Nuffield Health Brentwood Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

The evidence showed some shortfalls. 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 no training to be able to report incidents in line with policy.

The service had systems for recording safety incidents, supported by an incident reporting policy. Most staff understood what to report and how to use the RADAR incident reporting tool. Some staff had not completed induction training, and this meant that they asked senior staff to submit incident reports on their behalf. This meant that staff were not adequately trained to work autonomously and in line with policy.

Staff reported that concerns about patient safety or deterioration were sometimes dismissed. In one case, a patient with low sodium was escalated, but the anaesthetist only gave advice by phone and did not attend. Staff had to involve department heads to secure a medical review, causing delays in timely care.

Following patient safety incidents, staff debriefed with senior leaders and completed after-action reviews to support learning. While staff and community partners said lessons were shared, those interviewed couldn’t cite specific changes resulting from incidents. Governance meetings addressed incidents, as confirmed in reviewed minutes. Actions to prevent recurrence included the introduction of follow-up calls 48–72 hours post-discharge to detect post-surgical complications. Incident learning was shared with staff through safety huddles, team meetings, and email.

Staff were informed of incidents reported at other Nuffield Health sites through ‘flash alerts’ to share learning from incidents.

A total of 304 incidents had been reported in the 12 months prior to our assessment at Brentwood Hospital, of which 26 related to Surgery and were graded as moderate harm. These were reported by staff and action taken during the incident was recorded, such as faulty equipment, return to theatre or transfer out. We saw evidence of an incident relating to wrong wristband on a patient taken to theatre. The service has not reported any deaths or never events in the last 12 months related to surgery.

Most staff we spoke with understood duty of candour and were able to give examples of when this had been carried out. The service had carried out duty of candour in line with their policy 25 times in the 12 months prior to our assessment. This was carried out either verbally or in writing, we saw this evidenced where patients required an unplanned transfer out to an acute hospital.

A total of 22 patients were transferred out in the 12 months prior to our assessment. We saw evidence of learning in 8 of these incidents such as reminding staff staff of the importance of early mobilisation and documentation of pain assessments for patients who have struggled with pain control during admission prior to discharge.

The service worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. However, the monitoring processes were not robust to ensure safety checks were consistently managed by staff.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the patient group. The nurse in charge would review the next day’s admissions against the staffing allocation to ensure that staffing skill . For example, we were told if close monitoring was anticipated additional staff would be requested.

Managers told us they provided new staff with appropriate induction. When agency and bank nursing staff were used, those staff received an induction and were familiar with the area. Some staff we spoke with during the assessment told us they had not received a local induction to the area they were working in. This meant that they were not aware of the local systems, such as how to complete an electronic incident report form. We saw evidence of completed induction checklists for bank staff in theatres and endoscopy.

Staff told us that managers provided an annual appraisal and mid year review (for personal support and professional development) and appraisal of their work performance. The percentage of staff that had completed an appraisal in the 12 months prior to our assessment was 95%, in line with the hospital target. There was a system in place to ensure consultants working under practicing privileges had a current appraisal.

Managers ensured that staff had access to regular team meetings and meeting minutes were emailed to all staff to inform those not in attendance. We saw evidence of theatre team meeting minutes during the assessment.

Some staff we spoke with told us that they had not been given opportunities to attend courses to further develop their skills and knowledge. For example, health care assistants (HCA) were waiting to attend the healthcare course and had not received feedback on the length of wait.

Managers ensured that staff received the necessary specialist training for their roles. Ward staff told us they had been trained in using blood pressure machines, hoists and Hover Jack. A HoverJack is an air-assisted patient lifting device used to safely lift a person who has fallen onto the floor and transfer them to a bed or stretcher.

The service had a referral and admission process in place to determine if patient’s needs could be safely met. Preoperative assessments were carried out in advance of admission and documented within the care record booklet. Staff told us that short notice bookings would be added to planned theatre lists which resulted in additional workload and pressure. We saw evidence of a complaint made due to missed infection screening prior to admission, resulting in cancellation on the day of surgery.

