Chaucer Hospital

On this page

• 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. We assessed all quality statements.

The service completed assessments and followed patient pathways which were nationally recognised, and evidence based. Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Staff had access to the hospital’s policies and procedures. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.

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

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.

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.

The service made sure all surgical patients had a pre-operative assessment care pathway completed in advance of surgery and a decision to proceed. Patients listed for elective surgery (under anaesthesia and anaesthesia led sedation), were pre-operatively assessed dependent on the American Society of Anaesthesiologists (ASA) grade of the patient, grade of surgery and the urgency of the procedure. The ASA score helped predict a patient's risk of complications and guided clinical decision-making regarding anaesthesia and surgery. This was used with the patients’ health questionnaire, information checklist and other risk assessments. For example, risk of deep venous thromboembolism (clot in a vein) and infection.

Staff completed a comprehensive health assessment of each surgical patient. This included observations, tests and medical, surgical, social and physical history. Staff highlighted medicines allergies and safeguarding concerns using alerts. They used the assessment to decide whether to admit as planned, refer to a relevant specialist, postpone, or cancel the procedure.

Staff developed care plans that met patient needs identified during assessment. We reviewed 3 care plans and saw staff developed care plans that met the needs of patients, including management of pain.

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 had up-to-date policies and procedures to ensure care and treatment was delivered in line with national guidance and best practice. The National Institute for Health and Care Excellence (NICE) guidelines were reviewed at corporate level. Policies based on best practice and clinical guidelines were developed corporately and cascaded to the hospitals for implementation.

Policy updates was a standing agenda item at the hospital’s monthly clinical governance and medical advisory committee (MAC) meetings. Heads of department disseminated any policy updates and staff were required to sign to confirm they had read the update.

Policies we reviewed referenced national guidance including the National Institute for Health and Care Excellence (NICE), The Royal College of Surgeons’ Standards for consultant led surgical care and the recommendations from the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

Staff could access policy documents on the hospital’s database. They followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance.

The service completed clinical audits to check compliance with NICE and professional society standards. For example, NICE guidance NG24 and quality standard QS138 which provide recommendations for the appropriate use of blood and blood components in adults, young people, and children over one year old.

Leaders supported specialty-specific training with supervised practice before sign-off. Named mentors and supervisors supported staff practice in new specialties. The theatre user-group and clinical governance committee regularly reviewed competencies and allocations.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. They implemented staggered admissions to support periods of ‘Nil-By-Mouth’ and improve patient experience. Staff used pre-operative risk assessments which looked at malnutrition, frailty and cognition and gave patients information leaflets to support discussions. The service had processes to optimise patients’ health, including nutritional assessments and anaemia management. Staff encouraged patients to have healthier lifestyles, for example by giving up smoking, before admission.

The hospital had access to a full range of specialists to meet individual needs of patients in the service. For example, physiotherapists, pharmacists, speech and language therapists and dieticians.

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 across the surgical pathway.

Staff held regular and effective multidisciplinary meetings. For example, a communication meeting was held every morning and attended by a member of staff from every department. Staff and leaders discussed staffing, including allocations and staff absence. They shared incidents and learning from the previous day and planned operating lists for the day (including any anticipated issues). Staff performed safety checks such as confirmation that fire exits were clear. The service asked staff to share positive practice, staff nominations, and any other business.

Staff shared information about patients at effective handover meetings within the team. This included shift-to-shift and during transfer from theatre to recovery, and recovery to the ward. Staff used a standard template to support consistency and best practice based on a communication tool known as Situation, Background, Assessment, Recommendation, Decision (SBARD). This helped to ensure effective and safe patient information exchange.

Patients told us they felt involved in the planning of their care. They told us they received information explaining their surgical procedures and what to expect throughout their hospital visits, including the different teams involved in their care and treatment. They could tell us about the care and support offered pre-operatively, following the procedure and when discharged.

In addition, the clinical practice team hosted an annual clinical practice day. This event brought teams from hospitals within the Circle Group together to share best practices and collaborate. The events included external speakers who delivered sessions on best practice and evidence-based techniques.

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 hospital promoted healthier lifestyles by offering private health checks, personalised treatment plans, and supportive care tailored to individual patient needs, rather than providing specific lifestyle programmes. These services focused on early detection of risks, providing tools and guidance for patients to manage their health, and delivering care that respected their unique circumstances and goals.

The hospital promoted healthy eating by offering a diverse range of fresh, culturally appropriate, and nutritionally tailored meals that catered to individual patient needs and dietary requirements.

Staff promoted healthy lifestyles and reinforced this with key information. We saw health information posters across the hospital which raised awareness about mental health and wellbeing, healthy eating, regular exercise and pain management.

