Updated
20 October 2026
Date of assessment: 30 June 2026 – 1 July 2026.
We carried out an unannounced, comprehensive assessment on 30 June 2026 and 1 July 2026.
The assessment looked at diagnostic imaging which we have rated as good, surgery, which we have rated as good and outpatients, which we have rated as good.
We rated the service overall as good.
We carried out the assessment as the provider had not been inspected under our new methodology since 2016 when the service was rated good in all key questions across all assessment service groups.
Practice Plus Group Hospital, Emersons Green is an independent hospital which provides planned surgical, outpatient and diagnostic services to NHS and private patients. It specialises in routine elective care, including orthopaedics, ophthalmology, ENT, general surgery, gynaecology, urology and endoscopy, with a focus on short waiting times and planned procedures rather than emergency care.
The service operates from a modern, purpose-built facility with inpatient beds, multiple operating theatres and diagnostic imaging, supporting pre‑ and post-operative pathways within a single site. It provides consultant-led care and aims to deliver rapid access to treatment, with private pathways offering particularly short timescales for surgery.
Emersons Green functions as a high-volume elective surgical centre with strong performance against regulatory standards, efficient patient pathways, and consistently positive feedback, though its scope is limited to planned care rather than acute or emergency services.
Surgery:
Practice Plus Group Hospital Emersons Green is an elective surgical centre providing planned NHS and private care. Surgical activity includes orthopaedics, ophthalmology, ENT, general surgery, gynaecology, urology and endoscopy, with consultant-led services delivered from a purpose-built facility containing inpatient beds, operating theatres and diagnostic imaging services. The hospital focuses on routine elective procedures with streamlined pre- and post-operative pathways and does not provide emergency or acute services.
Overall, people received safe, effective, caring, responsive and well-led care. Care was delivered by skilled staff who completed thorough assessments, worked collaboratively across teams and involved people in decisions about their treatment. Patients consistently provided positive feedback about their experience, describing staff as kind, compassionate and responsive, and told us they felt well informed and supported throughout their care. The service made reasonable adjustments to meet individual needs, promoted continuity of care and used patient feedback to drive improvements. Governance processes provided oversight of quality, safety and performance, and leaders had identified and were addressing areas requiring improvement. However, we found some concerns relating to risk assessment documentation, environmental safety, aspects of theatre governance and culture, appraisal compliance, referral to treatment performance in some specialties, and staff confidence in speaking up and being heard by senior leaders. Despite these findings, patients' outcomes and experiences were positive, and the service was providing a good standard of care overall.
Outpatients:
Practice Plus Group Hospital – Emersons Green, provides a high-volume elective outpatient service supporting planned surgical pathways and consultant-led care for NHS and private patients. The service provides outpatient consultations, pre-operative assessments, follow-up appointments, diagnostic investigations and ongoing management across specialties including orthopaedics, ophthalmology, ENT, general surgery, gynaecology and urology. The hospital was assessed in 2016 and outpatients was rated good overall.
We carried out an on-site assessment of the outpatient department at Emersons Green Hospital. During the assessment, we reviewed evidence against the relevant quality statements within the safe, effective, caring, responsive and well-led key questions. We rated the service as Good.
The outpatient's department was previously inspected in March and April 2016 and was rated as good.
The service demonstrated a positive culture of safety. People's care and treatment were regularly reviewed to ensure their needs continued to be met, and staff worked collaboratively to identify and manage risks. Effective arrangements were with the local NHS trust to support specialist review and the transfer of patients when required.
The outpatient environment was clean, well maintained and suitable for the delivery of care and treatment. There were enough staff with the appropriate skills, experience and qualifications to meet people's needs safely. Staff treated people with kindness, compassion and respect and were committed to providing person-centred care.
The service had effective governance and risk management processes to identify, monitor and mitigate risks. Leaders sought feedback from people using the service and used this information to support learning and continuous improvement. Systems were in place to investigate concerns and complaints, and to ensure learning was shared across the service.
Diagnostic imaging:
The diagnostic imaging service provides a range of investigations, including MRI, ultrasound and X‑ray, to support timely diagnosis and pre‑ and post-operative care within elective pathways. Services are delivered within a modern, purpose-built environment with access to on‑site equipment, enabling a streamlined “one‑stop” approach to assessment and treatment.
