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 previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. This is the first assessment for this service. This key question has been rated good. This means people’s needs were met through good organisation and delivery.

Patients had good outcomes. During our assessment, we observed that people’s care, support and treatment reflected their needs.

The service protected individuals from discrimination based on their protected characteristics. This ensured people were at the centre of their care.

People were encouraged to live healthier lives and consent to care processes were undertaken appropriately. Staff worked to ensure that current outcomes and exploring best practice was part of their everyday work. However, we could not always identify the outcomes measures and action plans on a number of different audits.

The service had a policy on mental capacity and deprivation of liberty safeguards; however, staff were not always knowledgeable about these.

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

Staff provided care and treatment based on national guidance and evidence-based practice.

Staff worked together as a multidisciplinary team with the GP’s and other health care partners to benefit patients and provide the best outcomes for them.

Staff used appropriate assessments, completed and updated risk assessments for each patient. Staff identified and quickly acted upon patients at risk of deterioration. Patient needs were escalated appropriately.

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

Patients were able to self-refer privately or access services via an NHS referral. Initially all patients completed a health questionnaire, which was reviewed in advance of a consultant assessment and evaluation.

Outpatient services were offered up to six days a week. Clinics were held Monday to Friday 8am to 8pm and on Saturdays clinics were held from 8am to 4pm to support people who might not be able to attend during the weekday working hours.

People we spoke with told us they felt staff understood their health and emotional needs, especially if they were anxious about their proposed treatment.

Score: 3

The service provided care and treatment based on national guidance. Policies and procedures, assessment tools and pathways followed recognised and approved national guidelines. Care and treatment were delivered in line with legislation, standards and evidence based guidance.

Staff were aware of how to access relevant policies and procedures via the Intranet for reference. Staff were given regular updates if and when guidance was reviewed or practice changed. The majority of staff worked across clinics on a rota basis, so they received all updates.

Staff shared key information to keep patients safe when handing over their care to other staff during the daily morning huddle meetings.

The service monitored the effectiveness of care and treatment and used the findings to improve them.

Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

Score: 3

There was evidence of effective multidisciplinary (MDT) working in all outpatient areas. Staff held regular multidisciplinary meetings to discuss patients and improve their care. This ensured the efficient delivery of care and treatment to patients. Doctors, nurses and other healthcare professionals worked together as a team to benefit patient and supported each other to provide good care.

There was evidence that the multidisciplinary team was inclusive and well organised.

The outpatients department had a ‘one stop’ appointment process for patients who were attending the department from outside the local geographical area. This meant that patients were seen in other departments such as diagnostics and imaging and pre-operative assessment as required, all on one day, to prevent repeated attendance at the hospital.

Whilst on the assessment we attended a multidisciplinary meeting and observed good teamworking and best practice.

Score: 3

Staff supported patients to maintain healthy choices and healthy lifestyles. Patients were given advice on how they could be involved in monitoring their own health and wellbeing to maximise their independence and comfort.

Patients were asked about smoking and alcohol consumption as part of their pre-operative assessment. All identified smokers and patients who were deemed to be at risk of alcohol related complications were given advice leaflets.

Patients and visitors had access to both hot and cold drinks within the outpatient department Due to the transient nature of stay in the outpatient department, food was not provided.

Staff provided good care and treatment in line with latest evidence and good practice. People’s hydration and nutrition was appropriately managed with specialist input where required.

Score: 3

The provider recognised that patients within all its facilities needed to be confident in the quality of their clinical care and, as such, committed to a process of clinical audit, which sought to develop and sustain a culture of best practice throughout the organisation.

Within the outpatient department local audits were developed to address areas of non-compliance in the national audit programme and for any other local areas of concern. Examples included pre-operative assessments, patient consent and medical records.

Audit data we reviewed, which showed adverse results of audits were the subject of SMART (Specific, Measurable, Achievable, Realistic, Timely) action plans and follow up findings.

Care delivered by the hospital was in accordance with National Institute for Health and Care Excellence (NICE) guidelines.

Systems for appraising both medical and nursing staff were in place, in addition to training being available. Nursing staff reported that they had sufficient access to medical staff and could discuss patient related issues with them.

Staff used a recognised pain score tool to assess pain. Patient records we reviewed evidenced appropriate pain relief medicines were given to patients to manage symptoms.

Patients told us staff were good at monitoring them to ensure they received the right pain relief when they needed it.

Data showed for the period April 2024 to October 2025 89% compliance for cosmetic surgery entries in medical records

We saw evidence in patient care records that they were involved decisions about their care and treatment and in developing their care plans. People told us that staff answered questions about care and treatment openly and in plain English they could understand.

Data showed that for the period October 2024 to April 2025 100% compliance for pre-operative assessments in the outpatient department.

The hospital had policies and care pathways in place that were in line with national guidance, for example, the service had a policy on mental capacity and deprivation of liberty safeguards however, staff were not always knowledgeable about these as they told us it was infrequent to have patients who required a mental capacity assessment to assess if they had capacity to make decisions concerning their health needs.

Patients left the hospital after their procedure with their own copy of the discharge summary letter, which was also sent to their GP.

At the time of our inspection Friends and Family data showed that 100% of NHS patients had a positive experience in outpatients and 90% of private patients stated the same.

Score: 3

Staff gained consent from people in line with legislation and guidance, which was documented within the patient records. We observed staff obtain verbal consent from people before delivering care and treatment.

Records of consent that were reviewed were thorough and included details of the risks associated with the procedure.

Staff told us consent was gained before any sharing of patient information, both internally and with other primary care services.

Relatives and patients, we spoke with told us staff did not provide any care without first asking their permission. We looked at 4 sets of patient care records and saw consent was appropriately recorded in all of them

Patients received appropriate information prior to their procedure. Staff made sure they understood the information.

Data showed that for the period October 2024 to April 2025 showed 97% compliance for patient consent, against the service target of 100%

However, staff we spoke with were not fully clear on their understanding of the requirements of the Mental Capacity Act 2005 and the two stage process. They had very few situations where a mental capacity assessment was required and could not remember the last time one was undertaken in the department.