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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of 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.

Frontline staff we spoke with did not understand how the vision and values applied to their work. There was no other evidence to support how senior leaders communicated the provider’s vision and strategy to front line staff. We requested evidence of how staff implemented the local vision and strategy, but we were not provided with any.
We were provided with meeting minutes of the theatre strategy day in February 2024. This detailed actions to improve the delivery of patient care. However, there were no assigned names and dates to actions identified. Naming individuals on an action plan provides clear accountability, fostering a sense of ownership and responsibility for completing tasks.

Senior leaders told us that the new transformation programme was implemented in April 2025 to align with the corporate management of surgical pathways. This program would allow for early screening and risk assessing to ensure the patient was suitable for the Nuffield and improve safety and the patient’s journey.

Staff we spoke with did not feel that this would deliver high quality care. Leaders told us that not all staff were supportive of the new strategy. Staff were at times frustrated and stressed due to 2 pathways running concurrently. This was further impacted as not all consultants were aligning to the transformation, resulting in frustration and staff not being able to work efficiently. Senior management team acknowledged the need to engage the consultants and secretaries more, to align with the corporate led changes. Changes were due to be made to transformation programme paperwork following a corporate leadership meeting with staff.

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.

Frontline staff we spoke with did not understand how the vision and values applied to their work. There was no other evidence to support how senior leaders communicated the provider’s vision and strategy to front line staff. We requested evidence of how staff implemented the local vision and strategy, but we were not provided with any.

We were provided with meeting minutes of the theatre strategy day in February 2024. This detailed actions to improve the delivery of patient care. However, there were no assigned names and dates to actions identified. Naming individuals on an action plan provides clear accountability, fostering a sense of ownership and responsibility for completing tasks.

Senior leaders told us that the new transformation programme was implemented in April 2025 to align with the corporate management of surgical pathways. This program would allow for early screening and risk assessing to ensure the patient was suitable for the Nuffield and improve safety and the patient’s journey.

Staff we spoke with did not feel that this would deliver high quality care. Leaders told us that not all staff were supportive of the new strategy. Staff were at times frustrated and stressed due to 2 pathways running concurrently. This was further impacted as not all consultants were aligning to the transformation, resulting in frustration and staff not being able to work efficiently. Senior management team acknowledged the need to engage the consultants and secretaries more, to align with the corporate led changes. Changes were due to be made to transformation programme paperwork following a corporate leadership meeting with staff.

People did not always feel they could speak up and that their voice would be heard.

The service had 2 Freedom to Speak up Guardians for staff to speak to regarding patient care or working life. Posters were visible in staff areas with the names of 3 guardians , which was not reflective of those in post during the time of the on-site assessment. Not all staff we spoke with knew who their guardians were but told us that they knew what the service was there for. Not all staff u sed the service as they felt that it would not influence change with senior leadership.

Monthly meetings were held between the senior leadership team and FTSU Guardians to raise cases and actions required. Meeting minutes showed that senior leadership did not always carry out planned actions agreed within the meeting. Actions were allocated with a completion date and reviewed at the following meeting; this was in accordance with the FTSU standard operating procedure . Morale remained low amongst staff, despite initiatives such as staff engagement and treats trolley. This remained on the agenda for ongoing review.

Staff surveys were conducted to gather feedback on staff satisfaction. We were provided a dashboard for theatre staff and ward staff. The overall score for theatres was 7.8 with a participation of 95% and ward was 8.1 with a participation rate of 79%. It showed that all staff were not engaging in providing senior leadership with feedback on areas such as morale, workload and wellbeing. Evidence provided did not explain what areas staff were concerned with. There was an action plan in place with actions leaders had taken such as attending staff meetings and a treats trolley.

Staff did not feel confident that all consultants and anaesthetists would support when concerns were raised. Senior staff told us they would call or come into work to support ward staff if patients deteriorated. This meant that there was not a positive listening culture to access expert decision making and improved outcomes for patients.

An action plan was in place to address anonymous whistle blowers raising concerns around poor culture and support from senior leadership at the hospital. These included communication of safety issues and senior management attending departmental staff meetings and ‘we care’ staff recognition scheme. The success of the action plan was being reviewed and was ongoing at the time of the assessment.

Patients and carers had opportunities to give feedback on the service they received via a patient satisfaction survey. Data showed an average of 82% satisfaction was received for Nuffield Health Brentwood, from January to May 2025.

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.

Staff were able to apply to work flexibly. For example, flexible working agreements were made to accommodate personal circumstances, such as caring responsibilities or health issues.

A multi faith room was allocated daily and communicated at the daily huddle meeting to support religious activities. Staff were supported with time off to celebrate religious festivals.

The uniform policy promoted equality and diversity, ensuring they did not discriminate against any individual based on protected characteristics. For example, uniform was available to order in three quarter length sleeves for staff who required them for religious or faith reasons.