The service supports planned surgery by ensuring prompt access to imaging, contributing to reduced waiting times and efficient patient flow. Imaging is integrated with outpatient services, allowing patients to undergo investigations and clinical review within the same pathway, improving continuity and patient experience.
Overall, the diagnostic imaging service is characterised by accessible, efficient and patient -centred provision. It has modern facilities and strong integration into elective care pathways, supporting timely diagnosis and high-quality clinical outcomes.
Between July 2025 and June 2026, the service carried out 10,108 examinations at Emerson’s Green Hospital across all imaging modalities.
The diagnostic imaging service demonstrated a strong safety and learning culture, with effective risk management, appropriate staffing and well-maintained environments, alongside person-centred care. There were also evidence-based care and good multidisciplinary working. Patients were treated with kindness and respect, with services accessible, inclusive and responsive to individual needs, supported by visible and supportive local leadership fostering a culture of continuous improvement. However, some gaps remain in governance which require further strengthening to ensure full oversight and assurance.
We found a breach of regulations in relation to good governance.
Updated
21 April 2026
We carried out an unannounced, comprehensive two-day assessment on 30 June and 1 July 2026.
We carried out the assessment as the provider had not been inspected under our new methodology. The service was last inspected in 2016 where the service was rated good in all key questions across all assessment service groups, except effective, which was not rated under our previous methodology.
Safe:
The imaging service demonstrated a good standard of safe care across most areas and was characterised by a positive safety culture, effective incident reporting, strong safeguarding arrangements, robust staffing levels, and good infection prevention and control practices. Staff were well trained, empowered to raise concerns, and learning from incidents was shared across the service to drive improvement. The environment, equipment, medicines management and risk assessment processes generally supported the safe delivery of care. However, there were some shortfalls in safe systems and pathways, including gaps in information provided to some patients prior to contrast scans. While these issues did not appear to impact patient outcomes, they indicated areas where governance and care pathways required strengthening.
Effective:
The service provided effective, person-centred care and treatment, with staff assessing and responding to people’s individual health, wellbeing and communication needs. Care was delivered in line with national guidance and evidence-based practice, supported by strong multidisciplinary working, good consent processes and effective support for patients to manage their health. However, monitoring of outcomes required improvement, including an overdue Radiation Protection Adviser visit. Overall, most areas were good, with opportunities to strengthen outcome monitoring and governance arrangements.
Caring:
The service provided compassionate, person-centred care and treated people with dignity, kindness and respect. Staff tailored care to meet individual needs, promoted independence and choice, responded promptly to concerns and distress, and supported people to access services and information in ways they could understand. Patients were overwhelmingly positive about their experiences, describing staff as caring, professional and supportive. Staff wellbeing was also prioritised, contributing to a positive culture and the delivery of consistently good care.
Responsive:
The service delivered responsive, person-centred care that was tailored to individual needs and supported choice, inclusion and continuity of care. Staff worked closely with patients, carers and partner services to ensure care was coordinated, accessible and flexible, with good use of communication aids, translation services and reasonable adjustments. Patients were actively involved in decisions about their care, feedback was welcomed and acted upon, and waiting times and access to diagnostic services were well managed. However, the service did not always provide appropriate written information before CT scans involving contrast, which limited the quality of information available to some patients. Overall, the service demonstrated good responsiveness, with a minor shortfall in the provision of information.
Well-led:
The service was led by visible and supportive leaders who promoted an inclusive, positive culture focused on high-quality patient care. Staff felt valued, engaged and able to contribute to service improvement, and there was a strong commitment to learning, innovation and partnership working. However, governance arrangements required strengthening, with some outdated radiation governance documentation, gaps in committee oversight and mixed confidence in Freedom to Speak Up processes. Overall, the service was well led, with good leadership and culture, but some governance systems required improvement.
We found 1 breach of regulation at the service in relation to good governance.
We have requested an action plan, which will be requested upon publication of the final report.
Updated
21 April 2026
Assessment date: 30 June and 1 July 2026
We carried out an on-site assessment of the outpatient department at Emersons Green Hospital. During the assessment, we reviewed evidence against the relevant quality statements within the safe, effective, caring, responsive and well-led key questions. We rated the service as Good.
The outpatient's department was previously inspected in March and April 2016 and was rated as good.