The hospital’s website included information on treatment options and simple explanations of why patients may benefit from these. Staff assessed each patient’s health at every appointment and provided support for any individual needs to live a healthier lifestyle. Patients were offered advice or signposted to the relevant services to meet these needs.

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.

Between July 2024 and June 2025, the incidence of posterior capsule rupture (PCR) following cataract surgery was 0.058 %. This figure is lower than the national average. Leaders investigated the incident and reviewed their pre‑ and postoperative patient leaflets and enhanced them. They added clearer guidance on the discharge process and what to do should complications arise. A posterior capsule rupture is a tear in the delicate natural membrane that supports the lens during cataract surgery.

The service participated in relevant national clinical audits and performed well. The hospital maintained a database of all Patient Reported Outcome Measures (PROMs). All procedures and surgeries were recorded, and outcomes were monitored. The service completed 1086 cataract surgeries between May 2023 and June 2025 and 99% of patients reported health improvement. The percentage of patients reporting improvement following knee replacements was 95% and for hip replacements it was 99%. In addition, the service participated in other national audits which included breast and cosmetic implant registry, medical device and outcome and British spine registry.

Surgeons completed 648 procedures for joint and replacement surgery between 1 April 2023 and 31 March 2024. We saw the hospital submitted data to the National Joint Registry in a timely way and 100% of patients had consented for their data to be submitted (during 2025).

The hospital submitted the required notifications to the CQC in line with regulatory requirement of registered Providers. Hospitals are required to submit data to the Private Healthcare Information Network (PHIN), to ensure transparency and overall hospital performance. We saw data for Chaucer Hospital was complete and showed low rates of incidents such as unplanned transfers, readmissions and serious injuries. PHIN is a government-mandated, industry-certified, independent organisation which publishes information about the safety, quality and costs of private healthcare.

Leaders shared their audit proforma for sepsis management and included their audit results for managing a deteriorating patient. Actions were implemented to ensure this was continuously monitored and relevant staff had been identified to lead on this.

From July 2024 to June 2025 there were 2 unplanned returns to theatres. The provider monitored and reviewed unplanned returns to theatre, and transfers to local NHS trusts. The hospital benchmarked against similar hospitals within the Circle Health Group. The service told us the hospital had a slightly higher transfer rate than other hospitals within the Group, but numbers were low for the related activity. Leaders were assured there was clinical justification for the patients transferred to ensure their care needs were met and aligned to their Care of the Deteriorating Patient Policy.

From July 2024 to June 2025, there were 19 unplanned readmissions within 28 days of discharge at NHS trust or hospital. Readmissions were reviewed by staff and were mostly due to post-operative complications.

There were 24 unplanned transfers to their local NHS trust (during the same period). Seven of the patients were transferred due to cardiac issues, 10 were transferred due to venous thromboembolism and 7 patients required urinary catheterisation.

Staff used a nationally recognised early warning score (NEWS2) to identify patients who were at risk of deteriorating. This included observations of vital signs and the patient’s wellbeing. The scoring system provided clear guidance for staff if a patient deteriorated. We reviewed 3 patient records which showed they were completed in full although no escalation was indicated in all cases. The service completed audits to check for compliance with NEWS2 and assigned a red, amber, green rating based on audit findings. Between September 2024 and August 2025 compliance varied between 89% and 96%. Eighty-nine percentage was rated amber which meant actions were required. Leaders told us they had added some additional focused actions to improve compliance and had increased the frequency of audits to ensure improvements were made and good practice embedded. Audit findings were reviewed at clinical governance meetings.

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.

The hospital had an up-to-date consent policy and process. This helped to ensure consent was discussed with all patients in a way which was individual to their needs. Leaders audited compliance with their consent policy and results showed 100% of patients were consented correctly prior to surgery. Theatre staff told us there was absolutely no admittance to theatre without appropriate consent in place.

We saw evidence that the theatre team had activated ‘stop-the -line’ on 2 occasions in April 2025 due to consent issues. We also saw that a patient’s operation was cancelled on the day due to the patient’s hearing impairment, which meant they could not fully consent. Although this should have been identified at the pre-operative assessment, these incidents (and others), showed patient safety was priority.

Staff followed their internal process for seeking patient consent from patients in line with legislation and guidance, and this was clearly recorded. We observed staff asking patients’ verbal consent prior to examinations, observations and delivery of care. We reviewed 3 patient records and noted the consent forms were completed in full. We saw evidence that a 2-week ‘cooling off’ period was applied once the pre-treatment consent process had been completed. This reflected best practice endorsed by the General Medical Council.

Staff told us most of their patients had capacity to make their own decisions. They identified patients who lacked capacity during the pre-operative assessment process to determine whether they could be admitted for treatment at the hospital. They risk assessed patients on an individual basis and put adjustments in place to deliver safe care to the patient if needed.