Nuffield Health Shrewsbury 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 patient 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 alongside diagnostic imaging. At this assessment the rating has remained good. This meant patient’s 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. The hospitals strategy on a page included a vision and purposes, strategic focus, how the success would be measured and what they would do to achieve it. 

The hospitals vision and purpose to deliver clinical excellence for patients and partners across the region and strategic focus was displayed on hospital notice boards.  

Staff were invited to give their suggestions and staff suggestion boxes were available so they could choose to do this anonymously. We saw a “you said we did” poster; because of staff feedback about wanting more recognition a section of the daily huddle was allocated for staff recognition and achievements.  

Staff were focused on the needs of patients receiving care. 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. Many staff we spoke with had worked at the hospital a long time. 

Staff told us how everyone was helpful and there was a nice, friendly atmosphere. One member of staff told us how they were not a number but a name.  

Staff felt motivated about the future and planned changes for the service. The hospital had a set of values and behaviours for staff to follow. These had been created after the Nuffield Health wide moments that matter project. 

Team and Individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work. We saw the weekly news flash had patient praise champions when staff had been named when they had received positive reviews on social media.  

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 always did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.  

Staff consistently provided positive feedback about their leaders. They spoke of how their immediate manager was approachable, amazing, how they made them feel involved, well supported and that they promoted a no blame culture. Staff also spoke extremely positively of the hospital director describing them as very visible, inspiring, and motivating; they said they made them feel they could take on the world and described how they felt they had made the hospital come alive. 

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. Staff felt the leaders supported them to develop their skills and take on more senior roles.  

Senior leaders attended the outpatients' departments to assess for themselves how the service was running. Staff survey results in relation to leadership in the outpatient's department were positive with high scores in engagement, accomplishment, goal setting, organisational fit, peer relationships, and management support.  

The outpatient's manager was also a wellbeing champion; we saw that the service was utilised during our inspection. They were also involved in patient forums.  

Staff and leaders acted with openness, honesty, and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices 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.  

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Staff told us how they would respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.  

Staff knew about the Freedom to Speak Up (FTSU) Guardians and could name who they were. We spoke with FTSU Guardian during the inspection. They told us how they did not have any major themes or tends and were going to commence monthly walk arounds and went to the daily huddle. The hospital had 2 Guardians, and staff could contact them easily. There was no specific report completed by the Guardian; they fed back monthly to the senior management team. If staff felt unable to speak up via the usual routes they could raise the concern via a telephone number, they were provided with. 

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

Staff told us how they completed a diversity module as part on their training. Staff with disabilities were offered reasonable adjustments to support them to carry out their roles well. For example, we heard how a staff member had been supported well to return to the workplace after a period of absence and how they continued to be well supported.  

All staff had completed training in relation to bullying and harassment. Leaders monitored the diversity of the workforce. Nuffield Health had several colleague networks including a Muslim network, pride network, a social mobility working group, a neurodiversity network as well as a women's network that staff could get involved with if they wished. 

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on information about risk, performance and outcomes, and shared this with others when appropriate. 

The whole hospital had 15 information governance incidents over the last 12 months. As a result of the incidents actions were taken including retraining and reminders for staff, reissuing and reinforcing the clear desk policy, and discussions with staff. Leaders told us how they had seen a reduction in the number of information governance incidents. Information governance incidents were reviewed in quarterly information governance meetings and quality and safety meetings. Policies and processes were in place for when breeches occurred and each case was assigned a level of harm.  

There was an information governance policy. The hospitals practicing privileges policy detailed data protection within including how it was the responsibility of medical practitioners who were granted practicing privileges to manage data in accordance with legislation including data protection legislation. We observed that computers were secure as they were password protected. 

There was a clear governance structure, this included a quality and safety committee, a medical advisory committee, various forums including a water forum, health and safety forum, a patient focus forum as well as a hospital adverse incident forum.  

Nuffield Health had set out 5 ambitions. These were to provide the best care and support you can get anywhere, to deliver the best possible customer and patient experience, to be the best place to work in health and wellbeing in the UK, to be at least as efficient and productive as their competitors and to multiply their social impact and sustainability.  

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 (MAC) 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 were robust processes in place in relation to approval and review of practicing privileges. Compliance with practicing privileges information was monitored externally. The compliance for the hospital was 100% which included GMC compliance, indemnity compliance, and General Medical Council appraisal compliance. We reviewed the MAC minutes from August 2026 and saw topics of discussion also included Never Events across sites, companywide deaths, documentation, and the hospital risk register.  

