The New Victoria Hospital

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• 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 patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patient 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 this key question good. At this assessment the rating has remained good. This meant patient’s outcomes were consistently good, and patient’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 shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe.

Staff with appropriate seniority had discussions about the patients’ preferences and wishes if their condition deteriorated, and these were documented in the patient record. Decisions about care were made with consideration of the wishes of the patient and/or their family.

Staff assessed patients’ pain and used recognised tools to do so. Staff gave pain relief in line with individual needs and best practice and assessed how effective this was. Patients’ pain was managed prior to leaving the operating theatre to ensure it was adequately controlled before transfer to the ward. Where pain control was not sufficient, the surgical team administered additional analgesia prior to transfer.

Pain relief medicines was timed for maximum effect before painful procedures or to allow the patient to sleep at night. Patients told us they received pain relief soon after requesting it. They felt their pain was well managed.

We saw patients were generally calm, their faces appeared relaxed, and they were moving around comfortably, suggesting that they were not in significant pain. Staff reported that anaesthetist support was available for patients with complex pain needs. However, we did not observe this in practice, as pain was well controlled for the patients reviewed at the time of inspection.

The service had introduced a wellbeing team to support patients undergoing gender affirmation procedures. The team included mental health care workers and individuals with lived experience of the service, providing additional support throughout the patient pathway and supporting their needs.

The service supported patients to receive effective care and treatment by providing communication aids to meet individual needs. Hearing loops were available to support patients with hearing impairments. Adjustments were also in place to support patients who were neurodivergent, including allocation to rooms with reduced environmental stimuli, such as quieter air conditioning. These measures helped ensure patients could understand information about their care and treatment and participate in decision-making.

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.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. They used surgical pathways aligned to national standards, including the provider’s Five Steps to Safer Surgery policy, which complied with the National Safety Standards for Invasive Procedures (NatSSIPs). NatSSIPs provide the framework for developing Local Safety Standards for Invasive Procedures (LocSSIPs).

All the policies we looked at included a creation and review date, and clear references to current national guidelines. There were systems to communicate changes in guidance through meetings and management newsletters. We saw notice boards displayed up to date guidance to staff. Policies and processes took account of changes to the Royal Colleges guidelines and National Institute for Health and Care and Excellence (NICE) guidelines.

We looked at the pathway for people who were admitted for gender affirmation surgery on the NHS choices route, as well as self-pay/insured patients having other surgical procedures. The service supported the reduction of national waiting times for gender affirmation surgery by meeting its target number of patients within the agreed timeframe. All self-pay and insured patients were able to access surgery in line with their preferred timescales.

We reviewed 10 care records for evidence of completion of care plans and risks assessment of patients and found all patient’s had appropriate risk assessments undertaken such as falls assessments and venous thromboembolism (VTE) risk assessments. Patients waiting to have surgery were not left nil by mouth for longer than necessary.

Staff fully and accurately completed patients’ fluid and nutrition charts where needed. The information was used to inform care planning and delivery, including identifying when patients required additional fluids, nutritional support, or assistance with feeding.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition and used this to inform care planning and delivery. For example, patients identified at risk were provided with additional nutritional support, such as fortified diets or assistance with eating where required. Patients requiring special diets for clinical reasons, were assessed by dieticians and advice given as required

The service reported information to the Private Healthcare Information Network (PHIN). This information allowed the provider to benchmark itself against similar independent providers using a range of performance measures, including; patient activity volumes, length of stay, never events, patient reported outcome measures (PROMs), infections rates and number of complaints received. This data demonstrated the provider performed well in all areas measured.

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.

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

Staff reported healthy working relations across staff groups including between medical and nursing teams. We saw and heard examples of effective team working which was based on mutual respect and trust. For example, staff worked together to support a neurodiverse patient by adapting communication, minimising environmental triggers, and ensuring continuity of care, which helped the patient feel more comfortable and supported.

A daily huddle was attended by all heads of department and the senior management team to share and review service risks ,and to take timely action on matters such as staffing and facilities issues.

