Nuffield Health Derby 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.

The service demonstrated a consistently strong safety culture, characterised by openness, proactive incident reporting and a clear commitment to learning and improvement. Staff reported problems quickly and managers investigated them properly. Learning was shared to support continuous improvement. Staff felt empowered to raise concerns and multidisciplinary communication was effective. Well‑structured governance processes ensured that risks were identified, investigated and acted upon.

Teams communicated well, followed safety checklists and used clear handovers to make sure every patient got the right care at the right time.

Staff followed safeguarding arrangements to keep patients safe. Staff completed training and knew how to raise and escalate concerns.

Staff managed clinical risks well. Staff used recognised tools such as the National Early Warning Score (NEWS2), the World Health Organisation (WHO) safer surgery checklist and thorough venous thromboembolism (VTE) assessments to support safe care.

The care environment was generally safe, clean and well maintained, with strong fire safety, equipment oversight and housekeeping standards.

Staffing levels were adequate, teams were skilled and well supported, and patients consistently received timely, compassionate care. Infection prevention and control was a priority with strong audit performance, Gold level aseptic non touch technique accreditation and low infection rates.

However, the service did not always manage medicines safely. Some medicines were out of date, some labels were missing important information, and pharmacy checks did not always happen. Prescribing records were sometimes incomplete, and decisions about blood clot risks were not always written down. As a result of this we found that there was a breach of regulation. We also found that not all doctors recorded what was needed to prevent venous thromboembolism in pre-operative risk assessments.

We have asked the provider for an action plan in response to the concerns found at this assessment

At our last assessment we rated this key question good. At this assessment the rating has remained good. Patients were mostly 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 service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared widely across the service and more widely with the other provider locations, where appropriate.

Patient safety incidents were managed well. Managers encouraged a positive reporting culture, and staff confirmed that there was a culture of openness and honesty. Staff reported all safety concerns on the hospital’s electronic incident reporting system. Staff stated was easy to use. We reviewed incidents reported in the 12 months prior to our inspection which provided evidence of consistent reporting.

Staff felt able to act when they believed there was a risk to patient safety. A ‘stop the line’ process was in place, which meant any staff member could stop surgical activity if they had a safety concern. Work would stop until the team addressed the concern and agreed it was safe to continue.

The hospital had a quality governance policy in place which clearly set out everyone’s responsibilities. Immediate incident reviews, SWARM huddles (focused meetings to discuss an incident which take place soon after the incident), and ‘After Action Reviews’ (AAR) were carried out when needed.

Weekly adverse event meetings were held to discuss all open and newly reported incidents, and learning was shared in departmental meetings and daily safety huddles. Themes and concerns were discussed at monthly clinical governance meetings. Incidents were examined to find patterns or links to individual clinician. Where a link to an individual clinician was identified we saw evidence of action being taken to address this. Patient safety incidents were also discussed in quarterly quality and safety committee meetings.

We saw where incidents had been investigated, staff took action to reduce the chance of them happening again. Recent incidents included problems with incorrect documentation when patients were booked into the service. This issue had been identified as a theme by the quality and safety committee, and new processes were implemented to reduce the risk of it happening again.

Managers shared learning from incidents using an ‘Outcome with Learning’ (OWL) format. This explained what happened, what actions were taken, and what had been learned. These were shared with staff, and we saw them displayed in staff areas.

Staff showed an understanding of the duty of candour and the importance of being open and honest with patients when things went wrong. Duty of candour is a legal requirement which requires openness and honesty with patients if their treatment causes, or could cause, harm or distress. Data reviewed during the inspection showed that the service met its duty of candour responsibilities and acted openly when things went wrong.

The service acted on patient safety alerts and field safety notices from the government.

There had been one reported Never Event in the past year. Never Events are serious safety incidents that should not happen if proper safety measures are followed, such as operating on the wrong part of the body or unintentionally leaving an object inside a patient after surgery. Evidence showed that this incident had been investigated, actions were taken, and that learning was identified to reduce the risk of it happening again.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The hospital had an admission criterion in place for both private and NHS patients. Staff used this to decide which patients they could safety operate on at this hospital. For example, people with underlying health conditions which would mean that the surgery would be unsafe. Where this was the case, staff referred patients to an alternative provider such as their local NHS hospital.

