appropriately and there was evidence of learning from complaints and concerns in order to improve services.
• There was strong leadership from the service managers. Staff spoke highly of their managers. Managers promoted a positive team culture that created a “lovely place to work”. Managers worked hard to make the department an effective and safe place for patients, visitors and staff.