Nuffield Health Brentwood Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture.

At our last assessment we rated this key question as good, but it was combined with the outpatient’s department and was under a different methodology. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

The service had a clear shared vision, strategy and culture. However, they did not always support and understand the challenges of staff during the implementation.

Nuffield Health vision was “To provide the best care and support you can get anywhere”. The service told us they developed their strategy in conjunction with the heads of department and fed back to staff via department meetings and the appraisal process. This was set out in 5 ambitions for Nuffield Health with named leads data sets to measure success. These were aligned to staff appraisals. However, there was little sharing of the direction of the service together and to understand the challenges and the needs of people and their communities.

Staff reported that there were insufficient team meetings and often communication would be via email. The last full team meeting was held in January 2025. There had not been any recent diagnostic imaging staff meetings to share the vision, strategy and culture of the service. This meant that staff did not have the opportunity to contribute to team discussions about the service and hospital as a whole strategy.

We asked for evidence of the diagnostic imaging strategy or business plan. The only information we received was a quality improvement plan from December 2024.

The plan consisted of three workstreams; to implement a cardiac MRI service, reinstate the urodynamics service and upgrade an ultrasound machine. Some progress had been made on these workstreams, however, there was no evidence of a service business plan or service strategy provided. Additionally, the quality improvement plan did not include any initiatives to improve issues such as the experience for patients or improve support for staff development and wellbeing.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The overall lead for the diagnostic imaging service was the radiology manager with extensive experience who demonstrated a good understanding of the service and how the service operated. The radiology manager told us that the diagnostic imaging leadership team was under review, and a new deputy manager post was planned to support the manager and associated workload.

Staff we spoke with were positive about the support they received from local managers. We were told that development opportunities were available for staff.

Further details about capable, compassionate and inclusive leaders are found in the surgery section of this report.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

The hospital had a freedom to speak up (FTSU) policy which clearly identified the roles and responsibilities of all staff and provided guidance for staff around raising any concerns. Staff could raise concerns internally or externally. The FTSU policy was supported by the FTSU Standard Operating Procedure which clearly and comprehensively outlined the process to be followed when a concern had been raised.

Staff were aware of the FTSU guardian and there was a FTSU ambassador in the diagnostic imaging department. Staff understood how to raise concerns if needed.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Further details about freedom to speak up is found in the surgery section of this report.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service promoted workforce equality, diversity and inclusion through established policies and staff completing the mandatory training module “Belonging – Equity, Diversity & Inclusion in Nuffield Health”.

Staff that we spoke with did not raise any concerns about the inclusive working culture and said they were treated with respect and equity. Staff felt confident any concerns they raised would be listened to. The staff we spoke with did not raise any concerns of unfair treatment, discrimination or harassment in the diagnostic imaging department.

Further details about workforce equality, diversity and inclusion are found in the surgery section of this report.

The service had clear responsibilities and roles. However, they did not always act on the best information about risk and outcomes or share this securely with others when appropriate

The service did not give any evidence of any local diagnostic imaging governance meetings. However, the radiology manager attended the hospital governance meetings with other heads of departments, which provided them with oversight of risk at both a departmental and corporate level, and contributed to the meetings.

Staff told us that they did not get regular team meetings to discuss issues, and communication was mainly via email. There was not a clear framework of what must be discussed in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Whilst managers understood the key risks to the service, the department risk register was limited in content and had only been produced recently. The only two risks identified were for low staffing levels and a roof leak above the service. There was some evidence that both risks were being managed but lacked detail of mitigation and actions being taken or how they related to the hospital risk register.

Staff undertook or participated in local clinical audits. The audits were limited to provide assurance and that staff acted on the audit results when needed.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records. Staff maintained the confidentiality of records.

We found good compliance for training within staff groups in the diagnostic imaging department. This meant that there were effective systems to identify and ensure staff were adequately trained to meet patient’s needs.

Further details about governance, management and sustainability are found in the surgery section of this report.

The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

People who used the service told us care and treatment was well co-ordinated, and staff engaged and kept them informed about their scan procedure and the reporting of scan results.

There were processes in place to ensure there were suitable and appropriate referrals from organisations such as GPs, NHS hospitals which provided evidence of joint working.

The service was unable to provide evidence of working with external stakeholders, when this was requested as part of our assessment, other than evidence of working on an MRI replacement project with an external contractor.

The service did not provide any evidence of routinely engaging with local communities or collaboration with other providers to improve the quality of services provided.

Further details about partnership and communities are found in the surgery section of this report.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged ways of delivering equality of experience and quality of life for people. They actively contribute to safe and effective practice.

During our assessment we requested examples of innovation, learning or development. The evidence provided were details of three quality improvement projects for 2025. These were described elsewhere but involved implementing a cardiac MRI service, to reinstate a urodynamics service and to upgrade ultrasound machines. Some evidence of progress was demonstrated. There is also a significant development with an external organisation to install state of the art diagnostic imaging equipment. A new MRI scanner has just been installed.

Staff that we spoke with did not mention any innovation or improvement projects and were focused on the daily operation of the diagnostic imaging service mainly due to staffing constraints.

We were informed that there was no benchmarking of services with other providers and there was limited assurance provided on continuous improvement processes being utilised in the service.

Further details about learning, improvement and innovation are found in the surgery section of this report.