Nuffield Health North Staffordshire 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. Leaders had systems for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery. People 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. Patients 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.

At our last assessment we rated this key question good. At this assessment, the rating has remained good. 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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

There were processes in place to record incidents. Staff were able to give us examples of incidents that had happened as well as changes as a result of incidents. For example, to prevent falls a poster had been implemented in patient bedrooms with physiotherapists writing on requirements such as 2 to assist, or if crutches were needed. Nuffield Health North Staffordshire had been selected as an early adopter in a falls prevention pilot which was a national initiative being implemented across Nuffield Health hospitals. The aim of the pilot was to improve patient awareness of their individual mobility status, support staff in promoting and reinforcing safe mobility practices, and enhance patient safety through consistent communication, education, and increased awareness of falls risk. The programme was intended to support a proactive approach to falls prevention and to contribute to improved patient experience and safety outcomes across the organisation.

We saw that incidents were discussed in team meetings. Incidents discussed in the team meeting dated March 2026 included a transfer to the local trust and a return to theatre.

Leaders held lunch and learn sessions discussing incidents, learning, and timelines.

Leaders told us they were involved in after action reviews following incidents, and how learning points were identified. We heard how families and patients had been invited to these to ask any additional questions.

Staff were aware of how to report incidents, and some staff were able to discuss an incident that happened at another hospital. We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. Staff were able to identify and report risks, secure in the knowledge these would be addressed.

Training scenarios were held each quarter in which staff were rated on their performance. If it was felt they needed further training, the scenario would be repeated. Examples of scenario training included major haemorrhage, anaphylaxis and seizures.

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. 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.

There had been no reported Never Events in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

We reviewed the Nuffield Health North Staffordshire Quality and Safety Report May 2026 and found incidents were discussed including themes. For example, in May there were 2 unwitnessed patient falls when patients had tried to mobilise without assistance.

There was evidence that changes had been made because of feedback. Managers debriefed and supported staff after any serious incident.

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.

Safety and continuity of care was a priority throughout people’s care pathway.  Patients were assessed prior to surgery and findings taken into account when planning care and treatment. This included cancelling or delaying the surgery in cases where an underlying condition was identified.

Leaders audited compliance with the National Early Warning score (NEWS2). We reviewed the most recent audits February to June 2026 and found they scored above 96%.

Theatre staff completed surgical safety checklists, we reviewed 8 of these and found they had been completed correctly. Leaders completed endoscopy safety checklists and safer surgery audits. Safer surgery audits were based on 10 observations of practice. We reviewed the most recent audits and found they met the hospital's targets and consistently scored above 93%.

Patient records were a mixture of electronic, and paper based and were kept securely. IT connectivity was consistently available across the service to meet the needs of staff completing the records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

Care and support were planned and organised with people, together with partners and communities in ways which ensured continuity.

Staff explained how they sent off tissue and biopsy specimens to the laboratory. We found there was a clear audit trail when this happened.

There was a critical care transfer service level agreement which set out the guidelines for the transfer of patients who became critically unwell. However, at the time of the inspection there had been a delay in renewal of this. However, this did not affect ongoing transfers if required. There was also a statement of purpose relating to transfers out of the hospital. This included information such as clinical assessment, transport arrangements, follow up and handover.

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.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The hospital had a named safeguarding lead that staff could speak to if they had any safeguarding concerns and staff knew how to contact them. There were various routes of escalation if they were not in the business. These included access to level 4 trained staff and a level 5 trained national safeguarding lead. We heard examples of when staff had acted quickly to ensure patients were safe due to safeguarding concerns.

Staff received adult and children's safeguarding training. Staff safeguarding training compliance with safeguarding adults and children and young people at the hospital was 94.2% overall. Theatre staff compliance rate was 97%, pre assessment was 100% and ward staff 88%.

Bank staff safeguarding training overall on the ward was 64% and 88% for theatre. This was due to new starters on both the theatres and ward. All registered healthcare professionals had to undertake a half day virtual safeguarding level 3 training. They had to do this within 3 months of starting or produce valid certificates from an alternative employer. There were current safeguarding policies, and these reflected the national guidance for adults and children.

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

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.

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 patients 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.

A daily huddle took place at 9.15am. This involved the multidisciplinary team and included discussions on subjects such as hospital risks, staff with advanced life support or immediate life support who were on site in addition to bleep holders, visitors on site, any returns to theatres, delayed discharges, patients with a similar name, fire, safe staffing, soft intelligence, operational and supply chain issues as well as policy of the week.

