Nuffield Health Newcastle-upon-Tyne 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

Surgical services provided at this location included orthopaedic and spinal surgery, men’s and women’s health, ophthalmology and cosmetic surgery. There were two wards where surgical patients were cared for.

We looked for evidence that patients were protected from abuse and avoidable harm. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery.

Patients received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation.

Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

This was the first rated assessment for this service since 2016. This key question has been rated good.

This meant patients 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.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. We saw the service held a ‘weekly adverse events forum’ which summarised the adverse event, identified the degree of harm, recorded and tracked action taken in response.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured actions from patient safety alerts were addressed and progress was monitored. The service had a current patient safety incident response framework policy, which reflected service and national guidance. We observed daily huddles to create a safe space to identify what happened and why, and to identify where else in the service the learning may be relevant.

Staff raised concerns and reported incidents and near misses in line with provider policy. We saw evidence of incidents having been investigated through ‘after action reviews’, and sufficient action taken to reduce the risk of recurrence. We looked at the system for managing incidents.

One never event had been reported. We saw this had been fully investigated, subjected to an ‘after action review’ and discussion leading to identified actions to prevent recurrence. Never events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. Incidents were analysed to identify trends or themes and potential links to individual practitioners. Staff were able to identify and report risks and incidents. The service analysed patient safety incidents by month, type and severity of harm.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

We scored the service as 3. The service worked with patients and healthcare partners where required, 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.

All staff completed adult and children's safeguarding training. Overall compliance for completion of safeguarding adults modules was above the service target: level 1 - 95%, level 2 – 96% and level 3 – 94%. Similarly for safeguarding children modules, completion rates were level 1 – 92%, level 2 – 92% and level 3 – 100% (staff module).

Additional modules at level 3 had been developed specifically for senior managers and at the time of inspection had a completion rate of 85%, one senior manager (clinical head of department/theatre manager) had been unable to attend the module.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service had a policy for safeguarding adults and a policy for safeguarding children.

Staff knew how to make a safeguarding referral and who to inform if they had concerns, and expert safeguarding advice was available to support staff. There was a corporate named nurse and a named doctor for adult and child safeguarding trained to level 4.

Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies available and staff knew what happened when they raised concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. The registered manager had oversight of safeguarding within the service.

Discharge and follow up arrangements were organised safely. Patients knew what to expect and when they would be next seen by a nurse or doctor. Staff followed safe procedures for visitors visiting the wards and patients we spoke to told us they felt safe.

We scored the service as 3. 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.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We spoke to 8 patients and relatives during our inspection who told us they felt listened to, risk had been explained, and they were involved in decisions about their care and treatment.

For example, the preoperative assessment ensured patients' clinical risks were assessed on an individual basis and completed for all higher risk patients including the vulnerable and frail. We also saw the policies enabled identification of patients at high risk of developing sepsis through early recognition by involving them in assessments such as the national early warning score (NEWS2).

We scored the service as 3. 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.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We spoke to 8 patients and relatives during our inspection who told us they felt listened to, risk had been explained, and they were involved in decisions about their care and treatment.

For example, the preoperative assessment ensured patients' clinical risks were assessed on an individual basis and completed for all higher risk patients including the vulnerable and frail. We also saw the policies enabled identification of patients at high risk of developing sepsis through early recognition by involving them in assessments such as the national early warning score (NEWS2).

We scored the service as 3. 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 design, maintenance and use of facilities, premises and equipment kept patients safe. Staff were trained to use equipment and to manage different types of waste safely.

The design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients. Access to restricted areas was restricted by keypad.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was suitable equipment provided and used correctly, for example for patients who were at increased risk of pressure damage or a blood clot developing. Staff carried out daily safety checks of specialist equipment. There was ready access to resuscitation equipment on the ward and in theatres.

Instruments were sterilised off-site and were either single-use or sent to a central sterile services unit for decontamination. Collections and deliveries were twice daily, ensuring a consistent flow of sterile equipment. There was also the option to fast-track instrument sets when required. Other equipment was cleaned using a recognised and fully audited traceable system.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

We saw specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements.

Patients could reach call bells positioned by patient beds, and staff showed patients how to use them to summon help, we saw patients were responded to swiftly. The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the service policy. The risk of sharps injuries was minimised because of the safe management of sharp implements. Hazardous substances were stored safely and information about products was available to staff.

We scored the service as 3. The service made sure there were adequate numbers of 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 clinical staff including nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. New staff received a full induction tailored to their role, and bank and agency staff had a local induction to the area in which they were working. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work.