The service had clear systems in place to ensure patients were correctly identified and received the right treatment at every stage. During our inspection, we saw staff handing over information safely, including carrying out all required identity checks. In theatre, teams used the WHO surgical safety checklist to reduce the risk of errors, and we observed this being completed in full.

Staff safely managed the transfer of patients from the operating theatre to the recovery area.

Staff held regular and effective multidisciplinary meetings to discuss all patients and improve their care. Information was shared to support safe transitions between teams and shifts. Staff and managers described using structured handovers, daily safety huddles and briefings to review risks, staffing levels and people’s needs. This supported continuity of care and reduced the risk of gaps during transitions.

When it was required to transfer a patient to a different provider, such as an NHS hospital due to a deterioration in their condition, the service had clear ‘transfer out’ policy and processes in place which outlined how to do this safely and effectively ensuring that there was effective communication. There were templates to use when completing transfers such as an ISBARD (situation, background assessment, recommendation, decision) tool. This was a tool used by staff when communicating the need to transfer a patient, the use of the template provided a framework to ensure that staff did not miss any vital information during the transfer of care. Staff completed additional documents such as a patient handover and a transfer out checklist.

The service worked with patients and healthcare partners to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and demonstrated a strong understanding of safeguarding and their responsibilities. The service had a clear a safeguarding adults, children and young people policy, and staff were aware of this.

A named safeguarding lead was in place. Staff knew who the safeguarding lead was and said they felt confident escalating concerns to them when required. We saw safeguarding process posters displayed in the nursing office, which supported staff to recognise and escalate safeguarding concerns appropriately.

Staff received adult and children's safeguarding training. Staff received safeguarding training at a level appropriate to their role and had access to staff who were trained to level 4 and 5 should they require advice or support escalating concerns. Mental Capacity Act (MCA) training also formed part of mandatory training.

The service did not treat children, however young people aged 16 and 17 were occasionally referred to the hospital for surgery from a different Nuffield hospital. These patients were risk assessed for suitability prior to attending the hospital. Staff were compliant with national guidance and completed safeguarding training for children therefore knew how to make referrals to children services if needed.

Staff could access a policy and flowcharts which explained what steps to take if a Prevent concern (Prevent is a UK counter-terrorism initiative) was identified against both patients and staff members. 100% of staff had completed mandatory Prevent training. The service also had specific policies relating to female genital mutilation (FGM) and domestic abuse. Policies reflected national guidance and legislation.

Details of local and national safeguarding leads, who had higher levels of safeguarding training, were displayed in staff areas alongside the steps to take if a safeguarding or concern was identified.

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

Staff followed a clear inclusion criteria for patients undergoing surgery at the hospital. This meant patients received treatment in a setting appropriate to their individual needs.

Staff used a nationally recognised tool (NEWS2) to identify deteriorating patients. If staff identified patients were becoming unwell, they escalated this to consultants. T

The service used the WHO surgical safety checklist, in line with National Patient Safety Agency guidelines. Staff received training in the WHO checklist. At the time of our inspection 63 staff were required to complete this training, data showed that 90% of staff had completed this training. Patient records that we reviewed showed that the WHO checklist had been fully completed. WHO audits showed 100% compliance.

Consultants completed risk assessments to assess a patient’s risk of developing blood clots (VTE) after surgery. However, not all doctors recorded what was needed to prevent VTE in pre-operative risk assessments. This meant it was not clear which treatment to give to a patient to keep them safe. However, we saw evidence that that where needed, patients were given prescriptions to manage this such as medicine or compression stockings. Consultants continued to risk assess the risk of VTE throughout patients’ stay in hospital. This was in line with best practice. The service had a clear policy in place around this which was available to all staff.

Staff completed falls risk assessments and each patient room had information around how patients could prevent falls displayed.

There was a designated team lead by a clinical lead or the Resident Doctor (RD) who were allocated to attend any clinical emergency. An RMO is a fully qualified doctor who stays on-site in a hospital to provide continuous medical cover. The team were all trained in immediate life support (ILS) with the lead trained in advanced life support (ALS)

There were policies in place around how to manage a patient that deteriorated whilst within the service.

