Nuffield Health Derby 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 of a positive culture and effective leadership.

Leaders promoted a supportive and collaborative environment. Staff described leaders as approachable and felt able to raise concerns and contribute to improvements.

Governance systems supported oversight of quality and safety, and learning from incidents and feedback was used to improve care. The service also promoted innovation, including initiatives to support patient wellbeing.

At our last inspection we rated this key question requires improvement. At this assessment, the rating has improved to good. This meant services were well led and delivered good quality 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.

We score the service as 3. 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 patient and their communities.

The service had a shared direction and culture that staff understood and described consistently.

Staff described a culture focused on patient safety, respect and teamwork. Clear expectations about professional behaviour, patient centred care and safe practice were reinforced through daily briefings, team meetings and governance discussions. Staff across disciplines spoke positively about working relationships and said there was a shared understanding of how care should be delivered.

There was a clear emphasis on collaboration and collective responsibility. Staff described working closely across professional groups, including doctors, nurses, anaesthetists, pharmacists and administrative staff, to support safe and effective care. Leaders described how multidisciplinary working and shared decision making were embedded in day to day practice, helping teams respond effectively to patient needs and changing circumstances.

Staff survey results in 2025 showed that teams across the services worked well together, supported by strong peer relationships and a shared understanding of common goals. Staff reported positive management support and alignment with organisational values, enabling coordinated working across services.

For further detail on the service’s shared direction and culture on this location, please refer to the surgery inspection report.

We scored the service as 3. The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

Staff described leaders as visible, approachable and supportive. Staff told us managers had a good understanding of the clinical, emotional and operational demands of their services, particularly within oncology, where staff’s emotional wellbeing were prioritised. Staff gave examples of managers making reasonable adjustments, offering flexibility and providing direct support during difficult personal or professional circumstances.

Leaders demonstrated the skills, knowledge and experience required to lead services effectively. Endoscopy and oncology managers described how they maintained oversight of governance, safety and staffing, including training compliance, incident reporting and escalation processes. Staff told us leaders were knowledgeable about national guidance, safety alerts and local pathways and ensured this information was shared through briefings, meetings and day to day conversations.

Staff engagement data supported what staff told us during interviews. Staff survey results for 2025 showed strong engagement and positive scores for management support, peer relationships, organisational fit and autonomy. This indicated that staff felt supported by their managers, aligned with organisational values and able to contribute to decisions about their work.

We scored the service as 3. The service fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff told us they felt able to raise concerns, ask questions and share ideas with managers and senior staff. Staff described leaders as approachable and said they could speak openly about safety concerns, workload pressures or practice issues without fear of blame or negative consequences.

Managers described encouraging staff to contribute to discussions about safety, incidents and improvement actions, reinforcing that speaking up was viewed positively.

Staff said they felt supported when they raised concerns. Examples included managers responding promptly, offering advice or escalation where needed, and providing feedback on outcomes.

The service had a freedom to speak up (FTSU) guardian. Staff told us they were aware of how to escalate concerns and felt confident doing so if needed.

We scored the service as 3. The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

Staff told us they were treated fairly and felt respected and valued in their roles. They said they had not experienced discrimination, bullying or harassment and described a positive and inclusive working culture. Staff told us leaders were supportive and made reasonable adjustments where needed to meet individual circumstances. For example, a member of staff from the oncology unit told us they had been redeployed to a safer clinical area during pregnancy to support their health, safety and wellbeing. This demonstrated the service's commitment to promoting equality, diversity and inclusion and supporting staff to work safely and effectively.

For further information relating to this quality statement, please refer to the surgery inspection report for this location.

We scored the service as 3. The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support.

Leaders identified, monitored and reviewed risks to patient safety at multiple levels across the organisation. They reviewed the hospital risk register monthly, while the Quality and Safety Committee reviewed it quarterly. Governance and Medical Advisory Committee meetings also reviewed risks, supporting effective escalation and organisational oversight. Expert advisory groups reviewed national guidance, patient safety alerts and field safety notices, and staff tracked these locally through the electronic incident reporting system. This supported a coordinated approach to identifying, recording and managing risk.

Leaders and managers used a comprehensive programme of audit, surveillance and assurance activities to monitor performance, identify areas for improvement and provide oversight of service quality. This included audits of infection prevention and control, surgical site infections, medicines management, consent processes and compliance with clinical pathways. Findings informed governance discussions, action planning and continuous improvement activities.

For further information relating to this quality statement, please refer to the surgery inspection report for this location.

We scored the service as 3. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patient. Staff share information and learning with partners and collaborate for improvement.

The oncology service maintained strong partnerships with Macmillan Cancer Support and local NHS organisations. Staff worked closely with the local NHS trust. This supported coordinated care and access to services.

Staff delivered a free self-management programme four times each year. The programme was available to people living with and beyond cancer. This included NHS patients not treated at the service. Macmillan Cancer Support helped develop the programme. It supported people to manage cancer's emotional, physical and practical effects.

The service facilitated a monthly cancer support group. Oncology patients also participated in the hospital's patient forum. This helped shape and improve services. Information about oncology support services was available through the local NHS trust app. This enabled patients to access support when required.

The service provided practical support, including transport arrangements where necessary. Staff also offered a free cancer activity programme. This promoted physical wellbeing and quality of life during and after treatment.

For further information relating to this quality statement, please refer to the surgery inspection report for this location.

We scored the service as 4. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. Staff often encouraged creative ways of delivering equality of experience, outcome and quality of life for patient. Staff actively contributed to safe, effective practice and research.

Leaders and staff demonstrated a commitment to continuously improving services and outcomes for patients by using feedback, audit and shared learning to inform changes in practice.

Staff were encouraged to contribute to improvements in practice and described a culture where ideas and feedback were valued. Teams worked collaboratively to identify opportunities to improve patient experience and outcomes. For example, staff described adapting care pathways and environments to meet individual needs, including for people with additional communication or sensory needs.

The oncology unit participated in a partnership programme with a local university. The programme supported prostate cancer patients through a peer support group. It promoted physical activity to improve wellbeing and mental health. Leaders said the programme could extend to breast and lung cancer patients. The unit also piloted a digital cancer care platform for Nuffield Health. Following evaluation, the platform was rolled out across Nuffield hospitals. The platform enabled patients to record symptoms, concerns and wellbeing information. Oncology staff could review this information and respond to concerns promptly. The platform provided information, wellbeing advice and self-management resources. This showed how the service tested innovative approaches to improve patient support. It also improved patient monitoring and overall experience during treatment.

For further information relating to this quality statement, please refer to the surgery inspection report for this location.