Nuffield Health North Staffordshire Hospital

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• 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

This means we looked for evidence that people 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. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and given time opportunity and information to make informed decisions.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people 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.

The evidence showed a good standard. 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 had a current incident reporting and reviewing policy, which reflected provider and national guidance. The service had a proactive and positive culture of safety, based on openness and honesty. We saw staff listened to concerns about safety and investigated and reported safety events. The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. 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. 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.

Senior staff told us there had not been any serious incidents in outpatients over the last 12 months, and we saw evidence to corroborate this. Staff understood the duty of candour and were open and transparent and gave patients and families a full explanation if and when things went wrong. For example, we observed an outpatient appointment where a patient was aware of an incident that took place while in surgery. We saw that Duty of Candour, a legal and professional obligation to be open, honest, and transparent with patients when a mistake happens in their care, had been applied.

We reviewed the Nuffield Health North Staffordshire Quality and Safety Report June 2026 and found incidents were discussed for outpatients including details of actions and learning logged. A digital system was used by the service that involved logging, tracking, and managing adverse events, near misses or complaints. Incidents were analysed to identify trends or themes and potential links to individual practitioners. Staff knew how to complete incident forms, and reported support was available should they require it. Staff and patients were also invited to attend after action reviews of incidents they had submitted. We saw evidence of sharing learning from other hospitals incidents, and these were usually discussed in team meetings every other month.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and pre assessment processes generally ensured that initial essential information about the patient was received to determine if the patient’s needs could safely be met. However, staff were not always made aware on the day of appointments of patients in attendance with additional needs for example a learning disability or autism. The clinic overview list did not include this information, and these needs were not always identified prior to the patient arriving. We saw evidence of this when we asked staff if they were expecting any patients who required reasonable adjustments that day. However, we saw a good example of a patient’s needs being met by staff who knew how to make the adjustments required, which meant the patient was able to access the treatment they needed and had a positive experience.

Safety and continuity of care was a priority throughout people’s care pathway. Procedures undertaken within the department followed systems to ensure patient safety. We observed patients were assessed prior to surgery and had timely access to test results when planning care and treatment. This included cancelling or delaying surgery in cases where an underlying condition was identified. We saw patients were escalated to a multidisciplinary patient safety meeting to consider if their treatment would be safe to undertake. Consultant doctors worked both in the NHS and independent sector, the service could access Trust records and could share records in the case of a patient transfer to the NHS.

Patients under the care of other Nuffield hospitals can access care at other sites. This was accommodated to enhance the patient experience and reduce travel for patients who did not live close to the service. We saw evidence where patients had been followed up for blood tests and dressings at a location closer to home. The hospital digital system allowed access to patient records regardless of where they were being treated.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

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

The hospital had a safeguarding lead that staff could speak to if they had any safeguarding concerns. There were various routes of escalation, including access to level 3 and 4 trained staff alongside a level 5 trained national safeguarding lead. All staff were trained in adult and child safeguarding training appropriate for their role. 100% of staff working in the outpatient department (OPD) had completed mandatory safeguarding adults and children training. All staff we spoke to, including new staff, knew how to escalate a safeguarding concern and how to make a referral to the local authority.

Children under 16 years of age were seen as outpatients for consultations only, and young people over 16 were permitted to have procedures. The department had a registered children's nurse who checked if the child was comfortable to be seen in an adult environment. Staff also held child and adult disclosure and barring service checks (DBS) also referred to as police checks. All DBS checks were showing compliant and held on a central matrix to identify 3 yearly renewal dates. There was a designated waiting area for children although this was accessible to adult patients using the service.

The hospital had a chaperone policy which was visible to patients throughout the department. A chaperone is an impartial trained professional who is present during a physical examination. They act as a safeguard to ensure the consultation remains safe and professional for both clinicians and patients. A family member can be in the room with you but should not act as chaperone. We saw staff being called upon to perform chaperoning duties throughout the inspection. However, when gathering patient feedback, we were informed of an instance where the chaperone policy was not followed. This was fed back to senior staff on the inspection day.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them

We saw good examples of communication and explanations given to patients to understand their care. Staff gave patients as much support as they needed. We spoke to 17 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, we spoke to patients who had used the service for surgery on more than one occasion and said they never felt rushed and were given as much time as they needed to ask questions. Telephone interpreters were available should a patient require translation services.

