Woodthorpe 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

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people's care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This was the first assessment of this assessment service group. This key question has been rated good. This meant people's outcomes were consistently good, and people's feedback confirmed this.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 3

The service made sure people's care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patients were able to self-refer privately or access services through the NHS via a referral. At this initial entry stage, all patients completed a health screening questionnaire, which was reviewed before submission for consultant review. This included assessment for suitability of procedure and initial consent. During the preoperative stage staff made sure that patients health, care, wellbeing and communication needs were assessed following on from referral. The service had clear inclusion and exclusion criteria, if a patient had some risk factors, they would be discussed at a complex case meeting to make a final decision. If a patient had any additional needs that could not be managed at this hospital, they would not proceed.

Whilst on assessment we observed that staff had a person-centred approach and assessed patients needs regularly.

Score: 3

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

The service had up-to-date and evidence-based policies and procedures in place, which were updated when they needed to be in line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance. Staff at the service had access to these policies via the hospital intranet.

Whilst on the assessment we observed staff consistently following best practice throughout endoscopy procedures. Staff demonstrated good knowledge and understanding of best practice.

Patients had accurate advice on nutrition and hydration prior to procedures. Appropriate nutrition and hydration was provided for patients whilst using the service.

Score: 3

The service worked well across teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Whilst on the assessment we observed good teamworking between staff within the endoscopy department. Staff also told us that they had positive relationships across the whole hospital and worked well together.

Score: 3

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, reduce their future needs for care and support.

There were information leaflets available across the hospital, including within the endoscopy department, and leaflets relevant to the patient and procedure were provided during the process.

Score: 3

The service routinely monitored people's care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had achieved joint advisory group in endoscopy (JAG) accreditation. This accreditation lasts for one year. The aim of the JAG accreditation standards was to define a high-quality, safe and appropriate endoscopy service, delivered by a highly trained, highly supported and highly motivated workforce.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance the service collects data for patients who underwent endoscopy, including indication, waiting times and relevant auditable outcomes. There was an annual audit plan for the service with named leads and timescales. Individual endoscopists were also given feedback on their safety outcomes at least annually.

The service had received silver accreditation for aseptic non touch technique (ANTT) in January 2025. Accredited services undergo an annual review to demonstrate that they are maintaining the standards. Then following on from the site visit, the service went on to achieve gold accreditation In July 2025.

Score: 3

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Whilst on the assessment we saw that patient consent was always obtained appropriately at all stages throughout the endoscopy procedure. Consent was also documented appropriately in patient records where required.

The service did not operate on patients where it was known they lacked capacity to consent to treatment.

The service audited consent as part of the nursing and medical records audit. On the most recent submission for consent on 17 December 2024 the hospital wide score was 97%. There was one issue with illegible consultant handwriting which was discussed with the consultant involved.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance patients and carers were given sufficient time to ask questions or express concerns. Consent forms were signed by the patient or carer before the patient entered the endoscopy room. There were processes for those who cannot sign the form and the consent process was undertaken by a trained professional.