The Beardwood Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. We assessed 7 quality statements.

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

Good: This meant people’s needs were met through good organisation and delivery.

We looked for evidence that the service provided person-centred care to people in a way that they understood. We checked that there was equity in experiences and outcomes for people and that they were listened to. People were encouraged to provide feedback to the service and they understood the diverse population they served.

We have not awarded this service a score for Responsive.

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

We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff assessed individual needs as part of the suitability criteria to ensure treatments were person-centred. Staff followed the provider’s policy on privacy and dignity which included communication to meet each patient’s individual needs. Staff could access the provider’s policy for supporting patients with learning disabilities and / or autism. This supported staff to recognise any need for reasonable adjustments such as a passport or any additional communication needs to ensure individualised care.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service provided care to NHS patients and those who self-funded their care. NHS patients were referred from the local areas, whereas self-funded may be from a wider area.

The service was located in an area with a diverse multi-cultural community and provided care and treatment to people in the locality.

Following staff handovers, nurses were allocated patients to care for providing a point of contact for the patient and continuity of care during their stay.

The service had reached out to a number of organisations such as GP’s but also local schools, mosques and social clubs where they had offered free life support training.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff could provide information in a variety of formats that included larger font or easy read as well as translated into languages other than English.

The provider’s policy regarding interpreters and communication provided guidance for staff to follow to ensure appropriate processes in place. The service complied with the Accessible Information Standard with information available in a range of formats and personalised plans for patients. A hearing loop could be accessed if needed as well as interpreters.

The provider utilised two interpreter and translation services that could be sourced for patients whose first language was not English or there was a requirement for easy read versions of information. Patients with hearing or visual impairments could also be supported and a hearing loop was available if needed.

On discharge, information about treatment provided was shared with GP's for ongoing care and support.

We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

In addition to FFT, the provider collected service specific feedback in a range of formats. Feedback cards were provided that encouraged feedback for improvement and compliments. These had pictures to support text. There were posters displayed in multiple languages, other than English, requesting feedback on “How did we do today?”. Leaflets were available in formats including easy read. These provided guidance on how to complain to the service and included signposting to the NHS Ombudsman for NHS patients and the Independent Sector Complaints Adjudication Service (ISCAS) for self-funding patients.

In the 12 months prior to inspection, there were approximately 150 compliments received specifically for surgery.

The provider monitored feedback via an internet search engine where they had a score of 902/1000, in November 2025. This meant they were in the ‘excellent’ category. Examples of reviews shared by the service showed that they responded to their feedback online. These were displayed on notice boards for patients, staff and visitors to see.

There was an additional survey for the outpatient department that could potentially capture patients undergoing the surgical pathway pre-operatively but not specific to those patients.

Following feedback from patients, the service had developed an action plan tracker that showed when changes had been made and plans for further improvements. These were generally communication based that could enhance the patient journey.

There was a complaints process for the provider. In the 12 months prior to inspection there had been 14 complaints raised for surgery.

Staff received feedback on the outcome of investigation of complaints and acted on the findings.

When patients complained or raised concerns, they received feedback.

We reviewed a sample of complaints during our onsite inspection and found they had been responded to in a timely way and appropriately.

There had been no confirmed cases escalated to the Parliamentary and Health Service Ombudsman (PHSO) or Independent Sector Complaints Adjudication Service (ISCAS).

Leaflets were available to indicate how to submit feedback including signposting to the Parliamentary and Health Service Ombudsman (PHSO) for NHS patients and Independent Sector Complaints Adjudication Service (ISCAS) for self-funded patients.

We make sure that everyone can access the care, support and treatment they need when they need it.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service carried out a range of planned surgeries that were a combination of NHS patients and those self-funded. As the provider did not have facilities to treat patients assessed as high risk, patients were accepted that could be safely treated at the hospital. In the twelve months prior to inspection, the service had performed 204 ear, nose and throat (ENT) procedures, 1,112 general surgery operations, 408 gynaecology surgeries, 146 neuro surgical procedures, 3,606 orthopaedic surgeries, 13 otolaryngology procedures, 366 plastic surgery procedures, 447 urology surgeries and 15 vascular procedures.

At the time of inspection, there were 2,404 patients on the services NHS waiting list for all specialities. Of these 488 had been waiting 18 weeks and 15 had been waiting between 40 and 52 weeks. The average waiting time was 8 weeks. The service benchmarked waiting times with other similar services who treated NHS patients.

There was an electronic referral system for the provider for the specialities of trauma and orthopaedics, general Surgery, gastroenterology, neurosurgery, ENT, urology and gynaecology. The referral process was coordinated by the provider's North West HUB location. Referrals for the service are digitally triaged to ensure they meet the appropriate exclusion guidelines. Weekly internal slot management meetings are held to optimise scheduling.

In the 12 months prior to inspection, there were 727 operations cancelled for clinical reasons such as not meeting the inclusion criteria, unforeseen equipment failure or availability of the surgeon. All cancellations were graded as no harm for the patients. The service had identified themes from the cancellations and were progressing an action plan to address.

For the 12 months prior to inspection, theatre utilisation was an average of 49% against a local target of 75%. There has been a reduction in activity following the loss of Inter Provider Transfer (IPT) activity volumes, in May 2025, from the local NHS trust hospital.

Actions had been taken to increase activity including the recruitment of additional surgeons and anaesthetists, reviewing operating scheduling to maximise usage and working with cancellation working group to review any patients who did not attend or were inappropriately listed.

Staff supported patients with additional needs or adjustments such as cognitive impairment or learning disabilities.

If patients deteriorated during their stay, there were processes in place to escalate, assess and transfer to a local NHS hospital if needed.

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider’s equality, diversity and inclusion policy outlined responsibilities for both staff and patients to ensure that no one was discriminated against based on their individual status such as age, disability, gender, race, faith or sexual orientation.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff completed mandatory training in equality, diversity, inclusion and human rights. Compliance was 98%.

The provider confirmed that there is information related to patients with protected characteristics collected in a health questionnaire prior to surgery. However, they were in the process of reviewing how data could be used to capture this data for reporting and monitoring purposes as part of their patient experience and engagement strategy.

Staff could access range of documents to support patients with additional needs including a passport, this is me,’ a hospital communication booklet and a poster: ‘which language do I speak?’ The provider shared a recent example with us of how a patient with a hearing impairment was supported through their surgical pathway.

The provider shared examples with us of how patients had experienced person-centred care and reasonable adjustments had been made to support their surgery at the hospital. Care plans were individualised with patients positive about the care and treatment they received.

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and their future following discharge.

Staff ensured all relevant healthcare professionals and other relevant bodies are involved in planning the care and treatment of people with complex needs.

Staff provided patients with information and medicines if needed including advice about what to do in the event of an emergency or concern about recovery at the time of discharge.