The Care Quality Commission
  • Hospital
  • Independent hospital

Nuffield Health Brentwood Hospital

Overall: Good read more about inspection ratings

Shenfield Road, Brentwood, Essex, CM15 8EH (01277) 695695

Provided and run by:
Nuffield Health

All Inspections

During an assessment of Services for children & young people

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.

During an assessment of Outpatients

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.

During an assessment of Diagnostic imaging

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.

During an assessment of Surgery

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.

During an assessment of the hospital overall

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.

28 February and 10 March 2017

During a routine inspection

Brentwood Hospital is operated by Nuffield Health. The hospital/service has 42 beds. Facilities include four operating theatres (three laminar flow and one state of the art digital), one endoscopy theatre, 16 consulting rooms, and X-ray, outpatient and diagnostic facilities.

The hospital provides surgery, services for children and young people, and outpatients and diagnostic imaging. We inspected all three services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 28 February 2017, along with an unannounced visit to the hospital on 10 March 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

We rated this hospital as Good overall.

  • There was evidence of incident reporting, a good level of understanding of duty of candour amongst staff and actions and learning from incidents were discussed at the service’s Quality and Safety Committee meetings and Heads of Department meetings, and staff gave examples of where learning had occurred.
  • For the period October 2015 – September 2016, 100 per cent of patients were risk assessed for venous thromboembolism (VTE) and there were no cases of hospital-acquired VTE.
  • The pharmacy lead had recently ran a teaching session for nursing staff within the service to ensure good practice in medicines management. We were given examples of learning from these sessions such as clearer labelling of medications.
  • Staff knew how to report a safeguarding concern and who the safeguarding lead for the hospital was. The safeguarding lead ran training days each month. Training included ‘Prevent’ training to help staff identify individuals at risk of radicalisation and female genital mutilation (FGM) awareness.
  • mandatory training records which showed a current compliance rate of 97% overall for the whole hospital
  • We observed the World Health Organization (WHO) ‘Five Steps to Safer Surgery’ checklist being undertaken, alongside record completion, both of which were completed appropriately.
  • Staffing levels were assessed on a daily basis using the ‘professional judgement’ model and Nuffield Health at provider level was assessing the most appropriate acuity tool to use at the time of our inspection
  • The resident medical officer (RMO) attended each nurse handover which took place three times a day, between shifts, to ensure they were informed about patient conditions and progress.
  • Policies were updated in line with national guidance and best practice and shared at provider level.
  • The hospital responded to audits to improve patient outcome. For example the implementation of education and training to improve post operative analgesia prescribed before discharge from recovery, which increased from 60% compliance in September 2016 to 100% compliance in February 2017.
  • The hospital could access nutritionists from the community where more specialist advice or input was required.
  • PROMs results from November 2016 for NHS-funded patients receiving a primary knee replacement showed the service was within the estimated range of the England average. 
  • PROMs results from November 2016 for NHS-funded patients receiving a primary hip replacement showed the service was within the estimated range of the England average.
  • Funding had been agreed to improve the environment of the endoscopy department.
  • The service was compliant with referral to treatment (RTT) times for NHS patients admitted within 18 weeks of referral, with over 90% of patients admitted within this timeframe between October 2015 and September 2016.
  • The service had a structured process in place for the medical advisory committee (MAC) and Practising privileges were routinely discussed as part of the MAC.
  • The hospital had a risk register which was detailed with updates, progressions dates and actions to mitigate risks.
  • Service leads displayed strong leadership and management and there was a drive to promote a positive, open and transparent culture.
  • The service had recently refurbished their theatres department, including a development of a new digital theatre of which staff were proud of.

We saw several areas of outstanding practice including:

  • We saw evidence of the application of “Human Factors” approach, when the hospital investigated incidents. For example we reviewed one investigation which considered the training and competency of staff as well as custom and practice, as part of the review process. 
  • There was evidence of innovative work to improve and engage all staff in infection prevention and control, such as running lab experiments with staff to show the difference in bacteria levels with good hand hygiene practice, and an anti-microbial awareness week.
  • In January 2017 “Think Like a Customer” (TLC), was rolled out across the hospital and was part of the Nuffield organisations aspiration to become “one Nuffield” , with an aim to improving patient experience. There was a monthly newsletter published which included results from quality indicators, complaints and net promoter score, and also reviewed feedback from patients to improve the overall patient experience.
  • The hospital had a clear strategy to improve services for children and young people with evidence of progress completed in the last twelve months and with a clear progression for future developments.
  • The Senior Management Team ran a number of staff engagement strategies in the hospital to improve patient experience, to engage staff and to consistently review the leadership of the service. These included the “have you say make a difference” monthly meetings, and the annual “leadership MOT” review.

Professor Sir Mike Richards

Chief Inspector of Hospitals

9 January 2014

During a routine inspection

People were given information that helped them to make decisions and to consent to their treatment. They told us they were satisfied with the treatment they had received and that it met their needs.

One person said, 'The care and treatment has been spot on. There was someone there all the time after the operation, doing observations, checking on my pain and when I had eaten. The physiotherapist has been in already this morning and explained what you need to do and how to do it. They don't rush or push you.'

People told us that they found the hospital to be clean. We found that effective systems were in place to reduce the risk and spread of infection.

Staff were supported to provide effective care and treatment through induction, appraisal of their performance and training.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

11, 14 January 2013

During a routine inspection

People told us that they were given clear information on their proposed treatment and they were asked for their consent. We saw evidence of this in the care records that we looked at. One person said, 'I had good explanation and advice from my consultant and even better from the anaesthetist when I gave my consent.'

Records that we looked at showed people's needs were assessed and care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The care records were clear and made it easy to follow all aspects of the patient pathway from consultation through to discharge. They were signed at each stage by the nursing or medical staff responsible to show that proper procedures had been followed.

One person told us, 'The care is very good here. Staff checked on me regularly, especially to see if I had any pain and the response to the call bell was excellent.'

We saw that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. This included staff training and guidance and safe recruitment practices.

The provider had an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people using the service and others. People told us that they were asked for their views about the service and that they were satisfied with the care and treatment they received.