The service had a pre-transfer risk assessment tool which was required to be completed when a patient was transferred to another service, such as an NHS hospital in the event of deterioration.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The service had effective systems in place to identify, assess and manage risks within the care environment. Leaders monitored environmental safety through routine inspections, audits, risk registers and action plans, ensuring that equipment, facilities and technology supported the delivery of safe care.

Environmental risks were identified through internal and external risk assessments such as Patient‑Led Assessments of the Care Environment (PLACE) assessments, and direct environmental observations. These processes identified risks such as damaged flooring, uneven external surfaces, accessibility issues and housekeeping hazards. Actions were recorded, prioritised and monitored, including repairs, use of warning signage, improved housekeeping arrangements and seasonal controls such as gritting icy pathways. This reduced the risk of avoidable harm to people, staff and visitors.

Fire safety was managed through clear governance and oversight. The hospital operated within a fire safety framework with designated leadership responsibility. Fire alarms, extinguishers, fire suppression systems and fire dampers were inspected and serviced in line with required schedules. Where defects or non‑compliances were identified, remedial actions were taken promptly. Planned replacement of the hospital fire alarm system demonstrated ongoing investment in maintaining safety and compliance.

The service had suitable facilities to meet the needs of patients having elective surgery. There were 2 laminar flow orthopaedic operating theatres (specialised operating theatres designed to keep the air clean using a continuous flow of filtered air), 1 standard operating theatre and four recovery bays. There was one ward with private ensuite rooms.

Staff had access to enough equipment within the theatres which had all been safety tested and were in date. Staff kept theatres clean and free of clutter however there were visible areas where the flooring and walls had deteriorated. The service was aware of this, and it was logged on the departmental risk register. Managers were assured that they remained compliant with infection prevention and control guidelines.

Staff accessed theatres through a secure door, locked with passcode access. Access to the ward was not secure and could be accessed by anyone. The service was aware of the risk associated and this was on the departmental risk register with measures in place to mitigate risk. There were plans in place to upgrade the CCTV and security system, which included improved surveillance and controlled access doors to the ward in summer 2026. The service also employed a third party security provider to patrol the site and ensure safety.

Fire exits were clear, floors were non‑slip, equipment was accessible, and safety checks were up to date. Staff managed medical and electrical equipment to ensure it was safe and fit for use. Equipment was routinely serviced, tested and labelled to confirm safety status. Emergency equipment was standardised and accessible. Patient rooms were clean and tidy with call bells and emergency alarms available and easy to reach. Staff responded to call bells promptly.

The service had processes in place for the maintenance and checking of electrical equipment. All equipment that we checked had been tested and was in date.

Resuscitation trollies were easily accessible. The equipment kept in the trollies and the layout of equipment and medicines were standardised. Records indicated that the resuscitation trolley and their contents were checked in line with hospital policy. The trolley was secured with a tag which was removed monthly to check the entire contents were in date.

Hazardous chemicals and cleaning products were stored safely in locked cupboards, in line with Control of Substances Hazardous to Health regulations (COSHH).

We found out of date equipment in a phlebotomy trolley on the ward, this was raised with the lead nurse who immediately removed all out-of-date equipment. We also found a bariatric shower chair which was rusty and fell apart when we moved it. We raised this with the lead nurse who advised that as the service rarely treated bariatric patients this was not in use and immediately removed it from the ward.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough staff with the right qualifications, skills, training, and experience to provide the right care and treatment. The hospital used formal workforce planning tools across services, including wards, theatres, oncology and outpatient areas. Leaders reviewed staffing levels and skill mix daily through safety huddles and adjusted in response to patient acuity and demand. For example, leaders reported that typical nurse-to-patient ratios were 1:5 or 1:6 on the wards, with flexibility to increase staffing if required. Leaders and managers told us the workforce was stable, with low turnover and minimal reliance on agency staff. Theatres were staffed in accordance with the Association for Perioperative Practice guidelines. However, we identified concerns about staffing in the pharmacy department. Due to limited staffing, pharmacists could not complete medicines reconciliation for all patients admitted to the ward.

