Statement of Purpose


Under the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009, Regulation 12, it is a requirement that all health and social care providers produce a Statement of Purpose, in relation to the hospital’s regulated activities.

The hospital is regulated to provide:-

Treatment of disease, disorder or injury
Surgical procedures
Diagnostic and screening procedures
Family planning services

This statement has been supplied to the Care Quality Commission and is available for inspection by every patient and any person acting on behalf of a patient.

Aims and Objectives

New Victoria Hospital is a registered charity which aims to provide first class independent healthcare to the local community in Kingston upon Thames and the surrounding areas. The objective and commitment of the hospital is to provide safe, effective services across all of the regulated activities, to the highest of standards, in clean, comfortable and well maintained surroundings.

The needs and wishes of our patients remain our priority at all times. It is a fundamental objective of the hospital that patients be treated with compassion, respect and dignity and consideration of their individual needs are central to all service delivery.

Through the utilization of a professional, well trained, effective and motivated workforce we aim to take the hospital forward within a culture of continuous improvement and an environment that supports both corporate and clinical governance.

Private Medical Insurers

The hospital is on the BUPA and AXA PPP Networks and has arrangements with virtually all medical insurers.  Additionally, it is a BUPA Approved Breast Cancer Unit, BUPA Approved Colorectal Cancer Unit and BUPA Approved MRI Unit.

Registered Manager

The registered manager for the purpose of the Act is Mrs Gill Welch, 184, Coombe Lane West, Kingston upon Thames, KT2 7EG who is a Registered Nurse and holds the position of Director of Clinical Services.  

Organisational Structure

Please refer to the Organisational Chart.

Regulated Activities

All regulated activities take place within the premises of New Victoria Hospital at 184, Coombe Lane West, Kingston upon Thames, KT2 7EG.

The hospital is registered with the Care Quality Commission to provide the following regulated activities:-

Treatment of disease, disorder or injury

Both inpatient and outpatient provision is provided for adults and children 16 years and over. Children 16 years and under receive outpatient treatment only. An extensive range of treatment options, including interventional radiological procedures, physiotherapy and pharmacology are provided. Oncology and radiotherapy are not provided. The hospital provides level two critical care in its 2-bed HDU (High Dependency Unit). 

Surgical procedures

Both inpatient and outpatient provision, across the majority of surgical specialities, is provided to both adults and children 3 years and over.

Only very minor surgical procedures, under local anaesthetic, are carried out in the Outpatient Department.  An extensive range of surgical procedures, minor to complex major, are carried out on a day case/inpatient basis and performed under regional block, sedation, local, spinal or general anaesthesia.  Children aged 3 – 15 years inclusive undergo day case procedures only.  Cardiac surgery, major neurosurgery and termination of pregnancy are not provided.

Diagnostic and screening procedures

This service provision is available to both adults and children. A wide range of imaging, including prenatal diagnostic procedures and endoscopic procedures are provided in both outpatient and day case settings.

Family planning

This service is provided to women 16 years and over by Consultant Gynaecologists as part of their consultation/treatment/surgical options and may involve the insertion or removal of intra-uterine devices. There is no designated family planning clinic.

Departmental provision to support the regualted activities

Outpatient Department

The department provides a number of consulting rooms which are rented to consultants for the purpose of carrying out their practice.  In the region of 200 Consultants, across most medical and surgical specialities, use these facilities to see their patients, of all ages, for consultation and advice and in some cases to provide very minor treatment.  The department is fully equipped and staffed by Registered Nurses, operating from 08 00h - 20 00h each weekday and 08 00h - 16 00h each Saturday. 

Within the Outpatient Department the hospital operates a Breast Clinic which endeavours to provide a consultation with a breast surgeon, mammography and/or ultrasound examination and if possible, a diagnosis within two hours. 

A range of nurse led services are available within the department including phlebotomy, urodynamic studies, allergy patch testing and pre admission assessment.

Imaging/X-Ray Department

This department is adjacent to the Outpatient Department and provides imaging services for GP referred patients, outpatients and inpatients – both adult and paediatric.  The facilities include Digital fluoroscopy, Mammography, Ultrasound, CT scanning, and MRI.  A mobile x-ray machine is available for use in the inpatient rooms and operating theatre, along with an Image Intensifier for use in theatre. The department operates from 08 00h – 20 00h each weekday and 08 00h- 16 00h each Saturday. Outside these hours an on-call service is provided for inpatients.

