Nuffield Health Brentwood Hospital

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• 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 outstanding. At this assessment the rating has changed to 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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Regular updates from leaders ensured staff felt informed and included.

The children and young people’s service was managed by a paediatric lead consultant and a lead CYP nurse. Staff told us they felt respected, supported, and valued. They were focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients. Staff were positive and proud to work for the service.

We observed positive interactions between all members of staff regardless of seniority.

Further details about how the hospital shared direction and culture can be found in the surgery report. 

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.

Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in and around the hospital. They supported staff to develop their skills and take on more senior roles.

Staff told us they were encouraged to speak up and discuss their concerns openly. When staff had raised concerns, staff felt the management team were capable of taking appropriate action. Staff felt confident they could raise concerns or risks openly.

Further details on capable, compassionate and inclusive leaders can be found in the surgery report. 

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

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. There were QR codes that could be used to provide feedback for both parents and children. Managers reviewed feedback to make improvements to the way the service was delivered. The service had provided written explanations for the requirement for pregnancy tests to be taken by women prior to procedure. This change was made as a result of feedback from a parent who had requested more information.

Staff felt able to discuss and raise any concerns with their leadership team.

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 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.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was an embedded governance process that was set out in the service’s Children and young peoples (CYP) policy. CYP was advocated for by staff that had the most involvement in each of the patient’s episode of care.

The service was aware of key operational risks. This included the need for improved compliance for safeguarding and mandatory training, not having dedicated children and young people specific waiting and ward areas. The CYP forum and quality performance meetings included the risk register on the agenda and was circulated to staff within the service.

We were not assured that governance arrangements were always effective in promoting patient safety. A review of September 2024 meeting minutes indicated that leaders had identified gaps in compliance as consultants, anaesthetists, and paediatricians had not always provided evidence of completing safeguarding and paediatric basic life support training. An action was agreed for completion by December 2024. However, during our assessment in July 2025, we found that some consultants continued to practice without providing this evidence. Although the service addressed these issues shortly after our visit, it had not acted proactively to mitigate a known risk prior to our assessment.

The service completed monthly audits. This included a pain and medication audit. The documentation, consent and PEWS audit was undertaken through a review of 10 patient records and this showed a score of 99%. The pain and medication audit for March 2025 was scored at 98%. It was a review of 10 patient records that checked for appropriate recording of medication.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The children’s and young persons lead nurse had developed links with local health care providers and NHS services. This included local safeguarding service meetings where updates and key information were shared.

Further details on partnerships and communities can be found in the surgery report.

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

Staff were committed to learning and improving. Managers supported staff to attend courses that supported their development and contributed to improving services.

There was shared learning across the organisation. Leaders were able to identify changes that were made as a result of learning from other services. For example, tonsillectomy’s were scheduled for morning only lists to ensure sufficient safe observation time following a procedure.

Further details on learning, improvement and innovation can be found in the surgery report.