Staff undertook a wide variety of training relevant to their roles and responsibilities such as medical device training, NEWS2 and infection prevention and control. Mangers monitored staff training to ensure this was completed. At the time of inspection, 90% of ward staff, 98% of physiotherapy staff and 82.5% of theatre staff had completed their mandatory and role‑essential training.

Staff told us that they felt they had the appropriate training and confidence to recognise and respond to patient deterioration. Staff reported that they managed emergency transfers to acute hospitals safely, using consultant‑led decision‑making, providing appropriate clinical accompaniment, and maintaining clear communication with receiving services and relatives.

New staff received a full induction, and leaders tailored it to their role. We observed a new member of the nursing team working directly alongside an experienced member of staff as part of their induction. They would complete a number of shifts alongside experienced staff before working independently to ensure that they were working safely in line with the services standards.

Leaders used agency or bank staff only when necessary and mainly to cover short‑notice absences. Leaders inducted agency staff locally using a checklist that covered fire safety, escalation processes and clinical orientation. They gave bank staff the same induction and mandatory training as substantive staff. The hospital recruited resident doctors (RD) through an approved agency and treated them as part of the core team. RDs worked defined shifts with on‑call arrangements overnight, and senior staff monitored their rest and workload to reduce fatigue risks.

Leaders carried out annual appraisals for staff. Appraisals reviewed each person’s training needs to ensure staff had the right skills and knowledge for their role. This process helped the service plan future training and ensured staff felt confident in providing safe care.

Nuffield did not directly employ consultants, but the hospital granted them practising privileges. Practising privileges are the formal, contractual permissions that allow a consultant to treat patients within an independent/private hospital. Leaders used robust systems to confirm consultants had the skills and experience required for their roles. They granted practising privileges after completing a formal credentialing process that verified professional registration, indemnity, appraisal and scope of practice. When consultants worked with children and young people, leaders applied additional safeguards and checks. The Medical Advisory Committee (MAC) reviewed practising privileges regularly. The trust employing each consultant managed their mandatory training and appraisals, and MAC meetings reviewed this information. When we reviewed MAC minutes from the six months before our inspection, we saw that consultant appraisal levels were at 88% in December 2025 it was recognised that appraisal completion rates were low, but as appraisals were completed by a consultant’s primary employer the situation was to be monitored even though it remained outside their direct control.

Staff told us they felt the hospital was safe, understood their training expectations and felt supported by leaders to complete required training.

Patients told us the service met their needs promptly, and we observed staff responding quickly to call bells.

The service supported staff learning and development and ensured staff received any specialist training required for their role. For example, some healthcare assistants completed phlebotomy training so they could provide additional support to the nursing team.

Physiotherapists played an integral role in patient care and treatment, promoting recovery and rehabilitation. The service employed enough physiotherapists to keep patients safe and meet their needs, and physiotherapy staffing levels prevented delays in patient discharge.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service maintained oversight of infection prevention and control (IPC). Staff used established systems to identify and prevent surgical site infections and applied appropriate equipment and control measures to protect patients, themselves and others. Staff kept clinical areas and equipment visibly clean and well maintained.

Leaders had clear arrangements in place for infection prevention and control at a local service level. There was a clear structure that set out who was responsible for IPC across the service.

The Director of Infection Prevention and Control (DIPC) role is held by the Director of Clinical Services. The DIPC is supported by an Infection Prevention Lead and each clinical department has an Infection Prevention Link Nurse.

Leaders used these arrangements to monitor risks, review audit results, and check that the service was following national guidance. This helped make sure IPC standards were understood and applied across teams.

Housekeeping staff completed daily checklists of their duties to ensure that all tasks were completed. These were then submitted to leaders to ensure that they had oversight. The hospital worked to a star rating system which showed how well the house keeping team were performing in each area. The ward had a 5 star rating, which was the highest that could be achieved.

Staff followed core IPC principles, including correct use of personal protective equipment (PPE), and had access to aprons, masks and gloves. Staff kept theatre and ward environments clean, uncluttered and appropriately furnished. Staff had access to IPC policies and supporting guidance.

