Nuffield Health Brentwood Hospital

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• 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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment this key question was not rated as there was insufficient evidence. At this assessment the rating has been scored as good.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that 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 that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. A good assessment meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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

Daily safety huddles were carried out in the morning to review the patients on the lists for the sessions. Information from the huddle was then displayed on a staff notice area where the afternoon staff could see the information. Any specific needs could be planned or provided for the patients. An example was of a patient we observed who was in a wheelchair. The radiographer asked the patient about their needs such as their mobility level and the patient was made comfortable prior to a scan being undertaken.

The evidence showed a good standard. 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.

Policies and Standard Operating Procedures (SOPs) supported evidence-based practice and standards. For example, the diagnostic imaging service had extensive documents such as the Ionising Radiations Protection Policy, Procedure under IR(ME)R 2017 Referral criteria and the Radiology Assistant Practitioner Policy for scope of practice.

The diagnostic imaging department undertook some audit activity. Examples provided included mammographers participating in peer review and CT audits. The Nuffield Health audit programme for 2025 identified two annual audits (Contingencies audit and Radiation protection and compliance (IR(ME)R) audit) and 4 biannual audits e.g. scanner audit. Good compliance audit scores were obtained from the audits. However, we observed that the monthly audit tracker for 2025 had not been completed. This meant that we were not assured that there was oversight of the clinical audit plan.

The annual Radiation Protection Adviser audit was carried out in August 2024 and was found to be fully compliant with no improvements required. The audit refers to the level of compliance with the current regulations, standards and guidance relating to the use of ionising radiation in diagnostic imaging. It covers areas such as IR(ME)R 2017 procedures, protocols and records, general radiation protection records and equipment.

The service did not participate in any benchmarking activity with other similar external departments.

The evidence showed a good standard. 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.

Radiology staff worked with consultants to develop a list of their preferred protocol for each diagnostic procedure to create the correct image.

Staff also shared information about patients at the daily huddle meetings.

The team also had effective working relationships with wider hospital staff members. The diagnostic imaging manager met with other heads of departments and leads to exchange information and cascade to team members.

Some team members reported that there had not been a recent face-to-face team meeting for a while, but information was usually cascaded via email. This meant that staff could not raise issues at this forum and promote better team working.

Staff also described a flexible approach to working arrangements.

The evidence showed a good standard. 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.

Whilst there is limited time opportunity in diagnostic imaging to manage health and wellbeing and live healthier lives, we did observe that patient information leaflets were available in the department. A quality improvement initiative was underway to review the patient information leaflets within the department, to ensure that all the information was correct.

There was a noticeboard in the waiting area and included information to promote wellbeing, such as menopausal awareness.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent.

People who used the service spoke positively about the quality of the care and treatment they received. They told us staff met their expectations, and they did not have any concerns around the quality of their scan images or scan reports.

Staff were competent in using the equipment and technology available to support patients to improve their health.

We were not provided with any evidence of patient experiences monitored via patient experience feedback.

There was a process in place for the peer review of mammographers images and reports to gain assurance that scan procedures were carried out in line with national guidelines and the provider’s policies.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

We observed radiology staff discuss an ultrasound procedure with a patient and obtain consent to proceed with the examination and for a patient who needed a CT scan. In both cases a good explanation was given to the patients about the procedure being undertaken.

Staff told us they understood how to obtain informed verbal and written consent from people who used the service before commencing scans. Two out of three referral forms we looked at had consent recorded. The hospital has a consent policy, “Decision-making and consent to examination, investigations and treatment” which outlined the roles and responsibilities of all staff groups and was based on national best practice and guidance. The policy included guidance on consent for those whose first language was not English, patients with sight or hearing problems and patients who had a learning disability. Also, parental agreement to investigation or treatment for a child or young person.

93% of diagnostic imaging staff had completed training on the mental capacity act.

Further details about consent to care and treatment is found in the surgery section of this report.