The Beardwood Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We assessed 6 quality statements.

At our last assessment we rated effective as good. At this assessment, the rating has remained good.

Good: This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence that the service provided care by assessing peoples needs using an evidence-based approach. An audit programme monitored the effectiveness of care provided. Staff worked well together and ensured people consented to care and treatment.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed records for nine patients whilst on site and found them to be completed appropriately. These included a holistic assessment of needs, care plans that were up-to-date, clear goals and objectives, nutrition and hydration needs and pain management. The provider used mainly paper records although there were plans to transition to electronic that would include written consent.

The service completed records audits that covered all the areas of the patient journey. Compliance ranged between 81% and 89% in the 12 months prior to inspection. There was an action plan that included timing and dating of all entries in patient notes.

We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service was part of a larger organisation that delivered care and treatment nationally. Policies and procedures were standardised across the services for staff to follow locally. All policies we received were within their dates for review. These covered a range of healthcare needs to support care delivery.

The service participated in a range of internal audits that were benchmarked within the organisation with learning shared across the locations.

The service participated in a range of local audits that focused on patient risks and ensured treatment was in line with best practice. These included:

For national early warning scores (NEWS2) observation audits, in the 12 months prior to inspection, results showed that compliance had dropped to 84% from 89% but then improved to 92%. NEWS2 is a system used in healthcare to standardise the assessment of acutely ill patients and identify those at risk of deterioration. The action plan, from the audit, focused on ensuring NEWS2 scores were totalled, dated, timed and initialled as well as appropriate escalation based on scores.

The service completed audits of the malnutrition universal screening tool (MUST). This is a five-step tool used to identify patients at risk of malnutrition and provide support to improve nutritional status. Results had improved from 94% to 100%.

The service completed audits of the pressure ulcer risk primary or secondary evaluation tool (purpose-t) which is a tool to help healthcare professionals identify adult patients at risk of developing pressure ulcers (bed sores) by assessing mobility and skin condition. In the 12 months prior to inspection, audit results had declined from 91% to 80%. An action plan had been developed that focused on accurate completion of documentation.

The service had completed audits of falls risk assessments. In the 12 months prior to inspection, compliance had declined from 83% to 49%. There was a plan for these results, and other audits with actions for improvement to be discussed in the upcoming planned monthly team meeting and the hospital clinical governance committee. The action plan included ensuring accurate completion of all documentation such as a care plan in place and ‘falling sticker’ in the patients notes. A quality improvement lead had been appointed for the surgical ward as well as implementation of a daily quality walkaround by the newly appointed ward manager. Feedback was shared to staff at huddles three times daily to support and oversee this process.

The service had completed a pain audit that captured data for the 12 months prior to inspection. Compliance had varied but was at 87% in August 2025.

We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

There was a communication display board that was updated daily. This included the activity, where to access support, any incidents, complaints and messages to pass on.

There were regular meetings with other health professionals and we observed positive working relationships as a team. Staff handed over to each other at changes of shifts as well as information being shared at safety huddles.

The provider had introduced Multi-disciplinary (MDT) meetings twice weekly to discuss complex pre operative patients to help prevent cancellations.

The service had service level agreements (SLA) with outside organisations to support service delivery. There was an SLA with the local NHS trust for the provision of an emergency backup laboratory service for haematology including blood transfusion. This contract was dated 1 May 2023 to 30 April 2025. The provider was aware than the contract was passed the date for renewal but had been assured the provision would continue until the replacement contract was completed.

The provider worked with system partners to follow the standard operating procedure which covered arrangements for the emergency transfer of critically ill patients from independent hospitals to NHS acute hospitals in the local area. This SOP was due review in November 2025 by the clinical network.

We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The provider offered a range of services to the public such as support with weight loss, menopause or prostate screening. These could be accessed by social media platforms or the providers website.

The provider promoted the Royal College of Anaesthetists (RCOA) advice regarding preparing for surgery: “Fitter, better, sooner” that included practical support for a healthy lifestyle prior to surgery to promote enhanced recovery.

The RCOA leaflet was additional to the information produced and given by the service that explained what the patient should expect during their time before, during and after their surgery.

We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service monitored readmission rates. In the 12 months prior to inspection, there had been 41 patient readmissions. Of these 10 were graded as moderate harm with the remaining graded as low or no harm.

The service monitored patient reported outcome measures (PROMs). PROMs are questionnaires used to collect direct feedback from patients about their health status, symptoms, and quality of life for hip and knee procedures. The service reported a 98% improvement rate for hip replacements and a 96% improvement rate for knee replacements. These were benchmarked against the providers data and nationally available data and were better than those compared to.

Senior staff told us that they had provided additional training and supported staff to make appropriate decisions about patient care when considering if needed to be transferred to the local NHS hospital. This resulted in a reduction in those transferred out.

We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

There was a consent for assessment, care and treatment policy for the provider. There was an additional policy to support patients regarding the mental capacity Act (MCA) and deprivation of liberty and restrictive practice (DoLS).

We observed staff asking patient verbally for consent to conduct clinical observations such as blood pressure checks. Staff obtained the patient’s consent both at consultation and prior to surgery and recorded this in the patient record.

Consultant surgeons assessed each patient prior to surgery to ensure they had capacity to provide verbal and written consent and if they were suitable for surgery. Staff could use an interpreter service to support consent for patients whose first language was not English or if there was a hearing impairment.

The consent was completed on paper, however; the service was moving to an electronic system.

The service completed consent audits. In the 12 months prior to inspection compliance ranged between 94% and 100%.