Staff monitored infections linked to healthcare, including surgical site infections and infections identified after patients were discharged. This covered the full patient pathway.

Leaders reviewed infection data regularly in local IPC meetings. Any concerns were shared through the service’s governance processes.

In 2025, all reported infections were investigated. Infection prevention leads reviewed each case and sought advice from microbiology specialists where needed. This helped the service understand causes and improve practice.

The service had an IPC audit programme in place. This included regular checks on hand hygiene, aseptic practice and surgical scrubbing.

Over the last 12 months, hand hygiene compliance was lower in theatres (73%) compared to the ward (94%). Leaders used this information to identify gaps and put action plans in place, including improving mandatory training.

Audits highlighted some ongoing issues. These included staff not being bare below the elbows, wearing nail polish or having long nails, and some inconsistency in practice among consultants.

Staff raised concerns about poor hand hygiene with senior leaders. This helped ensure issues were addressed and standards improved.

The service carried out regular audits of aseptic technique and surgical scrubbing. Compliance was high, with aseptic technique at 92% in theatre and 100% on the ward. Surgical scrub compliance was 98% over the past 12 months.

The hospital used an assessment tool to monitor and improve infection prevention practice across the surgical pathway. This included checks on key areas such as pre-operative patient washing, which had 87.5% compliance.

Staff supported patients to prepare for surgery. For example, patients having knee replacement surgery were given antimicrobial skin cleanser and antibiotic cream before their procedure.

Data showed full compliance in some areas, including maintaining asepsis in theatre and skin disinfection, both at 100%. The service also recognised the risk of infection after surgery and gave preventative antibiotics when needed, achieving 100% compliance with this standard.

Staff completed Aseptic Non‑Touch Technique (ANTT) training as part of their mandatory training, which included both theory and practical components. The hospital aimed for 95% compliance and achieved 94% completion for the practical element and 95% for the theory. In 2025, the hospital achieved gold accreditation for ANTT by maintaining organisational compliance above 90% in both components, completing regular ANTT and hand hygiene audits, and submitting evidence confirming compliance.

National Standards of Healthcare Cleanliness (NSoHC) audits showed that staff consistently maintained a five‑star cleanliness rating across all areas. Leaders encouraged staff to attend infection prevention study days and supported a network of IPC link practitioners.

Data from the most recent Infection Prevention, Antimicrobial Stewardship and Tissue Viability Committee showed zero bloodstream infections, zero cases of Clostridioides difficile (a bacterium that causes severe inflammation of the colon and diarrhoea) and eight inpatient surgical site infections in 2025. When infections occurred, the service carried out patient safety investigations and implemented appropriate actions.

The hospital used tap filters to reduce the risk of legionella, a bacteria that can grow in water and cause Legionnaires’ disease.

Leaders implemented a decontamination policy for surgical instruments that followed national guidance and ensured staff could access it easily.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff did not always involve patients in planning.

Staff did not annotate medication administration charts with pharmacy interventions when issues were identified. This made it difficult to confirm whether concerns had been escalated to the relevant staff. The provider’s action plan stated that leaders would review staffing and introduce protected time to support staff in completing key ward-level tasks.

We found gaps in prescribing on drug charts, including missing details about medicine forms and antibiotic course lengths. “When required” medicines were prescribed without clear information on type, maximum dose, or purpose. In one case, the route of administration was recorded incorrectly, creating a risk of unsafe dosing.

Staff stored medicines securely in ward storage areas. However, we found that staff did not always record opening dates on liquid medicines, which created a risk of using them beyond their recommended expiry. We also found expired medicines. We raised this during our inspection and staff removed them.

Staff stored controlled drugs (CDs) which are medicines with potential for abuse securely and completed record‑keeping regularly. During the inspection, we found a controlled drug that staff dispensed out of hours in breach of local policy. After the inspection, the provider informed us that they had removed the processes that allowed this, in line with local guidance.

Limited staffing in the clinical pharmacy team reduced the support available. This meant pharmacists could not always complete medicines reconciliation for all patients on admission, which could impact patient safety. The service was aware of this and was working to improve staffing and processes.