There was also a daily huddle on the surgical ward. We reviewed some notes from these and found they contained information such as reminders, changes in policy, hand washing reminders, training interest and resuscitation scenarios.

There was a resuscitation lead who supported the hospital by organising external scenarios, dealt with resuscitation and safety notices and completed spot checks on resuscitation trolleys. Staff followed guidelines from Resus UK. We saw algorithms in place such as for anaphylaxis and choking. Patients were given a number to call following discharge for if they had any signs of infection, problems or concerns, apprehension, uncertainty, or confusion about what to expect.

There was a sepsis box on the ward. The box which was easy for staff to grab included items such as antibiotic guidelines, pathology referral forms, the sepsis policy, National Early Warning score (NEWS2) tools and equipment for taking bloods. The hospital was about to roll out a new box, but this was not yet in place. There was an up to date deteriorating patient policy to establish standards for monitoring and management.

The hospital had introduced Martha's rule call for concern. This meant there was a way to escalate concerns about a patient's condition to ensure they were reviewed promptly.

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.

Patient electronic notes contained risk assessments and tools to determine the level of risk. Staff competed bed rails risk assessments, Waterlow scores which is a clinical tool used to assess a patient's risk of developing pressure ulcers and assessments for venous thromboembolism. However, we also saw some gaps in recording. For example, staff were not always fully completing the bed rail risk assessments section relating to what actions had been taken when they were found to be at risk. Also, if the patient scored over 10 on the Waterlow score, they should have a skin bundle in place; this had not always been recorded. We raised this at the time with a senior nurse on the ward. We saw the pre assessment clinical notes audit from June 2026 and found it scored 96%, meeting the hospitals target of 90%.

The design, maintenance and use of facilities, premises and equipment kept people safe. Fire exits were clear and free from obstruction. Cupboards containing substances hazardous to health were behind a keypad locked door.

There was ready access to resuscitation equipment on the ward and in theatres. We checked resuscitation trolleys and found all items to be in date. Staff carried out regular checks. Emergency trolley and defibrillator checks were recorded. Tag numbers were recorded when the seal was broken and a new seal put on.

We found that anaesthetic machines were checked daily and this was recorded in the machine logbook. An external company completed portable appliance testing.

We found that 5 bays in the recovery room did not meet national recommendations for size. The hospital had put a standard operating procedure in place for the operational and risk mitigation of recovery bay usage dated July 2026. The document recognised that some recovery bays were non-compliant with national guidance. As a result, a range of clinical operational and environmental controls were implemented. These included actions such as only being utilised when other bays were occupied, not used for those at increased risk of post-operative deterioration, and patients with the lowest anticipated level of need prioritised for the bays,

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. There were effective means of ensuring repair of replacement of broken or missing equipment.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements. We reviewed the latest medical device audit last completed in June 2026 which scored 100%.

There was some specialist bariatric equipment such as a wheelchair, the beds and hoists also had a higher weight limit suitable for bariatric patients.

Patients could reach call bells. Call bells were positioned by patient beds, and staff showed patients how to use them to summon help. We saw call bells were responded to swiftly and the noise level from unanswered call bells was minimal.

The service had suitable facilities to meet the needs of patients’ families when necessary.

The hospital completed water risk assessments and had a water safety plan standard operating procedure. There was a water safety committee who met to discuss and approve any changes. The water committee included an external water authorising engineer and a consultant microbiologist.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with provider policy. Staff safely managed sharps and sharps bins were clearly labelled.

There had been significant investments in new clinical equipment during 2025 and 2026 as part of the organisation's commitment to continuous improvement. Key equipment investments included new anaesthetic machines and continuous patient monitoring systems, new orthopaedic surgical power tools, a spinal burr attachment to support complex spinal procedures and a bipolar transurethral resection of the prostate system for urology patients.

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 patients’ 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. Leaders used the Nuffield staffing tool which they were able to input data such as acuity and need to determine staffing establishments.

There was a safe staffing manual which was reviewed regularly, in date and version controlled. The manual had staffing ratios for both the ward and theatres. It contained further information around professional judgement, ward specific red flags and safe caring indicators.

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. During the inspection we found surgery was staffed in accordance with national recommendations.