All Radiographers are senior 1 level and registered with the HCPC.  All images are reported on by Consultant Radiologists and reports relayed to the referring clinician within 48 hours.  A range of interventional radiological procedures are performed in the department by Consultant Radiologists.

The Foetal Medicine Clinic provides a full range of prenatal diagnostic procedures and scans, performed by a Consultant in Foetal Medicine or qualified Sonographers.

Physiotherapy Department

The Physiotherapy Department comprises three treatment rooms and a gymnasium and provides predominantly an outpatient service within the department and inpatient services to the wards, which includes an on-call provision out of hours.  Patients can self refer to the department but the majority of referrals are by our Consultants and local GP's. 

General physiotherapy and specialised treatment sessions are available in back/neck pain, muscle/joint problems, women's health (obstetrics/gynaecology), and incontinence, acupuncture, headaches, therapy for hands and sports injuries.

The style of treatment provided is one of a very 'hands on' manual therapy approach with relevant electrotherapy, if required.  The department runs weekly antenatal classes and has a visiting neurological physiotherapy service which utilises the gymnasium three days a week.  The team of staff consists of all Senior Chartered Physiotherapists.  All Physiotherapists are registered with the HCPC and maintain their high standard of practice with regular CPD.

Pharmacy Department

The Pharmacy premises is registered with the General Pharmaceutical Society and licensed with the Home Office under the Misuse of Drugs Act, 1971, in the possession of Schedule 2 Controlled Drugs.

The department offers both an outpatient and inpatient service and is open from 08 30h – 18 30h each weekday and 08.30h – 12 00h each Saturday.  An on-call service is provided outside these hours for inpatients.

The department is staffed by 3 qualified Pharmacists; all registered with the General Pharmaceutical Society and 3 Pharmacy Technicians.  A full range of advice, information and pharmacological treatment options are provided.

Pathology Department

The laboratory is staffed by multi disciplined State Registered Biomedical Scientists and offers analyses in Biochemistry, Haematology, Endocrinology and Immunology. Any work not done on site such as Microbiology is sent to an accredited laboratory in London.  All disciplines are controlled and monitored by extensive quality control programmes both externally and internally and the department is accredited by UKAS and certified with ISO 17025.

The laboratory operates from 08.00h to 20.00h, for both outpatients and inpatients and offers an on-call service outside these hours for inpatients.

The laboratory is committed to the fastest turn around times achieved without compromising the quality of results or ethics. The Biomedical Scientists ensures their procedures are in line with new developments in methodologies and technologies within the industry, in the endeavour to improve internal scope of testing to meet consultant and patient needs.                    

Operating Theatres

The hospital has four operating theatres, three operating theatres and one endoscopy theatre.  The main theatres have a laminar air flow system in place to create an ultra-clean environment for joint replacement surgery. Fully equipped anaesthetic rooms and a 6-bed recovery area are situated within the department, staffed by qualified and fully trained personnel.

Class 4 CO2 lasers are used in the main theatre suite and all requirements for their safe use are met. 

Procedures ranging from minor to complex major are carried out and cover most surgical specialities with the exception of those mentioned above.  All procedures are carried out by Consultant Surgeons, supported by a range of anaesthetic options provided by Consultant Anaesthetists.

Professional staff in theatre are either Registered Nurses or Registered Operating Department Practitioners and are supported by 2 Healthcare Assistants who have achieved either a level 2 or level 3 National Vocational Qualification in Operating Department Practice, together with three porters. 

Robust policies and procedures are in place, reflecting best practice guidance, professional body recommendations and regulatory requirements to ensure patients receive the highest standards of safe practice.

A range of sterile, single use items are provided and decontamination of reusable items is carried out at a fully compliant decontamination unit, within close proximity to the hospital.

Endoscopy Unit

The Endoscopy Unit comprises a reception area, nine trolley bays and an operating theatre which is served from the main operating department.  All scopes are regularly maintained and checked and all sterilising is carried out in house, in accordance with the requirements of Hospital Technical Memorandum 2020.  Regular testing of the endoscope washer is carried out to ensure effective decontamination is maintained.

