The New Victoria 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 is the first assessment for this service as a stand alone assessment service group. This key question has been rated good. 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.

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.

Staff completed assessments in a timely way and adapted care to meet individual needs. Patient records included referral forms, relevant clinical information, consent documentation and details of any adjustments made to support patient’s needs. Staff completed health and safety questionnaires and confirmed medical history, allergies and risk factors before imaging to identify potential risks and support safe care. Patients received appointment letters with details of the scan and associated costs.

Care was personalised and reflected individual needs, such as anxiety, mobility issues or existing health conditions. Staff told us they could make adjustments, including arranging longer appointments for patients who required additional support. Patients told us they felt able to ask staff for help or raise any needs they had.

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.

A water fountain was available in the patient waiting area this was clean and well maintained. Patients said they were offered hot drinks and biscuits following procedures. Patients who needed to fast before their scan received clear written and verbal instructions in advance to ensure safe preparation.

Staff participated in regular audit cycles, including audits of image quality, compliance of radiology request forms with IR(ME)R requirements, reporting timescales and radiographer documentation. Action plans were developed in response to audit findings, implemented and the metric was re‑audited to support sustained improvement.

Audit results and associated action plans were reviewed by the imaging department management team, with oversight provided through governance meetings. Quality, Compliance and Risk meetings (QCRM) were used to review outstanding audit actions, and the imaging department maintained a tracker to monitor progress. Audit action plans included clear arrangements for communicating findings and training requirements for staff and the implementation of changes to practice.

Standing agenda items at imaging department QCRM included policy, procedure and document control, as well as safety alerts, guidance and regulatory updates. Each imaging modality had a designated lead who was responsible for keeping up to date with relevant regulations. These arrangements helped to ensure safety information was current and procedures reflected recognised best practice. We saw that policies were accessible to staff via the electronic document management system.

Staff monitored radiation doses to ensure they were kept as low as reasonably practicable and diagnostic referral levels (DRLs) had been established for all procedures undertaken. We saw these were displayed in imaging rooms; however, they were not available with mobile scanning equipment. We were told DRLS for mobile modalities were stored online.

The percentage of staff that had had an appraisal in the last 12 months was 97%. Most staff told us they were encouraged to take part in training and development opportunities.

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.

Patients benefited from joined-up care and clear communication between staff, teams and partner organisations. Multidisciplinary working was embedded across the service. Radiographers, imaging assistants, PSA staff and imaging department management worked together to plan and deliver care. Service improvement activity, including the review of risks, updating of protocols and sharing of learning, was monitored through imaging department and hospital wide governance meetings.

There were effective daily arrangements in place to oversee operational pressures and support safe service delivery. Staff also used regular handovers and team briefings to share information about patient safety, workflow and operational priorities. A flagging system enabled timely escalation of critical findings, and where imaging secretarial support was not available, radiologists communicated significant or urgent results directly to referring clinicians.

The hospital maintained effective communication and positive working relationships with external partners. This included close collaboration with the local NHS trust and with sister independent hospitals within Bupa. For example, leaders said with the introduction of the Bupa connected care pathways, policies, processes and shared learning were implemented across sites to support consistent and effective practice.

Team relationships were described by staff as positive and supportive. Teams met regularly to coordinate activity and address operational pressures. Staff said leaders were visible and approachable, and they felt informed and supported in their roles.

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.

Staff explained imaging procedures and results clearly, helping patients understand their care and next steps. When urgent or unexpected findings were identified, referring teams were contacted directly to ensure timely follow-up and continuity of care. Booking teams coordinated appointments around patients’ availability and treatment schedules to reduce disruption and support ongoing engagement in care.

The hospital provided a range of health promotion information through its website, including information on mental health, stress awareness and cancer awareness campaigns. Patients received detailed information about their scans in appointment letters, and staff told us information leaflets could be provided in printed format if required. We saw a range and supply of information leaflets for patients regarding cardiac conditions in the cardiac diagnostic physiology room.

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.

There were systems in place to measure performance, benchmark against standards and drive improvement through audit, learning and governance oversight. The service had key performance indicators (KPIs), which were used to assess its overall performance. Examples of KPIs included a report turnaround time of 48 hours, the management team said they were regularly meeting or exceeding this KPI. This was corroborated by data which showed in November 2025, 97% of reports met the key performance indicator (KPI) for completion within 48 hours and 93% exceeded their target and were completed within 24 hours.

The hospital was implementing a new IT system moving to fully electronic record keeping. The system included features such as a patient portal, which management said would improve communication with patients and increase their ability to provide information to patients such as scan preparation and results. The system was at an early stage of implementation at the time of the inspection and was focused on patient records. Management said they expected that further functionality would be introduced to improve monitoring and the use of technology to support patients more effectively. For consultants it was planned that the new system would give improved access to more clinical, surgical and patient information and functionality and ability to remotely order tests and prescriptions.

Patients received care that was safe, consistent and continuously improving. Staff used technology, audit and governance to monitor performance, identify risks and improve outcomes. Governance minutes showed that management continually reviewed outcomes and feedback to ensure that both clinical standards and patient expectations were met.

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.

Patients received care that respected their autonomy, rights and individual preferences. Staff applied the principles of informed consent consistently and demonstrated an understanding of relevant legislation and guidance relating to consent and decision‑making. Staff took practical steps to support patients to make their own decisions, including explaining procedures clearly and extending appointment times where required. We saw that consent was sought from patients before they received care or treatment.

The informed consent policy and safeguarding adults policy provided an overarching framework to ensure consent was obtained appropriately and patients’ rights were protected. The policies set out the organisation’s approach to informed consent, supporting decision making, assessing capacity and applying safeguards where restrictions on liberty were required. Both policies were in date with a specified review date.

Records showed consent was documented on patient files. Staff understood how and when to assess whether a person had capacity to make decisions about their care. Mandatory training records showed 100% compliance with Mental Capacity Act (2010) training.