An external contract provided a continuous trained and monitored resident doctor service, working one week on, one week off, remaining on site round the clock. Their rest periods were checked each morning during the safety huddle. These were long standing appointments who had gained familiarity with the hospital staffing team over the past two years

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift. Managers could adjust staffing levels daily according to the needs of patients. Theatre and recovery staffing was planned, based on activity and the skills needed. The service had low vacancy, turnover and sickness rates (4.3% at the time of inspection). Staff spoken to said they felt the service was safe and they were able to take breaks during their shift.

All patients we spoke with felt their needs were met in a timely way and we observed staff responded quickly to patients. We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, a comprehensive set of training modules had been developed for consultants including mental capacity act and deprivation of liberty safeguards.

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

The service had enough allied health professional staff to keep patients safe and meet their needs. Patient pathways and their discharge was not delayed because of a lack of allied healthcare professional input.

Consultant surgeons and anaesthetists were subject to a full assessment through the practising privilege process and were required to provide evidence of appraisal and re-validation. Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were. Overnight and weekend cover was provided with access to the admitting consultant for advice or to attend, if necessary.

We saw the service followed comprehensive and robust recruitment processes for all staff positions. All relevant recruitment documentation was recorded within systems holding personal files and electronic folders.

We scored the service as 3. 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 managed infection risks well and had environmental management, safe handling of specimens and standard precautions policies and protocols in place. Audits confirmed the safe handling of waste.

Patients received clear advice throughout their care about the risks of infection, preventative measures and wound care after discharge. Risk of infections was discussed in outpatients appointments and included on consent forms. Patients were advised and given leaflets on how to recognise infection, who to contact if concerned and if they have been given antibiotics. Patients were screened for methicillin-resistant staphylococcus aureus (MRSA) and methicillin-sensitive staphylococcus aureus (MSSA) in line with the MRSA and MSSA policy.

In theatre we observed the team used strict hand hygiene techniques, wore sterile gowns and gloves, and movement in theatre was minimised. Audits showed compliance with hand hygiene techniques, and compliance for training in aseptic non-touch techniques above 95%.

The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment, premises, theatres and ward areas visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen.

A provider infection prevention and control policy and supporting guidance was accessible to staff. Guidelines reflected national infection prevention control (IPC) guidance from Public Health England (PHE), and the Royal College of Surgeons. Staff had access to expertise in infection control as needed. The service performed well in local IPC audits. In the most recent audits, scores showed compliance with infection prevention and control measures in all clinical areas.

Staff minimised the risk of cross infection and we saw they followed best practice regarding the treatment and care of patients. The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and prior to use.

There was appropriate testing of water outlets and air exchange systems in theatres and staff understood the process for managing spillage of body fluids both on the wards and in theatres.

We scored the service as 4. The service always made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff always involved patient in planning, including when changes happened.

We saw the service had systems in place to ensure the optimisation of medicines and treatments were managed well to ensure patients were safe and their needs met throughout their stay at the hospital. Pharmacists were involved from pre-assessment as the service carried out advanced dispensing and also advised patients on the ward after admission and documented they had done so. In theatres, drugs were not drawn up ahead of a list.

Doctors reviewed each patient’s medicines on admission and provided advice to patients and carers about any changes. A pharmacist was involved in patient medicines reviews. Staff completed medicines records accurately and kept them up to date. There were accurate records of medicines administered in the operating theatre and recovery. Staff followed national best practice to check patients had the correct medicines when they were admitted, discharged or they moved between services.

Medicines including intravenous fluids were stored in line with local and provider policy and reduced the risk of misuse and errors. Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence. There was access to medicines needed in an emergency or at short notice at night and at the weekend.

There was sufficient equipment to allow the correct management of patients’ medicines, for example intravenous pumps, subcutaneous and self-administration pumps.

The accountable officer for the service attended the local intelligence network and distributed notes of the meetings to senior managers after the meetings. We saw the accountable officer had the responsibility for reporting any medication incident and learning to the local integrated care board.

The service had policies for controlled drugs prescribing, dispensing, ordering, receipt and storage, as well as counts and stock checks. The policy for discrepancies, incidents and investigations detailed all discrepancies must be investigated immediately and reported to the department manager, pharmacy manager and if appropriate, the accountable officer.

The service also had medicines optimisation, a medicines management, an antimicrobial stewardship and self-administration policies, as well as a medicines optimisation framework and governance structure.

Monthly counts and reconciliation audits were carried out on controlled drugs in recovery, each theatre, and wards showing 100% compliance. Pharmacy audits for January 2026 and April 2026 showed 100% compliance.

A set of additional training modules were available and included anaphylaxis management, influenza immunisation, intravenous additives, oxygen therapy, medical gases, diabetes and insulin management.

We saw evidence the service undertook medicines reconciliation when patients move between health and social care settings, for example a patient transferring to a rehabilitation unit was given additional medication while arranging prescriptions from their own general practitioner. A copy of all medication prescribed and their own medication was sent with them. The service had systems to record and print a summary of the patients electronic record as well as the discharge checklist.