Nuffield Health North Staffordshire Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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.

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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff were aware of the hospital’s vision to build healthier lives through their strategic narrative. The use of Nuffield Health’s 5 ambitions set clear objectives to ‘provide best care, best patient experience, best place to work, be effective and productive and multiply social impact and sustainability. The senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear of retaliation.

Team and individual staff achievement and success was recognised and celebrated. Staff were thanked for their work. Staff told us they enjoyed working at the hospital. They were supported by their immediate teams, which they described as being like a family, but also felt part of the wider hospital team. We saw a good example of staff being proud of a recent achievement to introduce hysteroscopy in outpatients. This meant easier access for patients and a shorter wait time for patients requiring the procedure.

Senior leaders had identified a lapse in the service led agreement (SLA) for critical care transfer to a local hospital trust. Arrangements were in place for the agreement to “stand at it is” until it has been decided how the SLA will be renumerated and managed.

Recruitment processes were underway to instruct a rehabilitation specialist; senior leaders told us they had engaged with the integrated care board to sit on the interview panel.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff at all levels told us they had leaders who were visible, approachable, and supportive. They described leaders as having an open-door policy and being ready to offer support when needed. Staff told us some senior leaders regularly visited their department to check in with staff and see if their assistance was required. Staff said they felt supported respected and valued. Staff said they were proud to work for the service and the high-quality care they provided.

We observed leaders model and reference the hospital's values when they spoke with staff. They demonstrated concern for the wellbeing of their staff and were focused on promoting a culture of high quality and safe patient centered care. Senior staff told us the hospital leaders were committed to improving the patient experience and their passion for providing high quality patient care had filtered down to the wider staff team. Leaders were experienced and had developed within the hospital into more senior roles. Staff spoke confidently about their leaders' capabilities and expectations of high standards within the department.

There was strong collaboration, team-working and support with a common focus on improving the quality and sustainability of care and patients’ experiences. The culture of the service centred on the needs and experience of the patients who used services. Staff were passionate about delivering high quality care and treatment for patients.

There were leadership development opportunities available, including opportunities for staff to develop their skills. Annual appraisals were in place for all staffing levels and identified areas of development.

Senior staff were able to give an example of where they had made positive difference to an incident that happened and demonstrated the correct learning approach. They were able to reinforce values and behaviours that were not accepted by the hospital and used for wider learning nationally within the business.

Senior staff were aware of risk and had a risk register to manage oversight. The department had identified risk, analysed impacts, and recorded control measures.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders and staff understood the importance of staff being able to raise concerns without fear of retribution. The freedom to speak up (FTSU) service was advertised across the hospital to encourage staff to share their concerns. All staff were able to name who they would go to with a FTSU concern. Staff also told us they had not used the service as they had been able to raise concerns within their teams, and these concerns had been listened to and dealt with.

One of the FTSU Guardians interviewed explained they took the role because they were passionate about patient care and recognised poor culture directly affects patient care. FTSU guardians within the hospital completed annual National Guardians Office (NGO) training in addition to 3 internal online modules. They reported they were given a dedicated number of hours per month to support them in their role. Examples were given where time was dedicated to a cultural awareness day and future planning for Freedom to Speak Up month where a presentation will be given around psychological safety.

The evidence showed an exceptional standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity, and inclusion. The service promoted equality and diversity in daily work and provided opportunities for career development. Nuffield Health North Staffordshire employed 189 staff across the hospital. Of the total workforce 29 staff identified as being from a non-white ethnic background. Within the leadership structure there were 46 staff of whom 8 identified as being from a non-white ethnic background. Employees represented a broad mix of backgrounds to reflect the population and community it was serving.

Inclusion and diversity training was part of staffs’ mandatory training programme; 100% of staff in the outpatient department had completed this. There were equality and diversity champions within the service to represent LGBTQ+ and inclusion around ethnicity. For example, the hospital shared examples of celebrations for Black History Month and Pride. There was also an example of a member of staff being accepted onto an Ethnic Future Leaders programme which supported staff from an ethnic background to become senior leaders. Colleague network groups included a Social Mobility Working Group, focused on reducing barriers to opportunity and helping create a more inclusive workplace regardless of socioeconomic background.

There was an equality, diversity and inclusion policy which noted at Nuffield Health "we believe every colleague should feel valued, respected, and included”. The hospital explained how it did not tolerate discrimination, harassment or victimisation in any form. Staff were required to complete the equality, diversity and inclusion learning module annually.

Senior leaders held coffee mornings and afternoon tea meetings, there was an open door policy for staff to speak directly about any concerns. Staff said some senior leaders were visible around the department, and they felt comfortable escalating any concerns. Examples were given where senior staff may work longer days to ensure they were visible to their whole team including consultants working late in their department.

Staff we spoke with reported flexible working arrangements were generally granted where the service could accommodate. There was a flexible working policy in place which informed staff how they could apply to have their working hours, schedules or location changed.

