All inspections: Practice Plus Group Hospital - Emersons Green

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.

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.

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.

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.

Emersons Green NHS Treatment Centre is an independent hospital, owned by Care UK, contracted to provide treatment for NHS patients free at the point of use.

The treatment centre provides surgery, outpatient and diagnostic imaging services for the following specialities: ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedics, gynaecology, urology and endoscopy.

Admission to the treatment centre for surgery follows strict referral criteria for people aged 16 years and over who require routine surgery.

There is an outpatient department within the treatment centre for routine pre- and post-operative appointments.

The treatment centre has an inpatient ward with 33 bed spaces. There are four operating theatres, one minor procedure room and two anaesthetic induction rooms, operating Monday to Saturday.

We carried out a comprehensive announced inspection of Emersons Green NHS Treatment Centre on 30 and 31 March 2016, and an unannounced inspection on 11 April 2016.

We inspected the following two core services:

• surgery

• outpatients and diagnostic imaging.

The overall rating for this service was good.

Our key findings were as follows:

Are services safe?

By safe, we mean that people are protected from abuse and avoidable harm.

There was a good incident reporting culture amongst staff, which was reflected in the consistent numbers of incidents reported in the hospital between October 2014 and September 2015. Learning from serious incidents and root cause analyses was shared with the whole Care UK organisation.
Staff were aware of the principles of the duty of candour and were open, transparent and apologetic to patients when things went wrong.
The treatment centre was visibly clean and staff followed infection prevention and control protocols.
Staff were aware of their roles and responsibilities in reporting a safeguarding concern and knew how to go about this process. Safeguarding policies and procedures were readily available and up to date.
There were good numbers of staff employed, with relevant skills, that kept people safe from avoidable harm. These levels were regularly reviewed to ensure changes in demand were adequately staffed.
The design of the treatment centre kept people safe at all times, with waiting areas free from obstructions and providing staff with good visibility of patients.
There was a good process for monitoring controlled drugs and breakages, including unannounced inspections of controlled drugs log books.
Patients who deteriorated were well supported by staff. Clear processes existed to ensure rapid and safe transfers to a local NHS acute hospital if needed.
We found out of date equipment stored on the ward.
Incident reporting data had identified a trend in poor reporting of patient allergies prior to October 2015. However, actions had been put in place and allergy reporting had improved.
The hospital identified a need for better communication between consultants and a clear system to flag urgent referrals.
The diagnostic imaging department only had one X-ray cassette reader, which would mean there would not be an on-site X-ray service if it broke down.
The hospital target of 90% compliance with mandatory training in January 2016 had not been met in outpatients or physiotherapy. In diagnostic imaging only 80% of staff had completed basic or intermediate life saving training.
We saw sediment on a patient water dispenser, and staff did not know if flushing of the dispenser took place, and could not produce any records of this.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

An evidence-based enhanced recovery programme was used for patients undergoing hip or knee replacements.
The treatment centre scored better than the England average in its hip replacement and varicose vein surgery for the reporting period October 2014 to September 2015.
Staff were qualified and had the skills to carry out their roles effectively, with a variety of internal training provided by speciality consultants.
There was good multidisciplinary team working across all departments to ensure effective patient care.
Discharge planning was started early at the pre-operation stage, including follow-up appointments and organisation of continuing care packages.
The use of best practice was evident throughout the treatment centre.
Staff felt their training was good and provided them with the necessary skills and knowledge to perform their role.
Diagnostic imaging was available seven days a week to inpatients within the hospital.
The outpatient department provided evening and weekend clinics in all specialities.
The hospital used approved national surveys to capture patients’ outcomes, including the use of a dedicated survey for patients with learning difficulties.
Diagnostic imaging staff did not always follow up urgent results with GPs.
Computer systems used to store images and reports were different throughout the Care UK diagnostic imaging centres and other NHS trusts. This meant images had to be sent over to the computer and transferred by a staff member to the patients’ electronic folder. We were told images were not always readily available because this was not always done.
The electronic patient record system was prone to slow down, and the hospital had identified a risk should it stop working completely.

Are services caring?

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

All the feedback we received from patients about the service was continually positive. Patients felt they were treated with dignity and respect and valued their interactions with staff.
All staff demonstrated genuine compassion for the people in their care, which was embedded into the culture of the departments.
Patients told us their family were involved as partners in their care. Patients felt able to raise questions and concerns and felt they were always responded to in a positive way and received information in a way they could understand.
Patients were seen as individuals and care was tailored to them, and explained clearly at each step of the way.
All patients were given a 24 hour contact number based in the hospital to call at any time if they were concerned about any aspect of their care or condition.
When care fell short of a patient’s expectations, senior managers were quick to engage with the patient to find a solution.

Are services responsive?

By responsive we mean that services are organised so they meet people’s needs.

