Kinvara Private 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

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice, policies were updated and referenced to national guidance. Patient reviews took place with other healthcare professionals to ensure patients were able to receive their treatment. Staff made sure people understood their care and treatment to enable them to give informed consent.

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.

The service had a comprehensive pre-operative assessment policy for staff to follow. It clearly outlined the roles and responsibilities of staff and that all pre-operative assessments must be undertaken by registered staff who had successfully completed relevant supervised practice.

Patients told us they had a pre-operative assessment, with their involvement, prior to admission to the service. The pre-operative assessment process identified key risks and allowed staff to assess their needs and preferences. The service had a clear inclusion and exclusion criteria in place to determine who could be treated safely at the hospital. As part of the pre-operative assessment process, people with certain medical conditions were excluded from receiving treatment at the hospital. This meant the majority of people treated at the hospital were considered to be “low risk”.

The service used paper records and completed regular documentation audits for patient records. All audits we reviewed showed consistent compliance. All records were stored securely on another floor in a locked room.

We looked at the care records for 10 patients. All of the records were well structured, legible and up to date. The assessment records included clinical details, medical history, prescribed medicines history, allergies, infection history, mobility, contact names for next of kin and other healthcare professionals (such as their GP).

Staff used a national early warning score system (NEWS2) and carried out routine monitoring based on the patient’s individual needs to ensure any changes to their medical condition could be promptly identified. The service monitored compliance of NEWS2 assessment and documentation which showed good compliance.

Staff carried out individual risk assessments and care plans were put in place where risks were identified. Records showed risk assessments and care plans were routinely reviewed.

The service monitored the number of unsuitable referrals that came from the partnering NHS hospital and shared this information regularly with them to reduce reoccurrence.

Patients received care according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and Royal College of Surgeons (RCS) guidelines.

Patients told us staff carried out regular monitoring and observations and that they received good care and treatment. Patients told us that staff asked them if they had any pain during and after their surgery. They said staff administered pain relief in a timely manner and were given information about their pain medication following discharge from the hospital.

Staff assessed patients for their preferred post-operative pain relief and used a pain assessment score to assess the comfort of patients. We observed pain score charts for patients in the recovery area after surgery and the anaesthetist supported pain management. We looked at 10 prescription charts and they documented the time pain relief had been prescribed and administered.

The service completed audits for pain management, and the most recent data showed 87.9% compliance from June 2025. As a result of that audit the service implement mandatory pain documentation training for all clinical staff within the quarter, focussed on proper scoring frequency (every 30 minutes in recovery) and completed discharge instruction protocols. They also established daily pain management huddles to review documentation compliance.

This was due for an updated audit in September and the service leads anticipated an improvement since the work they had done to improve compliance.

Patients nutritional needs were assessed as part of their initial assessment and staff completed fluid and nutrition charts where needed. The service completed audits for nutritional assessments and data showed that they scored 100% consistently. Patients told us they were offered a choice of food and drink. Food was provided on site, prepared by staff and was basic but patients were happy with the menu. Dietary requirements for patients were considered during pre-admission and the service had options available for patients with specific requirements. Patients told us they were given clear advice on what to eat and drink prior to surgery.

Staff followed up-to-date policies based on national guidance, such as National Institute for Health and Care Excellence (NICE) and The Royal College of Surgeons (RCS) standards. The hospital received regular updates on national guidance, drug alerts and shared these along with any policy changes to all staff.

Patients spoke positively about the way their care and treatment was coordinated. They told us the staff across the service worked well together as a team and shared information with their GP if they consented.

Multidisciplinary meetings took place with medical staff to discuss particular risks highlighted at patients pre-operative assessments. There was effective daily communication between multidisciplinary teams within the ward and theatres. Staff carried out ‘safety huddles’ on a daily basis to ensure all staff had up-to-date information about risks and concerns. There was daily communication between the pre-operative assessment staff and ward and theatre staff so patient care could be coordinated and delivered effectively.