We reviewed the senior leaders board meeting minutes and found they discussed key areas of governance including incidents, actions, risk registers, internal assurance, and quality strategy priorities.  

There was a hospitals medicines management and medical gases meeting. We reviewed the notes from July 2026 and found areas discussed included medicines management updates, regulatory compliance internal quality assurance review in addition to reviews of themes, trends and lessons learnt. 

Infection prevention policy compliance and new policies were discussed within the hospital infection prevention team. The hospital had a deputy director of infection control, within these meetings staff also discussed any outstanding actions, infection surveillance, contamination, audits and mandatory training.  

We reviewed the notes from the clinical heads of department meetings dated July 2026. Topics included an action log, safeguarding, mandatory training, complaints, clinical audits, duty of candour, performance development reviews, and general data protection regulation.  

We reviewed the quarterly hospital quality report from April to June 2026. The report had information on incidents, safeguarding, medicines management, infection prevention, audit results, complaints, patient experience, the site quality scorecard which scored an overall 100% in addition to complaints. The hospitals site quality score card was 100%, this included safety, effectiveness and experience at the hospital which all scored 100%.  

The hospital had achieved the National Joint Registry Quality Data Provider Award gold in 2025 for its commitment to patient safety through the registry.  

We reviewed several staff files and found staff had disclosure and barring checks, copies of passports as well as details of professional registration such as with the nursing and midwifery council.  

The hospital had a weekly hospital Shrewsbury flash to share information with staff. We reviewed the flash from 17 August 2026 which included a policy of the week, what is our knowledge gap, patient satisfaction scores on social media.  

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.  

Leaders made sure that accurate information was discussed and shared with key staff. For example, team meeting topics included key areas of governance such as lessons learnt from incidents, the risk register, infection prevention, and complaints. 

Leaders were aware of the risks in their department such as aging equipment in ophthalmology. This was working at the time of the inspection but as parts wear due to age they would find it difficult to replace. They were also able to tell us about the plans in relation to removal of this risk.  

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, leaders ensured action plans and the monitoring of these led to positive changes.  

The service had plans to cope with unexpected events and had a business continuity plan. Emergency plans were reviewed regularly. In addition to the daily multidisciplinary huddle which identified any operational risks, capacity issues, staffing concerns a further operational call took place daily to review the day's activity, address any emerging concerns and ensure plans were in place for overnight operations and the start of the following day. Each week the key stakeholders on call for the hospital were shared with everyone on site. 

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patient. 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, the hospital supported the community through its NHS contacts. The hospital had also attended a listening group open to local constituents discussing Fit for the Future. Through discussion with their consultants, they were also better able to identify where they may be able to support in the NHS. For example, they had recently launched a heart health clinic following recommendations from their cardiologists.  

Some senior leaders were part of regional networks to understand the needs of the community and the provider ambitions. Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. 

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. 

Staff were committed to continually learning and improving services. There were processes for learning when things went wrong or of good practice, either locally or nationally.  

Audits included asking staff specific questions to test their knowledge for example questions around safeguarding and incidents.  

Staff were supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. 

Staff were offered the opportunity to attend lunch and learn sessions. The hospital had arranged a session with a consultant to deliver an educational presentation on a topic of choice. Topics could be tailored to interests including areas such as orthopaedics, women's health, cardiology. The sessions were designed to be informative and interactive. We also saw clinicians had been invited to a learning session with a focus on helping clinicians access imaging more quickly and confidently for their patents.  

Staff and leaders were committed to excellence that centred on the patient experience. Where they saw a need, they worked together to find a solution. For example, there had been various quality improvement programmes including a quality improvement relating to customer communication which included calling patient's 48 hours after a consultation as well as one in relation to improving the booking process to increase utilisation, offer a better service to patients and to make booking easier.  

Staff told us that one area of improvement was due to the flexibly cystoscopy lists being brought downstairs into the outpatient's department and was working well. We saw that a new flexible cystoscopy pathway had been implemented which included areas such as equipment, medical records, the procedure and post procedure documentation. No procedures were performed using general anaesthesia or sedation in the outpatient's department.  

In 2026 the hospital was aiming to expand their impact through the delivery of a long-term conditions programme. The programme being a 24-week evidence-based intervention co designed with patients, academic experts, and healthcare professionals The intervention designed to bridge the gap between clinical discharge and community self-management.  

The hospital had achieved gold accreditation for Aseptic Non-Touch Technique valid from December 2025 to December 2028.