Where patients fell outside of the admission criteria, staff could explain the process of escalating to an anaesthetist and or consultant for review. These were discussed via multidisciplinary team (MDT ) emails using the referral form and were reviewed at monthly patient safety meetings. In the 12 months prior to our assessment, a total of 68 patients fell outside the admission criteria. The rationale for proceeding was provided in each case. We requested evidence of this for the last 5 patients that did not meet the admission criteria. We found all patients were reviewed in line with the service’s ‘Protocol for Admission Criteria’. Staff told us that they would not receive feedback on the escalated patients who did not meet the admission criteria. They felt this feedback would provide them with assurances that the systems were robust.

Inpatient ward staff were informed of identified risks at pre-operative assessment. Ward staff told us they would review this documentation and take necessary action. For example, booking a room closest to the nursing station if there was a risk of falls or asking when medication was stopped prior to admission.

Audits were conducted to monitor the compliance of patient safety and outcomes, these included but were not limited to return to theatre , infection prevention control (IPC), National Early Warning Score 2 (NEWS 2), National safety standards for invasive procedures (NatSSIPS) and resuscitation equipment.

During our onsite assessment, 5 out of 10 patient records showed discrepancies between Venous Thromboembolism (VTE) risk identified at pre-assessment and on admission. This failure could result in missed preventative treatment and serious post-surgical complications. Although the last VTE audit showed 92% overall compliance, the audit tool did not assess consistency between pre-operative and admission risk assessments.

We reviewed care records for completion of World Health Organization (WHO) Surgical Safety Checklist, a tool used in the NHS to improve patient safety during surgical procedures. Out of 9 records examined, 4 were found to be incomplete for debrief following surgery. This indicated that critical safety checks were not consistently performed before, during, and after surgical procedures.

Following the assessment, we reviewed audit data from the past six months. Compliance was recorded in only 7 out of 10 cases, suggesting that adherence to national safety guidance remained inconsistent. This posed a potential risk to patient outcomes and highlighted the need for strengthened oversight and staff engagement with the checklist protocol.

Follow up appointments were booked by the ward administrator prior to discharge. Patients were provided with relevant documentation to support after care and contact information for the ward. Where patients consented, staff carried out a follow up telephone call to screen for post-operative complications such as surgical site infections, VTE and bowel management as well as adequate pain control. Any concerns were raised with the resident doctor following the telephone consultation. This process was documented and evidenced in records we reviewed.
The service had policies and procedures to identify and support the transfer of patients that became critically unwell. Staff we spoke with knew their roles and responsibilities when a patient deteriorated and were able to seek support in a timely manner. However, some staff reported that they had experienced a reluctance from consultants or anaesthetists to attend when concerns were escalated to them. Departmental leads were available on call and would support on these occasions.

A total of 22 patients were transferred out in the 12 months prior to our assessment. There were no themes or trends related to these, and learning was identified. For example, reminding all ward staff of the importance of early mobilisation post operatively to reduce the risk of VTE. Nuffield Health Brentwood was an outlier for unplanned returns within the region of London compared to other Nuffield Health sites in June 2025.

The service had systems in place which worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, staff were not aware of how to complete safeguarding referrals in line with policy to share concerns quickly and appropriately without delay.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 3 in safeguarding adults and level 1 and 2 children’s safeguarding. Training compliance data showed 95 % compliance within the department, in line with target. The service had an updated safeguarding policy, which was in line with national guidance and described staff roles and responsibilities.

During our assessment, all staff interviewed demonstrated awareness of how to access the safeguarding policy online. However, they were unable to describe the process for completing the local safeguarding adult referral form in accordance with current policy requirements. This gap in procedural knowledge may hinder timely and appropriate safeguarding responses.

Despite this, staff consistently reported that they would escalate any safeguarding concerns to the most senior person within their ward or clinical area. The safeguarding lead confirmed that they had been contacted with concerns over the past 12 months, including occasions when they were off-site. This indicated a reliance on senior staff to escalate safeguarding concerns externally.

