Nuffield Health North Staffordshire Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patient were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service usually made sure patient’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service assessed patients’ needs before and during their appointments. Referrers included information about patients’ needs in referrals. Clerical staff telephoned patients before their examinations and took this opportunity to further assess their needs.

We observed an interventional procedure under ultrasound guidance. Staff assessed pain levels throughout, and the radiologist offered additional local anaesthetic if required. They also gave advice on staying pain-free after the procedure. Staff had access to mobility aids to assists patients with limited mobility and made sure patients were comfortable while being positioned for imaging. Patients had access to drinking water as needed, as well as a hot drinks machine.

The service usually planned and delivered patient’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies and standard operating procedures (SOPs) to plan and deliver high quality care according to best practice and national guidance. Policies and SOPs reviewed had creation and review dates and included references to current local and national guidelines. Staff had access to local rules in clinical areas and signed to confirm that they had read and understood them. Staff could demonstrate how to access clinical protocols.

There was a comprehensive folder for Ionising Radiation (Medical Exposure) Regulations 2017 documentation. Radiation risk assessments were carried out for all imaging modalities and reviewed annually. Staff could access radiation protection supervisors (RPS) in the service who had undergone the required training, and radiation protection advisers and medical physics experts remotely. At the time of inspection, there was not a specific RPS for theatres to oversee activities related to radioactive sentinel lymph node biopsies. However, the radiology manager was covering this responsibility as a temporary measure until member of theatre staff attended RPS training in September 2026. Staff kept logs of radioactive waste storage and disposal in line with provider policy and guidance.

At the time of inspection, the service did not participate in the Royal College of Radiologists’ Radiology Events and Learning Meetings, or any other discrepancy meetings. However, managers told us that they received feedback on imaging directly from consultants, and imaging carried out for NHS patients was often included in trust multidisciplinary meetings when asked how they were assured about reporting accuracy. Furthermore, 10% of all reports produced for an insurance company were audited for accuracy, and all mammography examinations were able to be peer-reviewed due to their low volume.

The service worked well across teams and services to support patients. Staff made sure patient only needed to tell their story once by sharing their assessment of needs when patient moved between different services.

Teams had effective working relationships, and we observed staff working co-operatively to support people. We viewed positive interactions between radiographers, radiologists, radiology department assistants, clerical staff and other hospital staff such as porters who supported each other to provide good care. One radiographer stated that “multidisciplinary working is excellent here”.

We observed a daily morning huddle which a representative from the imaging department attended. This involved the hospital multidisciplinary team and included discussions on safe staffing, hospital risks, which staff with advanced life support or intermediate life support were on site in addition to bleep holders, any patients with a similar name, as well as ‘policy of the week’. Staff attended radiology department meetings every 2 months where important information such as policy updates and shared learning was disseminated. The service held regular meetings with stakeholders including the third-party provider who reported all X-ray examinations and the integrated care board with whom the provider held a contract.

The service generally supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

The service had a range of health promotion information available in the department, including information on the potential risks and benefits of having an x-ray, a quick response code to access information from the Society and College of Radiographers on imaging examinations, and leaflets from a national breast care charity and a dementia charity. Further health advice could be found on the provider website covering topics including men’s health, women’s health, mental health and cancer.

The service monitored patient’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and they met both clinical expectations and the expectations of patient themselves.

Staff and leaders monitored the effectiveness of care and treatment through a comprehensive audit programme. This included monthly audits of dose reference levels, and quarterly audits on image quality, use of lead x-ray markers, ‘pause and check’ and inclusive pregnancy status. Staff also monitored compliance with the World Health Organisation (WHO) checklist, a standardised tool developed to reduce complications and mortality from surgical and interventional procedures.

Managers kept a file which recorded recommendations from each audit, the method by which they had communicated the recommendations to staff, and the next audit date. The service used the findings to make improvements and achieved good outcomes for patients. For example, compliance with inclusive pregnancy checks increased from 80% in April 2026 to 95% in June 2026 after staff were sent the April 2026 results along with a copy of the inclusive pregnancy status policy. However, overall compliance with the WHO checklist had fallen to 80% in July 2026. Managers planned to address this in the next staff meeting. Staff achieved 100% compliance in the latest post-operative x-ray notes audit, and image rejection rate was consistently less than 5%.

The service monitored reporting turnaround time, including the turnaround time of third-party service providers. Compliance with the 5 working day key performance indicator was 86% to 93% between April and June 2026. There were no exams not reported within 28 days throughout this period. The provider benchmarked performance in line with other Nuffield sites, and the service was roughly in line with the provider average. Patients we spoke with who had previously had examinations at the service said that they received their results quickly.

The service also monitored telephone call performance and benchmarked against other sites. We viewed data on call abandonment and saw that the service was the top performer in the north region.

The service did not participate in accreditation schemes such as Quality Standards for Imaging at the time of inspection.

The service told patient about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.

Information on examinations was usually provided before appointments for outpatients, and we observed staff explaining what they were going to do any why there were doing it to patients before obtaining their verbal consent. We observed an interventional procedure under ultrasound guidance and saw that the radiologist sought formal, written consent after a discussion about the benefits, risks and potential complications of the procedure. Consent for such procedures was part of the World Health Organisation surgical checklist, which the service audited.

We saw notices offering chaperones for patients throughout the service. Staff could access interpreters to support patients to give informed consent, including for BSL and face to face interpreting when necessary. The service had a consent policy which was up-to-date and provided patients with written information about the consent process prior to attending for appointment. The policy also referenced how staff should seek consent from young people under the age of 18 years of age.

All staff received and kept up to date with training on consent and the Mental Capacity Act and knew where to access current polices. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.