Staff told us they had a good relationship with consultants, RMO’s, pharmacy and allied health professionals, such as physiotherapists. They told us that they did not encounter any issues with accessing medical advice when required. The healthcare assistants told us they received good support and worked well with the nursing staff and the managers.

The hospital opened on Saturdays, however this was just for day cases. The theatre manager planned procedures a month in advance to ensure adequate staffing and resources to support. This process worked well to anticipate any gaps and prevent any lack of resources during or post operatively. All 4 leads of the service were available on call out of hours on a rota basis, as well as the RMO.

We saw theatre staff work together to complete the safer surgery checklist and patient preparation prior to surgery. Patient records showed and we saw, that there was routine input from nursing and medical staff and allied health professionals.

Staff worked across health care disciplines and with other agencies when required to care for patients. Ward staff liaised with several different services when co-ordinating a patient’s discharge. This included hospitals, GP’s, community services, and social services.

Feedback from stakeholders was mostly positive. They told us they worked very well together to ensure effective care pathways. This included a good working relationship with consultants who worked at both hospitals and regular meetings maintained strong relationships with management.

Patients told us they received good support from staff and were provided with information around healthier living. Staff told us they routinely discussed health promotion and lifestyle choices with patients. They told us people needing additional support could be referred to other healthcare professionals, such as dietitians.

Staff told us they provided patients with advice on how to refer or gain access to external NHS services, such as for counselling, smoking cessation or alcohol liaison services if required.

The service had relevant information promoting healthy lifestyles and support on the wards, such as posters for urology awareness month in September.

The provider’s admission booklet signposted patients to the NHS website for information and guidance for eating a healthy, balanced diet.

Patients completed a health questionnaire prior to treatment and this was used to identify areas of support. They were provided with relevant health information materials, such as leaflets on smoking or alcohol use.

Patients said they felt listened to and were involved in discussions about their care and treatment. Patients spoke positively about the quality of the care and treatment they received. They reported positive outcomes after surgery such as an improvement in mobility and being able to do daily household tasks. They were pleased with their rate of recovery and said they had been fully informed about the recovery process and what to expect.

Patients told us they did not have to wait long for appointments and had no delays. They told us they had received after care support from consultants and physiotherapists.

The service monitored clinical indicators and performance standards for patient safety, IPC, incidents, patient experience, audits and staffing.

The service had processes in place to monitor outcomes and post-operative infections. They completed audits and surveillance of surgical site infections (SSI’s).

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 national joint registry (NJR) data for 2024/2025 showed that patient outcomes, revision rates and mortality rates for hips and knees at the hospital were within the expected range.

The service had a comprehensive audit programme that included audits for VTE, falls, nutrition, hydration, fasting and NEWS2. The service shared audit results at team meetings and audits had associated action plans to drive improvement.

Patients told us they provided written consent prior to commencing treatment and all the risks and benefits of the treatment were clearly explained to them.

Staff had the appropriate skills and knowledge to seek consent from patients. Staff were clear on how they sought verbal informed consent and written consent before providing care or treatment. The consultants sought consent from patients undergoing surgery during the initial consultation and again on the day of surgery.

Staff told us they had received training in and understood how to obtain informed verbal and written consent from patients before providing care or treatment.

Staff were aware of the legal requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberties Safeguards (DoLS). This was incorporated within safeguarding training. People who could not give consent were not routinely referred to the service for treatment.

Staff clearly recorded consent in the patients records and made sure people consented to treatment based on all the information available. Consent forms showed the risks and benefits were discussed with the patient prior to carrying out a surgical procedure. Records we looked at showed that consent forms had been signed and patients had received a copy.

The provider’s policy for consent to examination or treatment provided guidance to staff on how to obtain consent. Staff told us they also sought advice from managers and the safeguarding lead if they needed support and guidance around consent to care and treatment.