There was a safeguarding lead within the service to support staff with safeguarding concerns. However, not all staff were aware of who they were and how to contact them. The service shared concerns quickly, for example a referral was made and followed up with their GP and the service received feedback on the outcome.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff within pre-operative assessment screened patients based on their past medical history and escalated concerns in line with the admission criteria. We saw evidence of this and staff we able to give examples of following this process. Staff discussed support needs prior to admission to reduce risk depending on the type of surgery. We saw evidence of surgery being cancelled on the day due to inadequate support being available post operatively. During the assessment a patient was staying an additional night in hospital as there was no one to support them at home following knee surgery. This demonstrated the priority of patient safety.

Staff reported care plans and risk assessments were used to inform them of identified risk. There was no audit which looked specifically at the compliance of risk assessment. However the quarterly patient records audit included the review for the completion of risk assessments. The last audit showed a 100% completion of risk assessments.

Staff identified deteriorating patients using tools such as the national early warning score (NEWS). NEWS audits completed in the last quarterly audit showed a compliance of 96% for recording and escalating NEWS2 scores in line with policy. All staff we spoke to during the on site assessment were able to tell us how they would escalate any deteriorating patient concerns.

However, within the care record document there was no reference to guidance or standard operating procedure of actions staff should take if risk was identified. For example, what action should be taken if a waterlow score of 10 or more was identified. Staff told us they would use their clinical judgement. This may result in inconsistency in quality of care of identified risk.

Clinical staff received face to face training in basic life support to provide the skills to respond to life-threatening emergencies. However, administrative staff only received online training due to a change made corporately. Some staff we spoke to did not feel as confident as a result of the change in training. Staff knew how to call for emergency assistance if there was an emergency.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Clinical areas were secure with swipe access and intercom entry. Environment risk assessments were in place to minimise risk to staff and patients such as fire, falls and legionella . Risk assessments were in date and we saw evidence of annual review. The hospital had 3 laminar flow theatres. Laminar flow theatres utilise a ventilation system designed to maintain a sterile environment in operating rooms. We were told the hospital did not use body exhaust suits to further reduce intraoperative airborne contamination in line with best practice.

The service mostly carried out daily safety checks on equipment to ensure it was safe for use. During assessment we checked the resuscitation trolley on the surgical ward for completion in line with policy. There were gaps in daily checklists on 7 occasions over the last 3 months and we found an expired consumable. This was escalated immediately and replaced by the ward manager during assessment.

Where equipment was faulty it was reported in line with local and national guidance. For example, the Endoscopy team tested the Oxygen flowmeter and detected a fault, and reported the device via the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card process.

Blood spill kits were sealed, dated and available in clinical areas. However, not all staff we spoke with knew where they were stored in the event of requiring it.

There was a contract for servicing of equipment and staff we spoke with knew how to log faulty equipment. Asset stickers were visible on electrical equipment reviewed on assessment within clinical areas.

Staff we spoke with in theatres told us that at times they did not have the necessary equipment and consumables to deliver care. During such times a local resolution was found, such as borrowing from other sites and suppliers across Nuffield Health. Incident reporting for the 12 months prior to our assessment showed 44 occasions where staff had formally reported a direct impact on service. Examples included sterilised kit with missing parts and holes in sterile wrapping of trays. There were no reports of surgery being cancelled due to a lack of equipment or consumables. Incidents were raised via the governance structure to inform senior leaders and were discussed in the morning huddles.

Staff told us that senior leaders were supportive of requests to purchase replacement equipment through the capital expenditure process. However, this process was lengthy and could take months.

The ward had a room with adjustments for dementia or risk of falls. Adaptions included a large red toilet symbol to indicate the bathroom, a red coloured toilet seat and handle bars. Staff told us they had dementia friendly clock that they could place in the room if required.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The hospital had a governance structure and quality assurance framework for accountability and assurance relating to infection prevention and control (IPC). This was supported corporately by the Director of IPC and a team of infection prevention link practitioners from departments within the hospital. The hospital had engaged with external agencies and partners to ensure compliance with national IPC measures. For example, the Integrated Care Board (ICB) quality visit had highlighted wash basins needed to be Healthcare Technical Memorandum (HTM) compliant. Staff told us that these works needed approval and a date planned.