Patients are given sedation only within the unit and doses reflect the recommendations set out by the Royal College of Anaesthetists. Children aged 3 years and over or any other patient requiring a general anaesthetic have their procedure undertaken in the main operating department.

Procedures carried out in the Endoscopy Unit are gastroscopy, duodenoscopy, bronchoscopy, cystoscopy and colonoscopy, all undertaken by Consultant Clinicians and supported by fully trained theatre and recovery staff.


The hospital has two wards - Alexandra Ward and the Charles Hutton Day Unit.

Alexandra Ward comprises  21 single bedrooms with en-suite bath/shower and toilet facilities, accommodating both inpatient and day-case patients.  Each room is equipped with piped oxygen, nurse call system, including assist and cardiac arrest calls, direct dial telephones, three levels of lighting, satellite television, WiFi and secure facilities for valuables. Within Alexandra Ward there is a 2 bedded High Dependency Unit equipped to care for CCL2 patients.

The Charles Hutton Day Unit comprises 14 bays with shared bath/shower and toilet facilities, accommodating day-case patients.  Each bay is equipped with piped oxygen, nurse call system, including assist and cardiac arrest calls, WiFi, iPads and valuables storage.  

Nursing staff on the wards are fully trained and qualified to care for patients compassionately, in a multi speciality environment. Robust Clinical Governance processes underpin their practice which is monitored, reviewed and evaluated on an ongoing basis.

Nursing staff are required to deliver high quality care to patients, within a prescribed model, to ensure standardised practise with an emphasis on assessing the patient’s individual needs and wishes. Continuity of care is assured through the established Named Nurse process whereby our nurses aim to have a therapeutic effect on their patient’s recovery. Best practice guidelines, professional body recommendations and regulatory requirements underpin the prescribed care and supports the care pathway followed. 

Pre registration nursing/midwifery students are seconded to the hospital where they are supervised and supported in their learning needs. 

Nursing staff are trained to deal with medical emergency situations and a significant proportion of them are qualified to care for patients who require high dependency nursing up to a level 2 critical care classification.  It is the policy of the hospital, however, to transfer patients, once stabilised, to a dedicated critical care unit, if such care is required. Formal transfer arrangements are in place for both adult and paediatric patients.

Staff are trained in all available equipment which is maintained, serviced and calibrated on a regular basis. 


Ensuring patients have access to their friends and relatives, as much as they wish whilst in hospital, is seen as essential for their well being.

Visitors are therefore welcomed at all times, from 09.00h – 22 00h, dependent on the patient’s condition and wishes.  Additionally, there is a direct dial telephone in each patient’s room and assistance is provided for those patients unable to make contact with their friends and relatives independently, as required. There is wireless internet connection within each patient room to enable e-mail contact with family and friends. All visitors are welcome to have free beverages and may purchase food if they wish to eat with their friend / relative. 

Governance processes to support the regualted activities

The hospital is accredited for the quality of its services with CHKS Healthcare Accreditation and Quality Unit and is certified ISO 9001:2008. In addition the hospital is certified ISO27001, Information Security Management System with the British Assessment Bureau.


The hospital has 170 employees, although a significant number are part time which produces a whole time equivalent number of 140.  All professional staff hold the appropriate qualifications and skills necessary to carry out their duties and robust recruitment procedures ensure only staff with exemplary professional and personal backgrounds are employed.

Nursing staff and other non medical healthcare professionals are all registered with the Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC), as appropriate and all staff undergo a period of orientation and if necessary, clinical supervision during the initial period of their employment or ongoing, as required.  Staff training is recorded and every member of staff partakes in an ongoing process of individual performance review with their line manager, to ensure they are fully up to date and practicing to the required high standards.

The hospital provides facilities to Consultant medical or dental practitioners who hold, or have held at retirement, substantive Consultant posts within the NHS.  These Consultants, to whom practising privileges are extended, are required to comply with the hospital policies and procedures and regulatory requirements, including: regular proof of registration and licensing with the GMC, evidence of annual whole practice appraisal and are subject to ongoing Clinical Governance monitoring to ensure they fulfil fitness to practice criteria.