The treatment centre worked with local Clinical Commissioning Groups, GPs and the patient forum group to plan and develop services for the local population.
Services were flexible to meet the needs of the population and planned to ensure continuity of care from department to department.
The hospital took all complaints seriously and investigated them. Where possible, managers offered face to face meetings with patients to discuss their concerns.
The hospital was meeting all of its referral to treatment standards. All waiting times for a first appointment were six weeks or less.
The hospital was improving relationships with GPs in the community to understand reasons why referral rates had declined towards the end of 2015.
The hospital used a pager system to alert patients when they were ready to go through to the clinic, and identified patients this was not appropriate for.
Staff monitored and audited the length of time patients spent in each department during their journey through the clinics using a traffic light computer system.
Staff volunteered to put on extra lists to help treat a group of patients from Wales. The treatment centre provided a coach to bring all the patients to the hospital and provided food for all patients.
Where treatment or care had to be delayed or cancelled, the hospital supported patients and fully explained the reasons why and what would happen next.
Patients who had additional needs, such as those with learning difficulties, were offered extra support such as longer clinic appointments, and pre-procedure experience visits along with their relatives or carers.
The hospital did not have sufficient parking for all of its patients, and a patient told us their partner had missed their consultation because they could not park.
Not all staff were aware of the electronic flagging system for patients with additional needs.

Are services well-led?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

The treatment centre had a challenging, yet achievable, vision and strategy that staff were aware of and involved with achieving.
Work was actively ongoing with external stakeholders to help deliver the vision and strategy, and to provide the best service for patients.
The senior management team were an enthusiastic, committed team delivering safe, patient centred care. Staff and patient engagement was embedded in the culture at the treatment centre.
There were strong governance processes at all levels in the treatment centre, with a monthly quality assurance meeting attended by all clinical and non-clinical staff, as well as the patient forum.
Staff told us they felt very well supported by their immediate line managers, the divisional management team and the executive team.
The diagnostic imaging department was working towards achieving accreditation with the Imaging Service Accreditation Scheme.
There was a strong culture of openness and transparency.
The vast majority of staff spoke highly of the working culture. Senior management were visible, approachable and engaged with staff.
Some staff felt senior management styles could be overpowering at times, although this was not reflected by the majority of staff we spoke with.
We did not see evidence of a strong emphasis on promoting the safety and wellbeing of staff, and a number of incidents reported showed staff were sometimes working through breaks.

We saw several areas of outstanding practice including:

The treatment centre had a policy that allowed any member of staff at any time to call a multidisciplinary team meeting if they had any concerns about any aspect of a patient’s care.
The safeguarding policies and procedures were well established and well understood by staff who gave us many examples of where the safeguarding process had been followed to help protect vulnerable adults receiving care in the hospital.
Pharmacy staff were involved in projects to help simplify information given to patients about their medicines. This included easy-read medicines sheets and a colour-coded system for the administration of eye drops post-surgery.
The senior managers were very visible and welcomed engagement with staff and patients in both a positive and constructive manner, and frequently served as first point of contact in situations where patients were unhappy with services.
A patient forum was set up to engage with patients and be involved with a lot of internal processes and meetings. In particular, patient forum members attended and participated in the monthly clinical governance meetings.
Staff were very quick to offer patients apologies and the opportunity for a conversation following an incident where something had not gone as well as it should. Learning from these conversations and subsequent investigations was shared throughout the Care UK organisation.
The hospital welcomed and was responsive to patient feedback, including feedback about patient toilets and adding specialty food items to the canteen menu.
The physiotherapy enhanced recovery programme allowed detailed monitoring of the effectiveness of patient treatment at six weeks, with the option to refer back to the consultant if any concerns about the patient’s progress arose.
Free telephone calls were available for all patients to landlines and mobile phones to enable them to remain in contact with their family during their stay.

There were some areas where the provider needs to make improvements.

The provider should:

Ensure effective communication takes place between consultants at all times and implement a clear system to flag urgent referrals.
Consider having a contingency plan in case the diagnostic imaging computed radiography reader breaks down.
Ensure mandatory training is completed in accordance with Care UK targets.
Maintain records of regular tap flushing.
Ensure effective stock management is in place and that out of date items are removed from circulation.
Implement a system to ensure diagnostic imaging staff follow up urgent referrals with GPs in all cases.
Consider alternative parking arrangements for patients and relatives.
Ensure the pharmacy recording, tracking and monitoring systems are fit for purpose.
Consider enhanced training for prescribers to make sure all referral information is taken into consideration at the time of prescribing ‘to take out’ medication.
Ensure the number of patients booked into a clinic is appropriate to the length and staffing of that clinic.
Ensure staff are allowed time to take allocated meal breaks.

Practice Plus Group Hospital - Emersons Green

All Inspections

During an assessment of Diagnostic imaging

During an assessment of Outpatients

During an assessment of Surgery

During an assessment of the hospital overall

30 & 31 March and 11 April 2016

During a routine inspection

Are services safe?

By safe, we mean that people are protected from abuse and avoidable harm.

Professor Sir Mike Richards

Chief Inspector of Hospitals