Staff maintained equipment well and kept it clean. ‘Clean’ stickers were visible on some equipment, but dates suggested cleaning had taken place some days previously. For example, we found a blood pressure machine with a ‘I am clean’ sticker dated 16 June 2025 during our onsite assessment on 8 July 2025 and an intravenous pump with no clean sticker within the store room. However, staff we spoke with told us that they would clean any equipment again prior to use if a sticker was not present or dated. We did not always see this being carried out during our assessment.

We reviewed the last cleanliness audit data for surgery and found an overall score of 99% in all areas.

All ward areas were visibly clean, had required furnishings and were well-maintained. Within Endoscopy, curtains were labelled with change date and staff knew how to request these to be changed sooner if required. They told us there was a plan to consider using rigid screens to offer privacy for patients and reduce infection control risk.

Cleaning records within clinical areas such as ward, theatres and Endoscopy were up to date and demonstrated that the ward areas were cleaned regularly. Staff told us there was a robust cleaning process following the discharge of patients from the ward. However, the recent ICB visit had highlighted there was a lack of cleaning schedules to support mattress cleaning following discharge. We saw this included in the most recent ward audit, scoring 100%. Separate decontamination areas within Endoscopy supported the manual cleaning and sterilisation of equipment in line with national guidance. The department were applying for their Joint Advisory Group (JAG) accreditation certification within endoscopy. The aim of the JAG accreditation standards is to define a high-quality, safe and appropriate endoscopy service, delivered by a highly-trained, highly-supported and highly-motivated workforce.

Staff adhered to infection control principles, including handwashing and bare below the elbows. Personal protective equipment was available in all clinical areas we visited. Hand gel dispensers were in the corridors of the ward outside patient rooms. Staff advised they would use the sinks in the medication storage room or patient washrooms to wash hands with soap and water. Hand towels and soap was available.

Patients were routinely screened for infections such as MRSA at pre assessment and there was a process in place to report surgical site infections (SSI). In the 12 months prior to our assessment there were no reported never events or surgical site infections. However, there were two healthcare associated infections (HCAIs) reported with a single incidence of E. coli bacteraemia infection & Klebsiella bacteraemia infection. This was consistently lower than other Nuffield Health sites.

Housekeeping staff told us that cleaning agents and equipment was stored in a locked cupboard when not in use. We found chlorine disinfectant tablets were not stored safely and correctly within an unlocked sluice room. This meant systems were not always effective to protect vulnerable service users from accessing dangerous products. We escalated these concerns, and action was taken to ensure the product was locked away.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems in place to support the safe prescribing, administration and storage of medicines. Medicines reconciliations (the process of gathering accurate information about a person’s prescribed medicines) was completed on admission and pharmacy staff clinically screened prescriptions to ensure patients received appropriate treatment. Staff were knowledgeable about the medicines they administered and had access to pharmacy support throughout the day.

Medicines were stored securely and checked regularly, including controlled drugs which were audited routinely. Patients were supported with clear discharge counselling, including medicine timetables and explanations of what each medicine was for. Discharge medicines were prepared early to support timely discharge.

Emergency medicines and resuscitation equipment were available and checked regularly. Staff were allocated roles during medical emergencies, and this was documented at handover. Staff completed training and competency checks, including annual IV training and peer assessments around medicines optimisation. However, consultant prescribing was sometimes unclear, with shorthand and missing indications for PRN (when required) medicines. However, pharmacy oversight helped to mitigate this risk.

The service was using Sugammadex (a reversal agent for anaesthesia) following surgery. However, the indication for use wasn't always clear on the prescription or clinical records. VTE (Venous thrombolytic embolism) prophylaxis was prescribed in line with consultant protocols, although these varied between consultants and were not always personalised to individual patient needs.