The service had clear responsibilities, roles, systems of accountability and effective governance. Staff used these to manage and deliver high-quality, sustainable care, treatment, and support. Staff always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service did not directly employ any medical staff; all doctors held practicing privileges. There was a thorough process for approval of practicing privileges including provision of documents such as proof of identification, references, latest appraisal, proof of medical indemnity insurance, and General Medical Council registration. Candidates underwent consideration of suitability by the Medical Advisory Committee and were interviewed by the hospital director before approval. Consultants were required to sign an annual self-declaration that mandatory training including basic life support training was up to date; the service did not directly monitor completion of mandatory training.

There was a medical advisory committee led by a chair and supported by the service leaders, which included approval of practicing privileges and review of clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required. There was a practicing privileges policy in place.

We saw risks, actions, and audits were all discussed and there was shared learning across the hospital. Staff told us they received feedback from audits that were undertaken. Governance leads and management functioned effectively and interacted with each other. Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. There were monthly governance meetings and monthly quality and safety site meetings where leaders reviewed incidents, complaints, audits, and risks.

We saw quality overview data that considered patient safety, effectiveness, and patient experience. Areas were assessed using data from incident reporting, patient & consultant & staff feedback, consultant compliance, and consultant management performance. Each area was measured to support performance monitoring and improvement at the hospital, seeing an overall score of 97% and within the target range. The report overview also identified areas that were below the target, which was the case for medicine incidents, where none had been recorded for the period January to end of June 2026.

We saw a current risk register highlighting areas of concern within the hospital. The department had identified parts were no longer available for a piece of equipment. This had been escalated and a plan put in place should the equipment fail or need replacing.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patient feedback was captured through different survey tools. 100% of patients said they would be likely to recommend the hospital to friends or family if they needed similar care or treatment.

The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders such as the integrated care board (ICB). -The ICB supported the hospital with their recruitment campaign for a rehabilitation specialist, offering to sit on an interview panel. The ICB supported the hospital with their recruitment campaign for a rehabilitation specialist, offering to sit on an interview panel. This post was particularly important to the hospital to map any vulnerable areas within the community identifying health inequalities and addressing these demographically with a focus on prevention and 1 day pathways into the hospital for treatment and consultation.

Staff worked well with other services within the hospital, and we saw collaboration between departments. Patient's could meet with staff and members of the hospital's senior leadership team on open days to give feedback. Patient forums provided an opportunity for patients to contribute to service development, share experiences and influence improvements. Staff undertook face-to-face visits to GP practices, community-based teams and opticians to strengthen referral pathways and share service updates. Consultants led education sessions for GPs and primary care clinicians, supporting appropriate onward referral and shared pathway understanding. Staff delivered community health checks, talks and screening events in partnership with local employers, schools and community groups.

There was oversight of referrer relationship visits. For example, there were 264 GP visits in 2025. This supported keeping referral routes current and gave system line partners a direct line to raise access issues. Consultants led 14 continuous professional development sessions for GPs and primary care clinicians over a 12 month period. This supported appropriate referral into the right outpatient pathway. The service reached over 1,400 people through community and employer-based events. This opened additional, non traditional routes into outpatient services for the wider population. Responsive capacity management maintained private pathway access and NHS referrals, which demonstrated active collaboration with the ICB on system level capacity decisions.

The service recently implemented an agreement with a local hospital trust’s arthroplasty department for monthly reports of readmission data. This data supported the hospital to look at any themes captured and implement any lessons learned around reasons for readmissions.

The evidence showed a good standard. The service had a good focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

All staff we spoke to were committed to continually learning and improving services. Staff said they were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. They had a good understanding of how to make improvements happen and were supported to undertake training to extend their roles. Leaders encouraged staff to speak up with ideas for improvement and actively invested time to listen and engage. We saw examples of staff engagement in learning based scenarios. A recent training session following an investigation gave staff the opportunity to apply lessons learnt and embed good practice. We found innovations were taking place in the service and the service had recently been accredited to provide cystoscopy within the department which had led to a reduction in waiting times for the procedure and consultants were complimentary on its effectiveness.

Information was in accessible formats, and through patient feedback it was identified communication as an area for improvement. The complaint team had invited patients to have conversations and inform improvements such as leaflets and review letters that go out to patients. Improvements have also been seen in the level of communication to patients for example information around fasting before surgery. All acknowledgement complaint letters have a booklet attached so patients and their representatives understand means of escalation for their complaint.

Staff were proud to be voted hospital of the year 2025 within Nuffield Health. This was a new initiative amongst all Nuffield hospitals and awarded annually. Patient satisfaction showed targets were reached and areas of improvement supported by action plans. Google reviews generally received 5 star feedback and were overall positive. The vision and values of senior leaders recognised everything achieved was achieved together and teamwork offered good patient care. Exit interviews were conducted centrally then themes fed back to hospital after analysis had been done to identify any trends for why staff were leaving. Recent analysis demonstrated no trends were identified.