The teams worked together to prepare patients for what to expect post-operatively and when they returned home. Plans for discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. Discharges were planned at an early stage to ensure they were safe and appropriate for the person’s needs. Information was shared between teams and services to ensure continuity of care. Regular multidisciplinary (MDT) reviews and meetings were held for some specialities, for example gender affirmation surgical patients. These meetings were attended by consultants, RMO’s, gender affirmation clinical nurse specialists, nurses, allied health professionals, and the wellbeing team.

Staff worked across health care disciplines and with other agencies when required to care for patients. For example, nurse specialists delivered training and provided information to district nurses and GP’s across the country on caring for gender affirmation patient’s prosthetics and wounds following patient’s discharge from hospital.

The patient records we reviewed included input from a range of clinicians involved in their care, This facilitated the sharing of information to ensure a consistent approach to care and treatment pathways.

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.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. Staff provided advice and support to help patients adopt healthier lifestyles and reduce future health risks. For example, we saw evidence of interventions to support smoking cessation and alcohol reduction.

Patients undergoing elective operations had access to information about their condition, their treatment and how best to prepare for surgery. Staff spoke with them about how best to optimise their outcomes after surgery and how to modify their choices to ensure better health.

Staff provided relevant information promoting healthy lifestyles and support to patients on an individual basis. This included individualised postoperative advice following surgery.

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.

Staff used recognised tools, including the National Early Warning Score (NEWS2), to identify and respond to clinical deterioration, supporting timely intervention and improved patient outcomes.

Patients reported positive outcomes following their care and treatment. They described improvements after surgery, including increased mobility and the ability to carry out daily activities. Patients also said they were satisfied with their rate of recovery and felt well informed about what to expect throughout the recovery process. They told us they had access to appropriate aftercare, including support from consultants and physiotherapists, which supported their recovery.

Staff monitored the effectiveness of care and treatment through audit and benchmarking to compare with other similar services. The service used the findings to make improvements, such as the sips until surgery initiative, and achieved good outcomes for patients. The service participated in national audit programmes such as performance reported outcomes measures (PROMs) and the National Joint Registry (NJR). Audit findings were reviewed and monitored at clinical governance and Medical Advisory Committee (MAC) meetings to drive improvement and learning.

The service monitored a range of clinical indicators and performance standards, including patient safety, infection prevention and control (IPC), incidents, patient experience, and staffing. This data was used to benchmark performance against other hospitals within the provider and indicated that the service was performing well.

Processes were in place to monitor patient outcomes, including surveillance and investigation of surgical site infections (SSIs) and related readmissions. Clinical outcomes were positive, with low readmission rates of 0.34%, a return to theatre rate of 0.54%, and a surgical site infection rate of 0.45%. The service held relevant clinical accreditation, including Joint Advisory Group (JAG) accreditation, demonstrating the endoscopy service was providing high-quality, safe, and patient-centred care, which had been validated against national standards

The service had an audit programme covering areas such as venous thromboembolism (VTE), falls, nutrition, hydration, fasting, and NEWS2. Audit results were shared with staff and supported by action plans to drive improvement. For example, following an audit of pre-operative fasting, a “sips until surgery” prompt was introduced into admission documentation to improve consistency and support appropriate oral fluid intake prior to surgery. Subsequent re-audits demonstrated an improvement in compliance.

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 supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff followed the services policies related to consent, mental capacity, deprivation of liberty and restrictive practice, as relevant.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Consent for surgery was sought by the most appropriate doctor and included discussions about the benefits, potential complications, the risks and alternative options. Staff clearly recorded consent in the patients’ records. There was also a checklist within the pathway to ensure the consent form was checked prior to surgery going ahead; this was completed in all patient records we checked. Consent audits were completed, with outcomes shared with staff, and these demonstrated good compliance with national consent requirements.

Patients said they were involved in decision making about their care and treatment. They could describe the risks and benefits they were told about prior to surgery. Staff sought permission before sharing patient information with family or friends. We observed staff seeking verbal consent before providing care or treatment.

Where specific requests had been made by patients, for a same sex health care professional or theatre team, this was discussed and provided whenever possible. Chaperones were provided if requested.

Interpreter services were available for patients whose first language was not English, supporting patients to understand information and enabling informed consent to be obtained. These were arranged in advance of admission for surgery, to ensure they were in place when required.