The service had clear responsibilities and roles, however there was a lack of accountability and good governance.

The service had a governance structure to support the flow of information from frontline staff to the senior management team and to the corporate board. The hospital board and infection prevention and surgical site surveillance team met monthly. Clinical speciality committees met quarterly and reported to the Quality and Safety Committee and Medical Advisory Committee, which met quarterly. Weekly rapid response and patient safety meetings were held with heads of department to discuss incidents, learning, safety and risk, which fed into the monthly board meeting. We requested the last 3 governance meeting minutes and MAC meeting minutes. There was a formal structure of the meeting and review of both clinical and operational performance such as incidents, training and current risks cited on the risk register. MAC meeting minutes did not demonstrate any formal consultation regarding the pre-optimisation programme which was launched in March 2025 when we reviewed meeting minutes between October 2024 to April 2025. This meant that we were not assured that all consultant staff were consulted on the changes to support other clinical staff in the safe implementation of the pathway.

Quality and governance board meetings reviewed site-based risk, governance, incidents and complaints as well as performance against other Nuffield Health sites within the London region, using a site quality scorecard. The site quality scorecard was a percentage based on domains within safety, effectiveness and experience of staff and patients.

Staff we spoke with were not always aware of local departmental audits and learning from complaints and incidents. This meant that systems and processes in place were not effective in communicating with staff.

The hospital had engaged with external agencies and partners to ensure compliance with national Infection Prevention and Control measures. For example, the Integrated Care Board (ICB) quality visit in April 2025 had highlighted wash basins needed to be Healthcare Technical Memorandum (HTM) compliant. Staff told us that this was in the process of being changed within endoscopy.

Staff maintained and had access to the risk register at directorate level. Senior leaders told us that risks identified within departments were escalated at daily huddles or monthly risk meetings to escalate to board. There was evidence that the risk register had been reviewed in the April 2025 clinical governance meeting minutes. We were told that if risks were resolved prior to the quarterly governance meeting, they were not placed on the risk register. This meant that only long-term risk was added to the risk register.

Potential risks to service and staff that we had identified during our assessment, such as equipment sterilisation and implementation of transformation program, were not included in the risk register.

Engagement with medical consultants was via the MAC. Staff told us they escalated concerns regarding consultants to be raised at the MAC by senior management. However, they saw limited action and change, leaving staff feeling frustrated and unsupported. We reviewed the last 3 MAC meeting minutes from October 2024 to April 2025 but could not see that concerns had been escalated and how these were addressed.

Limitations in audit methods meant areas of non-compliance, such as missed implant pauses and debriefs, were underreported. This prevented leaders from identifying and addressing specific safety shortfalls.

Senior leaders had a transformation program action plan, developed in March 2025 and reviewed in June 2025. None of the planned deadlines had been met and there was limited supporting evidence against the progress updates. This meant the system was delayed and did not demonstrate how leaders were assured that actions would meet the objectives in a timely manner to reduce stress on staff.

Care records were stored securely in a locked room to maintain confidentiality. However, the care record booklet lacked clear references to guidance or standard operating procedures outlining specific actions to take when risks were identified. In the absence of formal guidance, staff relied on their clinical judgement, which may lead to variability in the quality and consistency of care provided. Poor compliance for notes audits did not have a clear action plan provided to demonstrate how leaders would address this.

We found poor compliance of training within staff groups within the surgery department. This meant that oversight was not robust and systems were not effective within the service to identify and ensure staff were adequately trained to meet the patients’ needs.

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.

Directorate leaders engaged with external stakeholders, such as the Integrated Care Board and local NHS trust they carried out contracted work for. We spoke with external stakeholders, who reported that the provider engaged and communicated well and were responsive in sharing learning with partners. We saw evidence of meeting minutes with stakeholders.

The NHS bookings team held regular meetings with the NHS trust to discuss referrals where information was missing, in order to avoid unnecessary delays in offering appointments and surgery. This had reduced administrative delays, improving access for patients.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Frontline staff were unable to give examples of innovation or improvements made in relation to incidents or complaints within the surgery department. Leaders did not provide examples of changes made in response to complaints when this was requested as part of our assessment. However, a manager told us that follow up phone calls post discharge were introduced following a patient incident. This showed the service were responsive and implemented change to improve safety.

There was limited evidence of leadership development opportunities for staff within surgery. Staff within theatres were developed to support the growth within the department. Theatre staff were mentoring and training as well as succession planning, with a deputy theatre manager who acted up when required.

We were provided with 2 local quality improvement work action plans developed within the surgical department in the 12 months prior to our assessment to improve the safety and quality of the service. These had named and dated actions to ensure it was effectively implemented and within trajectory to meet deadlines set.

The service was working towards the Joint Advisory Group (JAG) on gastrointestinal endoscopy accreditation review in July 2025. This accreditation would be awarded if the service consistently met specific standards for patient experience, clinical quality and staff training.