Staff Training and development

In-house and external training is provided and supported in order to facilitate each employee’s training requirements and Continual Professional Development (CPD).  Clinical staff receive mandatory training in resuscitation - adult and paediatric, infection control, safeguarding children and vulnerable adults, blood transfusion management, blood glucose monitoring, data protection, customer care, equality and diversity, handling complaints and Health and Safety including risk assessment, Control of Substances Hazardous to Health (COSHH), fire and manual handling. Non mandatory training relevant to the individual and organisational needs is provided and supported, as appropriate.

Clinical governance

The hospital is committed to the delivery of safe, effective care and services.

Throughout the organisation and in relation to all regulated activities, robust Clinical Governance processes monitor, review and evaluate all clinical practice, incidents, accidents, complaints and adverse outcomes. 

Risk assessments are carried out throughout the organisation and are continually under review. Controls are put in place to minimise all identified risks and reviewed for their effectiveness against any incident, accident or adverse event.

Key performance indicator data is collected and reviewed on an ongoing process. All activity and adverse outcome data are collated for each Consultant user and this is reviewed quarterly by the Medical Advisory Committee and provided annually to each Consultant for evidence of their continuing fitness to practice.

Equality and diversity

Access to the hospital services is clinically based and non discriminatory to any group of individuals. All services are at ground level and accessible to all, with each entry point manned to provide help and assistance if required.

Patient’s individual needs form the basis of the care provided and their involvement is central to the planning and delivery of all care and treatment. Where support is needed to maintain the patient’s independence, facilitate their understanding of the proposed care/intervention or provide spiritual or group support, provision is made by way of disability aids, interpreters or contact to the relevant religious representative or support group.

Privacy and dignity

It is essential that patients undergoing care/treatment at New Victoria Hospital are treated with compassion, dignity and respect.  This is central to the high standards of care expected and an essential component of how our services are delivered.

Staff are required to address patients at all times in a respectful way and be mindful of their personal dignity by ensuring that they do not talk carelessly in front of others or attend to personal matters without ensuring that complete privacy is being maintained. 

Suitable clothing is provided to patients going for diagnostic tests or surgery, to preserve their dignity as much as possible.  All inpatients are cared for in private rooms with en suite facilities and therefore their privacy is assured as much as possible. Patients in the endoscopy unit, although in trolley bays, have their privacy maintained as much as possible with the use of curtains.

Patient information

The provision of information is considered of paramount importance at every stage of the patient journey to support each individual’s decision making and is central to the consent process. Before patients can decide about treatment/investigations, they are provided with comprehensive information about their condition, the possible treatment options and the risks and benefits of that treatment. An extensive range of booklets and information sheets are available and as much information as possible is provided in the outpatient setting and prior to admission.

At discharge, written follow up advice is provided and contact details of the hospital supplied should the patient require support or assistance in the first few days following discharge.

Patient feedback

Patient feedback is actively sought and their views on the service provision influence service delivery. All inpatients and day-cases are handed a satisfaction questionnaire on arrival and invited to comment on their experience of the service. Outpatient departments seek feedback periodically. All completed questionnaires are forwarded to an external service provider for collation and any feedback requiring follow up action is flagged to the Quality Manager for investigation and remedial action, if required. A report is produced quarterly analysing the results and this is reproduced on the hospital’s website. 

Patient complaints

The hospital prides itself on providing patients with the best available hospital care. However, if we fail to meet expectations we recognise that complaints provide an opportunity to examine the hospital services and ensure a culture of continuous quality improvement.

The hospital is a member of the Independent Sector Complaints Adjudication Service and as such complies with the Independent Sector’s Code of Practice and the Independent External Adjudication scheme. The Code of Practice is designed to effectively manage, respond to and resolve complaints.

Booklets, providing an overview of the hospitals Code of Practice and procedure for making a complaint, are displayed in reception areas and patient rooms. The booklet includes the name and address of the Care Quality Commission and the Independent Healthcare Advisory Services. 

The Code of Practice is reproduced in full for any patient or their representative, as and when requested.

Patient consultation

The nature of the hospital, being an acute predominantly surgical unit, means that virtually all patients are admitted for elective surgery for which the average length of stay is as low as 1.36 days.  It is therefore impractical and illogical to create any formal arrangements for patient consultation such as may be found in a large NHS unit.  The principle method of obtaining patient feedback is by the patient satisfaction questionnaires and of course, from frequent personal contact of the staff who are looking after them.