There had not been any agency staff usage in the theatre during the 3 previous months from April 2026 to July 2026. Bank staff usage was 887 hours. Ward staffing was determined through a combination of registered nurse and nurse associate skill mix, patient acuity and dependency levels, patient numbers and nursing workload as well as professional judgement by ward leaders and matrons.

We reviewed staff files and found staff completed competencies such as administration of medicines, venepuncture, safe use of bed rails and venous thrombosis assessment and management.

New staff had a full induction tailored to their role before they started work. We reviewed a sample of staff inductions and found they included mandatory training, team huddles, risk assessment, fire and resuscitation. Managers supported staff to develop through constructive recorded annual appraisals.

Mandatory training for pre assessment, ward and theatres was compliant at 96.9% overall. Bank staff compliance was 77%. Leaders told us this was because they had recently had 5 new bank starters. No shifts were given to new bank staff until all online modules were complete.

The hospital ran 2 practical mandatory training sessions per month on site. The site administrator actively booked places for staff ensuring course places were utilised. Heads of departments monitored staff compliance and discussed this at departmental meetings. Staff were able to manage their own training compliance and complete courses at convenient times for them.

The director of clinical services met regularly with recruitment agencies and ran recruitment campaigns. They also attended careers fairs at universities and offered incentives such as refer a friend, and ‘golden hellos’ for clinical staff.

The service turnover rate over the last 12 months was 11.90%. The service had a low sickness rate of 3.48% for the last 3 months.

Patients felt their needs were met in a timely way and told us staff responded quickly to call bells. 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.

Advanced life support was not a mandatory requirement for anyone within Nuffield Health policy. Leaders told us while the Association for Perioperative Practice (AfPP) sets expectations relating to ALS competency as part of its accreditation standards, these requirements were to be addressed through the formal accreditation process. North Staffordshire Hospital was working through the AfPP Accreditation Toolkit in preparation for accreditation and it was anticipated to be submitted for inspection in Autumn 2027. As part of the programme, any additional training requirements identified through the AfPP standards would be implemented in line with the accreditation timescales.

There was guidance in Nuffield policy on the roles, responsibilities and training requirements for medical emergency team members. This set out the training expectations of team members, At the time of the inspection there were 2 staff members on the ward with ALS training and 3 in theatre. Staff with ALS/ILS training were discussed in the daily huddle. It was a requirement that the resident doctor had valid ALS training. The requirements for a paediatric immediate life support doctor were met through the presence of the resident doctor.

Some staff also received basic life support (BLS) training. At the time of the inspection compliance for pre assessment staff was 100%, theatre staff 95% and ward staff 68%. Leaders told us this figure was due to registered nurses undertaking immediate life support (ILS) training annually, so did not require this. At the time of the inspection 3 staff members’ BLS training had expired, and 3 staff had not yet completed their initial training. Where necessary, mitigations had been put in place in relation to this; ILS training compliance for permanent staff was 94.4% overall, and bank was 76.5%. This was because there were 6 new bank staff who had started in post and the hospital were either awaiting certificates to be uploaded or awaiting proof of compliance.

Ninety eight percent of staff had completed their appraisals on the surgical ward. We reviewed a sample of appraisals and saw they contained objectives, performance summaries, a section on development as well as a section on future focus.

The service supported the learning and development needs of staff and made sure they 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.

The hospital had access to online training. We heard how some staff had completed nurse associate training and of nurses who had completed top up degrees. Some staff had also completed National Vocational Qualifications.

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 were shared on notice boards.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

Allied healthcare professionals such as physiotherapists formed an integral part of the patient care and treatment pathway and promoted recovery and rehabilitation.

There was oversight of medicines optimisation and ward-based support for staff from a pharmacist.

The service had formal arrangements for a resident medical officer to be on-site when patients were receiving treatment and care. The 2 resident medical officers in the service completed a working pattern of 7 days on and 7 off each. There were escalation processes should the resident medical officer feel unable to complete their shift.

Consultant surgeons and anaesthetists were subject to a full assessment through the practice privilege process. They 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.

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. 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 and the premises visibly clean.

Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. We saw some areas had 'I am clean’ stickers to show equipment had been cleaned. There was a cleaning team who did various shifts throughout the day. They also completed deep cleans as required and prepared rooms for admissions.

We reviewed some team meeting minutes and found they contained an update on infection prevention. The update noted there had been some missed opportunities in relation to jewellery, upcoming training, and information on recent infections.

