Nuffield Health North Staffordshire Hospital

On this page

• 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

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 patients 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patients’ needs were met through good organisation and delivery.

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.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff we spoke with had awareness of how their work contributed to achieving targets.

Staff were focused on the needs of patients receiving care. The service 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.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration. Heads of departments were able to nominate staff including those who received special mentions in patient surveys for Nuffield Health's 'High 5’ awards.

Staff felt motivated about the future and planned changes for the service. Team and individual staff successes were recognised and celebrated. Staff were thanked for their work.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

There was a leadership structure in which included a theatre and pre assessment manager.

Staff mainly felt their immediate leaders were visible and supportive. They told us how they felt they were approachable and spoke of seeing the hospital director when they did coffee mornings or attended the morning huddle. Staff were able to give feedback.

Leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for patients and staff.

Leaders had completed leadership courses such as an apprenticeship in leadership. They also spoke of the leadership courses that were available on the online academy. We reviewed several appraisals and saw leaders had thanked staff for their work. They also contained regular check ins and any additional conversations that had taken place.

Leaders were able to give us examples of how they had dealt with difficult situations in relation to staff performance whilst following provider policies and procedures.

Leaders took incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attend wards and departments to assess for themselves how the service was running.

Staff and patient survey results were acted upon for example results were shared and discussed in team meetings. Leades were aware of their individual scores and had access to review results and to receive feedback.

The service fostered a generally positive culture where patients and staff felt they could speak up and their voice would be heard.

Staff told us when they had raised valid concerns or felt they would be able to, were or would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially. Staff were aware of the Freedom to speak up guardians.

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Senior staff on ward areas were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

There were 2 Freedom to Speak Up Guardians employed by the hospital, alongside 2 champions. There were no specific themes or trends in reporting. The Freedom to Speak Up Guardian attended health and safety and quality meetings to get insight such as areas of understaffing for example which could feed into concerns. Information was gathered from staff in a variety of ways such as through attendance at quality and safety committee meetings, speaking with staff and anonymous surveys.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

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.

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.

Staff received bullying and harassment training as part of their mandatory training and all areas had achieved compliance above 94%. A leader was able to give an example of how they had considered reasonable adjustments for someone who was going to begin employment in the service.

Staff were able to report behaviour or attitudes which were negative in style and to provide feedback in staff surveys. We reviewed staff survey questions in relation to diversity and inclusion and found staff in theatres scored 9.1 out of 10 and on the ward, they scored 8.9.

There were several staff networks and groups including a pride network, muslim network, women's network, neurodiversity network and a social mobility working group. The networks were open to staff. Nuffield Health also promoted a range of equality, diversity, and inclusion activities such as pride month, international women's day, black history month, disability history month and religious and cultural events.

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 operated effective governance processes through various committees and on-site activities. There was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the provider. Performance data was analysed and compared within the provider organisation and where improvements were needed at the location level, action plans were developed to make this happen.

There was a medical advisory committee led by a chair and supported by the service leadership, 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 reviewed several practicing privileges files and found they contained evidence of up-to-date appraisals, enhanced disclosure and barring checks, medical indemnity insurance, GMC registration, and Information Commissioner’s Office registration. The service reviewed practicing privileges every 2 years; they did not directly monitor completion of mandatory training.

The hospital operated both central and local audit programmes. Audit findings and actions were electronically tracked and monitored, while locally selected audits provided assurance on compliance, new initiatives, and continuous improvement. Audit results, findings, and emerging trends were then reviewed at the Quality and Safety Committee and discussed with heads of department during quarterly governance meetings to ensure appropriate oversight, shared learning, and continuous improvement. The heads of department then cascaded results, learning and actions to their teams via their departmental meetings.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

There was a site level red, amber, green rated audit dashboard. The dashboard provided a visual summary of audit performance against agreed standards and compliance requirements. There was also a standardised medicines audit framework.

The monthly hospital quality report and site quality scorecard were the primary sources of organisational assurance and governance information, providing oversight of surgical quality alongside other clinical services and supporting effective governance, accountability, risk escalation, and continuous improvement.

