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

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.

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. At our last assessment we rated effective as good, At this assessment the rating remained good.

The service ensured patients’ care, treatment and support achieved good outcomes and promoted a good quality of life. The service enabled patients to have the best outcomes because their needs were assessed promptly and effectively. We saw that outpatients’ care and treatment reflected these needs and that staff provided evidence-based treatment. Staff monitored patients’ outcomes and worked together to encourage patients in their ongoing recovery.

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.

Patients attended a pre-operative pre-assessment appointment in the Outpatient department (OPD) to assess their overall health and communication needs prior to surgical procedures. Clinics allowed patients' progress and wellbeing to be checked on their return to the hospital after their procedures. Any changes were monitored and would be documented on their hospital records.

We reviewed 10 patient records on the OPD minor procedure pathway. These showed patients were assessed using various tools, including an adapted World Health Organisation (WHO) Surgical Safety Checklist, wound assessment chart (where appropriate), traceability (i.e. the system whereby the staff tracked and verified the entire lifecycle of medical devices or surgical instruments used) and pain. There were red flags noted, consent verified, including whether this was verbal or signed and evidence of clinical review. It was also noted that patients were involved in their care planning.

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.

Staff or the service delivered care in line with legislation and current evidence-based good practice and standards. We reviewed patient feedback and found it to be positive. Patients told us they were given information which explained their treatment and how it was most appropriate for their needs. They said staff helped them prepare for the interventions provided and aftercare advice was provided that supported their recovery.

Wider leaders shared updates to national guidance and corporate policies with the relevant heads of the department. These were then cascaded down to staff through team meetings. Staff could and were encouraged to review local policies and consider all available methods to improve patient care. Policies used followed best practice and national guidance, such National Institute for Health and Care Excellence (NICE) and those from the professional bodies, such as the Royal Colleges.

There are regular staff engagement activities, such as colleague updates and a monthly all-colleague newsletter. These highlight hospital-based topics, but also shared updates on departmental development, advice on clinical practice as well as service-wide development. For example, the Aseptic non-touch technique, which involved OPD staff, was highlighted in the April 2025 edition.

The leadership attended regular meetings of the integrated governance and risk committee, where clinical effectiveness, updates in clinical practice and guidance were routinely discussed.

The hospital had accreditations and certifications in national and international schemes, including certification by the International Organisation for Standardisation (ISO) for digital security, Joint Advisory Group (JAG) accreditation for endoscopy, and was preparing a paediatric JAG accreditation. Theatres had a gold quality data provider award with the National Joint Registry (NJR). Hospital departments held CHKS accreditation. And they had begun the process for VTE exemplar status.

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.

Staff worked together to enable patients to have an easy journey through Outpatient Department (OPD) services. We saw guidance for ‘patient passports’ for patients undergoing gender affirmation interventions. These were documents which enabled patients to share their well-being and communication needs in a simple way. They ensured that all teams were aware of the patient's wishes and that people only had to give their details once.

We saw staff conduct handovers concisely and thoroughly. We observed the daily ‘huddle’ meetings for both the pre-assessment and the OPD nursing teams, each huddle was attended by the OPD management. The meetings covered aspects of safety, care and planning for the day. The team members checked in with each other and shared good news and praise for individuals as well as formal updates.

Staff across all roles, including nurses, consultants and administrative staff, told us there was good communication between professionals at all levels. Staff said they felt confident to challenge clinical teams or managers if they had concerns about a patient or questions about decisions or processes.

OPD leaders and senior hospital leaders told us there were plans to strengthen collaboration across the Bupa Group teams and departments, particularly for patients receiving care across different Bupa locations. This aimed to support timely, coordinated care and improve the overall patient experience.

There were established links with local NHS services. There was a contact with NHS partnership pathology services with regular service monitoring meetings and direct lines of communication between the OPD leadership and the dedicated pathology co-ordinators. There were also formal protocols around patient transfers to a local acute NHS trust, with good professional relationships and extensive knowledge of operational systems used within the NHS trust reported.

We did not look at Supporting people to live healthier lives during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

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.

The service submitted evidence to demonstrate benchmarking of incidents with comparable services. This ensured performance was monitored against similar providers and supported identification of trends, variances and opportunities for improvement.

The hospital submitted data which indicated that clinics were generally scheduled in response to patient demand and that cancellations were uncommon, supporting continuity of care and timely access for patients.

Hospital‑submitted data showed that, over a 12‑month period, there were 1,793 did not attend (DNA) appointments out of 53,038 (3.4%), indicating overall good patient attendance.

The service also monitored cancellations, including both clinical and non‑clinical factors, which supported oversight of service performance.

Between April 2025 and March 2026, 45 incidents of delays or failed clinics were recorded (0.08% of all clinics), with 39 (0.07%) due to delays and six (0.01%) attributed to administrative factors. This shows that delays and disruptions were infrequent and that systems were in place to identify and review these events to minimise impact on patients.

Leaders also submitted information to the Private Healthcare Information Network (PHIN) and met statutory reporting requirements to the Home Office, Care Quality Commission and accreditation bodies. The service had local monitoring arrangements. These included local systems to review incidents, maintain oversight of performance, and support learning and improvement in outcomes. External reporting requirements continued to be met while internal data was used to ensure timely review and action.

The endoscopy service maintained Joint Advisory Group (JAG) accreditation, with work ongoing towards paediatric JAG accreditation. Hospital departments held CHKS accreditation, and the OPD team demonstrated involvement in wider initiatives, including sustainability, supporting continuous monitoring and improvement of service outcomes.

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.

Staff followed policies on patient consent and on specific measures to accommodate those with extra requirements, including people with a physical and/ or mental health needs. There was also guidance on gaining consent from those who might need assistance with communication. We observed staff request consent just before a procedure, to check that patients were still comfortable in going ahead.

Staff could assess and record patients’ capacity to consent appropriately when needed and were able to explain what the processes would be when patients lacked capacity. The service also considered the person’s wishes, culture and history in planning their treatment. When we reviewed patient care notes, we saw that patient consent to treatment had been recorded, including the type of consent provided. When we observed staff, we saw they consistently gained patient consent.