The hospital team had been awarded gold accreditation in aseptic non touch technique which was valid until 2028. The ward had a cleanliness rating of 100% as of July 2026.

We noted 5 moments of hand hygiene posters for staff. Theatres operated a clean/dirty corridor route. Dirty linen and clinical waste were disposed of in appropriate bags and locked containers within theatre. Clinical waste was removed by in house porters daily to holding points prior to collection.

We reviewed the ward cleaning schedule with tasks to be completed by nursing staff such as commodes, blood pressure machines and bins. The list was recorded to be completed over 7 days a week and had some gaps, however leaders told us they were weekly not daily tasks. This could be confusing to staff and there was no clear oversight or audit of this.

The hospital monitored surgical site infections. A surgical site infection crib sheet and learning response tool was completed when an infection occurred. We reviewed a sample of these tools and found they contained a chronology, individual detail, the type of infection, areas for improvement and areas of good practice. If any patients had infections, they were placed last on theatre lists. There were 0 cases of E. coli bacteraemia, methicillin-resistant Staphylococcus aureus (MRSA), bacteraemia and clostridium Difficile in April and May 2026. All admissions in April and May 2026 were screened for MRSA.

We reviewed audits over the last 3 months and found that wards and theatres met the target compliance rates and scored above 98% in their national standard of healthcare cleanliness audits. Leaders also undertook hand hygiene observation audits; results in April to June 2026 were 98% for the ward and 100% in theatre.

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 a provider infection and prevention and control policy and supporting guidance that was accessible to staff. The providers guidelines reflected national infection prevention and control (IPC) guidance from Public Health England, and the Royal College of Surgeons. Staff had access to expertise in infection control as needed.

The service performed well in local IPC audits such as hand hygiene and surgical scrub. When areas for improvement were identified they were recorded on an action log with a responsible person and a target date to review. Actions identified from audit in March 2026 included a hand hygiene opportunity missed and sluices not checked.

We saw staff were following infection control principles including handwashing and the use of personal protective equipment (PPE) as outlined in the services PPE standard operating procedure.

Theatre practice minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients. The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination.

Staff supported infection prevention and control measures by following uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas had arms bare below their elbows to allow for full hand decontamination.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients’ in planning, including when changes happened.

The service used systems and processes to safely prescribe, administer, record and store medicines. Fridge temperatures were controlled electronically and monitored by pharmacy. Where temperature excursions occurred, departmental staff were alerted by the external monitoring company. Staff told us this worked well as they had previously had telephone calls to alert them to this.

Medicines were stored in line with local and provider policy and reduced the risk of misuse and errors. Keys to the controlled drug cupboard were held by the nurse in charge of the ward.

We checked medications cupboards and found all medicines to be in date. The controlled drugs record book always had signatures of 2 nurses in addition to stock balances. Controlled drugs are medicines requiring more control due to their potential for abuse. We observed the process of a nurse administering a controlled drug and saw 2 nursing staff signed for this in addition to doing a stock check and discussing if the patient had any allergies. They also discussed the patient's pain level with them. The service had clear guidance for staff about the safe use of antibiotics and opiates, which were controlled drugs

The onsite pharmacy team completed any stock checks. Staff returned any out-of-date medicines to the pharmacy and had a returns box. The pharmacy opening hours were 9am to 5pm Monday to Friday. The pharmacy was not open on the weekend, but dispensing could take place with the resident medical officer if needed. However, staff told us this was infrequent, as take home medications were routinely dispensed in advance of discharge. They were able to contact the pharmacist in an emergency if needed and they would attend at the weekend.

Staff followed systems and processes to prescribe and administer medicines safely. Staff completed medication administration charts. Medicines management updates were discussed in team meetings.

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 practice to check patients had the correct medicines when they were admitted, discharged or they moved between services.

Staff learned from safety alerts and incidents to improve practice. Leaders told us how flash alerts were emailed to the heads of department to disseminate to staff.

Leaders completed medicines audits. We reviewed the most recent audits for controlled drugs and found that the department scored above the target of 95%. They did not meet the target of 92% for theatre medicines security in June 2026 due to the key code in the central room not being changed and not being locked due to ease of access for staff in active theatre lists.

Nuffield Health is a registered charity and is therefore exempt from the requirements to hold Home Office licences for stocks of controlled drugs. The pharmacist was responsible for the ordering of controlled drugs and the supervision.