We reviewed the last 3 board meeting minutes and saw topics discussed included staffing, quality and safety, practicing privileges and projects.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared in team meetings and newsletters as well as in huddles.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution. Staff contributed to decision-making to help improve sustainability and improve quality of care.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

We reviewed a sample of staff files and noted that the staff members right to work was documented, alongside Nursing and Midwifery Council personal identification numbers, copies of passports and enhanced disclosure and barring service checks.

Leaders held lunch and learn sessions where discussions took place about incidents, learning and educational pieces. There was also a supper and learn held for staff who worked the night shifts.

In relation to sustainably, patients were asked to shower at home if possible, to reduce laundry, bring their own slippers and wear their own underwear. There was a green plan which detailed actions taken to reduce carbon, energy goals, recycling, and waste goals.

The hospital governance lead was responsible for site reports and responded to any adverse events. There was a weekly adverse event forum which the heads of department were expected to attend and to bring along another member of the team. The governance lead used an adverse event tracker to monitor any adverse events; these could be tracked to individual wards/areas.

There was a departmental risk register. This was colour coded and was reviewed at departmental governance meetings.

The hospital had various service level agreements in place. They kept a log of these including any expiry dates.

There were processes in place in relation to service level agreements and the monitoring of these. The tracker was reviewed and held by the hospital director's personal assistant.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, we saw the local integrated care board had visited and provided feedback.

Leaders and staff actively and openly engaged with patients, staff, the public and local organisations to plan and manage services.

The hospital held patient forums which were open to all registered patients. The meetings took place twice a year in person at the hospital. The meeting had a set of objectives including discussing areas of concern from themes and reviewing proposed services or development initiatives.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. Staff often encouraged creative ways of delivering equality of experience, outcome and quality of life for patient. Staff actively contributed to safe, effective practice and research.

There was a day case joint arthroplasty standard operating procedure that outlined the roles and responsibilities of each department involved in the patient pathway. Under the pathway patients received 3 structured follow up telephone calls. On day 1 the ward nursing team followed up to assess overall wellbeing and recovery. On day 2 the pharmacy team discussed pain management and the safe stepdown of analgesia, and on day 3 the physiotherapy team reviewed mobility, progress and any rehabilitation concerns. The reasons patients were not suitable for discharge on the day of surgery were audited.

Leaders held weekly multidisciplinary patient safety meetings to review patients with actual or potential risks. Staff from key clinical and governance teams attended, with consultants and anaesthetists involved in complex cases. Any staff member could raise concerns for discussion. This process supported early risk identification and the proactive management of patient safety.

All arthroplasty patients were invited to attend a comprehensive joint school as part of their preoperative preparation.

A member of the pharmacy team identified that the local NHS trust was changing a medicine in response to national supply issues and recognised an opportunity to align prescribing practices across organisations. This reduced the risk of prescribing and administration errors for clinicians working across multiple settings and supported continuity of care for patients transferring between services. Working collaboratively with the clinical governance lead, consultants and the local NHS trust, the team reviewed trust guidance, agreed dose conversions and developed an implementation plan, which was approved by the Medical Advisory Committee in April 2026. To support safe implementation, pharmacy staff updated relevant policies, produced clinical guidance, and provided education and support to staff, helping to ensure a consistent approach to the new prescribing pathway.

If staff had a concern in the first instance they could go to their manager, they could talk to the Freedom to Speak Up Guardian or go to Human Resources. They could also call someone 24 hours a day.

All patients undergoing colonoscopy received written information in addition to verbal counselling on how and when to take their bowel preparation. The hospital also applied a sticker containing a quick response code to each bowel preparation box directing patients to a website. This provided patients with additional guidance on taking the oral solution, information on how to prepare for a colonoscopy and answers to frequently asked questions.

Day case knee arthroplasty medication compliance charts had been devised for patients to take home with them. The charts had tick boxes for days of the week so patients could tick to say they had taken their medication and made it clear when they should stop specific prescribed medicines. It also had additional detail for example, to explain the medicine may be addictive and how it should not be taken for longer than the prescribed period.

The hospital has introduced a new day room to treat cataract patients in chairs to improve patient experience, reduce cost, increase throughput and productivity.

Nuffield had developed Carbapenemase producing Enterobacterales advice and guidance for patients. The leaflet had information about the bacteria, how it was controlled by staff, how to avoid the spread and if people could be cured of it.

Nuffield Health North Staffordshire had won hospital of the year award in the Nuffield Health excellence awards 2025.