We observed a consultant explaining the risks and benefits of surgery to a patient. If a patient became acutely unwell during an outpatient appointment, the hospital would contact the emergency services. There was a deteriorating patient policy in place.

We saw the hospital had implemented Martha’s Rule and had information posters around the hospital informing patients of this. Martha’s Rule is a patient safety initiative that gives hospital patients, families, and healthcare staff the right to request an immediate, 24/7 urgent clinical review from an independent team if they believe a patient is deteriorating and their concerns are being ignored.

Staff enabled patients to give feedback on the service they received via surveys. Patient survey results showed that 95% of patients felt they were involved as much as they wanted to in decisions about their care and treatment.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The resuscitation trolley was situated between outpatients and the diagnostic imaging department, although it was the responsibility of outpatient staff. Systems were in place for daily and weekly checking. Staff checked items on top of the trolley, such as the defibrillator and suction unit, daily and performed a complete trolley check weekly. However, although the last date for the whole trolley check was days before the onsite assessment and signed as compliant, we found several items of paediatric resuscitation equipment to be out of date. This was fed back to senior staff and the items were replaced on the inspection day. All other items were present and in date.

We saw a first aid kit secured to the wall in a visible area and the contents were in date. The risk of sharps injuries was minimised because of the safe management of sharp implements. Sharps bins were secured to the wall and were correctly labelled and a temporary closure. Medical equipment had been checked and there were stickers to validate the portable appliance testing was in date. There were both clinical and general waste bins in place clinical areas. Waste was segregated and labelled in accordance with policy. Staff disposed of clinical waste safely, both inside and outside the building.

Fire exit doors were clear of obstructions and fire safety equipment was wall mounted and in service date. Service agreements were in place for all equipment and staff had a spreadsheet of when servicing was due or responsive maintenance required. Where appropriate we found rooms fitted with digital keypads that required additional security these were secure and had digital locks fitted. Spill kits were readily available to staff in the dirty utility room.

There were hydration stations for visitors, where drinking water, tea, and coffee were available free of charge.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified through annual appraisals and 1 to 1 meetings any training needs their staff had. Staff were encouraged and given time and opportunity to develop their skills and knowledge. The hospital had a “grow our own” philosophy, and as part of succession planning were committed to developing staff to improve retention and reduce staff turnover. For example, we spoke with a healthcare assistant who was being funded to develop into a nursing role within the department. We saw a senior nurse was trained in British Sign Language. The extended development opportunities supported staff to meet the needs of patients receiving care.

Staff had received and were up to date with appropriate mandatory training, with a 100% completion rate in outpatients. Bank staff had modules of mandatory training outstanding but had not completed it due to not covering any shifts recently, we were told this training would be completed before any shifts were offered. Staff also received monthly or bimonthly face to face training on different subject topics. All staff on duty had basic life support training, and the unit had a registered nurse trained in advanced life support and another trained in immediate life support.This advanced training meant staff were prepared to manage deteriorating patients and treat cardiac arrests before the full emergency team arrives.

All new staff had a corporate induction and were supernumerary to staffing levels. New staff going through induction were supported by a “buddy”. The buddy would go through the induction workbook and would check in with the new member of staff, so they were supported. Senior staff would be available to review the progress of new staff with buddies to ensure learning was on track and discuss any additional learning needs. Staff working in outpatients had completed or were currently working through a competency package. Competency tools are used to evaluate whether the worker could safely and effectively apply clinical and professional skills in real practice. Competency checks included thrombosis assessment and management, venipuncture, chaperoning, assisting a consultant with a minor procedure, clinical skills, blood work, prevention and management of surgical complications, wound care, and anti-embolism stockings.

Managers provided staff with supervision, meetings to discuss care management, to reflect on and learn from practice, and for personal support and professional development, and appraisal of their work performance. Staff reported they received monthly supervision check ins and 6 monthly appraisals which were split between the outpatient manager and senior staff nurse. We viewed this data and audit overviews which confirmed a 100% compliance rate. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. We saw examples of this where staff had extended their roles in Advanced Life Support and tissue viability. Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We were told staff could access team meeting minutes, policy updates, NICE guidance, and other general information online on a shared drive.