The service demonstrated a positive culture of safety. People's care and treatment were regularly reviewed to ensure their needs continued to be met, and staff worked collaboratively to identify and manage risks. Effective arrangements were with the local NHS trust to support specialist review and the transfer of patients when required.
The outpatient environment was clean, well maintained and suitable for the delivery of care and treatment. There were enough staff with the appropriate skills, experience and qualifications to meet people's needs safely. Staff treated people with kindness, compassion and respect and were committed to providing person-centred care.
The service had effective governance and risk management processes to identify, monitor and mitigate risks. Leaders sought feedback from people using the service and used this information to support learning and continuous improvement. Systems were in place to investigate concerns and complaints, and to ensure learning was shared across the service.
Updated
21 April 2026
We carried out an unannounced, comprehensive 2-day assessment on 30 June and 1 July 2026.
We carried out the assessment as the provider had not been inspected under our new methodology. The service was last inspected in 2016 where the service was rated good in all key questions across all assessment service groups, except effective, which was not rated under our previous methodology.
Safe:
People were protected from avoidable harm and the service maintained a good standard of safety. Systems and processes supported safe care, including effective referral, transfer and discharge arrangements, safeguarding processes, good medicines management and effective infection prevention and control measures. Staffing levels met patients’ needs and staff received training for their role. However, we identified some areas for improvement, including inconsistencies in risk assessment documentation in theatres, concerns from some staff about reporting culture and some staffing pressures during patient transfers. There were environmental risks relating to storage and security of hazardous substances, variation in resuscitation equipment, and some gaps in policy oversight. Leaders had recognised many of these issues and had taken action or developed plans to address them.
Effective:
People's needs were assessed and care was delivered in line with best practice, resulting in positive outcomes and experiences. Staff completed thorough assessments, personalised care planning and multidisciplinary reviews to ensure people's needs were understood and met. Care was delivered by suitably skilled staff working collaboratively across services, and outcomes were monitored through audits, patient-reported outcome measures and governance processes, with evidence of improvements in function, pain and quality of life. Patients told us they were involved in decisions about their care and knew what to expect throughout their treatment. However, there were some areas for improvement, including low appraisal compliance in theatres, some evidence of teams working separately from one another within theatre without collaboration, and inconsistent participation in national audit programmes. Overall, the service provided effective care and treatment.
Caring:
People were treated with kindness, compassion and respect and were involved in decisions about their care and treatment. Patients consistently provided positive feedback about staff, describing them as caring, supportive and responsive to their needs. Staff understood and accommodated people's individual needs and preferences, including communication, cultural and additional support needs, and promoted choice, independence and dignity throughout the care pathway. Patients told us they felt listened to, informed and supported. However, some staff described concerns about wellbeing, morale and support from senior leaders. Despite this, people's experiences of care were consistently positive and the service remained caring overall.
Responsive:
People could access care in ways that met their individual needs and preferences. The service made reasonable adjustments for people with additional needs, provided information in accessible formats and used effective communication support, including interpretation services. Care was coordinated across teams to promote continuity, and patients told us the service was accessible, responsive and easy to use. Feedback was actively sought and used to improve services, and patients consistently reported positive experiences. However, some patient information leaflets were out of date. Most patients did not experience delays and waiting times for referral to treatment standards met the NHS target set. Overall, the service provided responsive and person-centred care.
Well-led:
The service rating for well-led has changed from good to requires improvement. Leadership and culture did not always support high-quality, person-centred care. While staff generally felt supported by immediate managers, senior leaders were not always perceived as approachable, responsive or receptive to concerns. Some staff reported bullying, favouritism, inconsistent treatment and fear of repercussions for raising issues. Freedom to Speak Up processes were established and well understood, but staff confidence in being heard remained variable, particularly within theatres. Staff were not always clear on the organisation's vision and values. Governance arrangements were generally effective, with clear accountability structures, risk management processes and audit systems supporting service quality and sustainability. The service demonstrated a strong commitment to equality, diversity and inclusion, and worked effectively with partners and local communities. However, opportunities for learning, innovation and continuous improvement were not fully embedded, with staff not always feeling involved in improvement activity and limited evidence of research or innovation.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
Or, if we have requested an action plan, this will be requested upon publication of the final report.