The outpatient department was fully staffed, having recently recruited 2 healthcare assistants. Managers told us that most staff were longstanding and the service did not use agency staff. When necessary, managers deployed regular bank nursing staff to maintain safe staffing levels and had 3 registered nurses cover shifts when required. A tool was used to determine staffing levels although this indicated sometimes planned activity in the department exceeded staffing targets. A new staffing tool had recently been introduced and senior staff felt able to mitigate any differentials between planned and actual staffing levels. In addition to this a working group had been set up to review staffing on an ongoing basis. We were advised the service would cancel minor procedures if staffing levels were not sufficient, although they said this has rarely happened. Staffing rotas were prepared a month in advance to ensure sufficient staff are on duty to cover clinics. All staff we spoke with felt staffing was not an issue in the department and felt that there were enough staff of a suitable skill mix to manage the workload. We were told a senior member of the nursing team reviews the data regularly and applies professional judgement to ensure staffing levels and skill mix are appropriate to meet patient demand, adjusting where required. This additional oversight provides assurance that staffing remains safe and effective, even when the tool indicates staffing variances.

There was adequate 24-hour medical cover provided by a Resident Doctor. We saw examples where they had managed care and supported in accessing timely review of patients.

Arrangements for consultant mandatory training were mixed; some received training provided by Nuffield whilst others had training provided by the NHS if they were working there substantively. Nuffield didn't directly monitor compliance for those doing NHS training; they accepted a self declaration from the consultants. Most Consultant appraisals were also undertaken in their substantive roles. Once completed, these were emailed to Nuffield to add to their staff record. Practicing privileges were in use for doctors working at the hospital and there were systems in place to manage the governance of this.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

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, we saw audits that would have supported actions taken to improve shortcomings. Staff used equipment and control measures to protect patients, themselves, and others from infection.

All areas were visibly clean, had suitable furnishings and were well-maintained. Cleaning records were available on the intranet and, up to date, they demonstrated that the areas were cleaned regularly. All clinic rooms had handwashing facilities and personal protective equipment stations were well stocked. Staff adhered to infection control principles, including handwashing and arms were bare below the elbow. Hand gel was available in all clinical areas and was also visible for use by members of the public in all other areas. Staff maintained equipment well and kept it clean, ‘Clean’ stickers were visible on some equipment, but not always dated. Clinical waste bins were emptied twice a day and stored in the dirty utility room before being taken outside to a lockable waste bin. Patient and staff toilets were visibly clean.

All appropriate staff had formal clinical competency certification for Aseptic Non-Touch Technique. This is a globally recognised standard used by the NHS and other healthcare systems to protect patients from healthcare associated infections. The service had a 3 step cleaning system in use for decontamination of cycstoscopes, and we saw completed records for each item cleaned. The department had mostly achieved 100% in audits, which included aseptic non-touch technique, cleanliness, and hand hygiene. There was no healthcare associated infections reported in the department but saw action plans from previous audits to capture any identified infections coming into the department, and clear escalation routes to report this.

The hospital had achieved a 5-star cleanliness rating from the provider audit team. We saw work rotas that allocated individual staff to a clinic room to check each week. There was an overview sheet that staff signed to state they had checked the cleanliness of the room and its equipment.

We saw disposable curtains were in use in the clinic rooms, but we could not find a change date on these. Infection prevention and control policy requires them to always be visibly clean, tracked with specific installation dates, and replaced at least every 6 months unless soiled.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

They involved people in planning, including when changes happen.

Staff followed good practice in medicines management storage, dispensing, administration, medicines reconciliation, recording, disposal of, and did it in line with national guidance. All prescribing was on an electronic system and could be dispensed anywhere inside or outside the hospital.

Fridge temperature checks were linked to the pharmacy. Any temperature variation was picked up by the pharmacy team and actioned to ensure medicine was not compromised. We saw that in a recent heatwave, staff changed the location of the fridge as internal temperatures had increased.

Staff were rostered to undertake a monthly check of medicine expiry dates and requested replacements from pharmacy. The hospital pharmacy team performed regular stock audits. There was evidence of pharmacy and senior staff medication scrutiny and medication management through a comprehensive auditing system. The outpatient department consistently scored 100% in all areas over the last 2 years.

Staff in outpatients could contact pharmacy regarding pain control and had designed an information leaflet entitled ‘Managing Pain Relief after a Procedure’. The information leaflet was very informative and were informed by senior staff this will be used to standardise Nuffield's approach to pain. It was recognised in the information leaflet that when pain is controlled well patients recover more quickly.