St Hugh's Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had a good learning culture and information was shared across all departments and staff. People were protected and staff understood how to safeguard people. Staff could raise concerns and were listened to. Learning was shared throughout the organisation and across the wider hospital group.

The facilities and equipment were clean, well-maintained and met the needs of people. There were enough staff with the right skills, qualifications, and experience. Staff had appraisals and could access training. This enabled them to meet the ongoing requirements of their patient group

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Any incidents staff raised were reviewed at the patient safety group and the hospital’s weekly Patient Safety Incident Review Group (PSIRG). We observed the patient safety group whilst onsite. This enabled a multidisciplinary staff approach to patient safety.

Staff knew which incidents to report, and how to report them.

Staff could follow up any incidents on the hospital’s electronic risk reporting system. They received feedback and updates on incidents they had reported.

Managers shared incidents with staff at team meetings. We reviewed team meeting minutes. These showed incidents had been recorded and discussed. The minutes documented how lessons learnt had resulted in improvements being made.

We saw evidence staff adhered to the duty of candour. For example, when a wrong site image had been taken, they explained what happened to the patient and apologised.

The service with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had a clear referral process and system. Administration staff specifically aligned to the area monitored all referrals electronically.

The hospital used the NHS’ Picture Archiving and Communication System (PACS). Staff could access diagnostic images from patients’ NHS records and share images generated at the hospital. This meant they could provide continuity of care for patients. There was a pathway of alerting to ensure images were reported on promptly, and they could seek an urgent image review where required through their local NHS partners

The service lead attended the daily multidisciplinary team (MDT) daily safety huddles. At huddles staff discussed serious incidents, equipment issues, patient risk, safeguarding, discharges, and staffing levels. The hospital followed the Patient Safety Incident Review Framework (PSIRF ) principles. Leads identified individual and thematic incidents for review.

The service work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had in-date safeguarding adults and children’s policies and procedures in place. The policies outlined the objectives, explained abuse-related terminology, identified training requirements, duties, roles and responsibilities of staff. The hospital’s safeguarding lead was available for diagnostics staff. The on-call management team could also advise on safeguarding concerns.

Staff knew how to identify and report any safeguarding concerns as per provider policy. This included raising referrals to external agencies, such as the local authority safeguarding team. The department undertook gynaecological scans. Staff knew how to identify and report female genital mutilation (FGM).

Clinical staff were trained in safeguarding adults levels 2 and 3. 90% of staff were trained in safeguarding children level 2. This met the provider target.

However, safeguarding adults level 3 training was 81%. This did not meet the provider trust’s 90% target, however the education lead had oversight and reminded staff who had not completed to book onto a training session.

This training included the Mental Capacity Act and Deprivation of Liberty Safeguards. The hospital’s safeguarding lead and head of clinical services as well as hospital director were both trained to safeguarding level 4. One of them was always available for staff to raise concerns.

No staff had needed to make a safeguarding referral in the 12 months before our assessment. However, we heard about shared learning from safeguarding notifications across the provider group.

The service work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff responded promptly to any sudden deterioration in a patient’s health. They had completed training in recognising the deteriorating patient. This meant they understood how to manage people’s risks during an emergency. Staff had access to the Resident Medical Officer. They could be called and transfer patients to the local NHS hospital if required. We heard examples where staff had managed an unwell patient and followed the local protocol. Resuscitation trolleys were checked daily, and all items were in date.

We observed radiology teams undertaking procedures using the Local Safety Standards for Invasive Procedures (LocSSIP) guidelines. Staff understood the risks of radiation exposure, and this was included in their pre-procedure checks.

The service had pause and check procedures in place which leads audited. This was a critical safety protocol designed to ensure correct patient identification and compliance.

The service detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care

The design of the environment followed national guidance. Service facilities included fixed x-ray-controlled areas. A controlled area was in each x-ray facility or room, and a mobile x-ray was available for use. Staff carried out general radiography procedures within this department, such as x-rays.

The service also carried out ultrasounds and contrast imaging.

All service environments and waiting areas were clean, tidy, safe and well maintained.

Staff carried out safety checks of specialist equipment. Equipment met the quality assurance standards required by the Ionising Radiation Medical Exposure Regulations (IR(ME)R) regulations. Staff had their own personal dosimeters, and all personal protective equipment (PPE) was serviced and readily available to staff.

We saw risk of radiation exposure notices throughout the department.

Clinical waste was disposed of correctly.

The service managed referrals for magnetic resonance imaging (MRI) scans. This mobile unit was onsite twice a month and was provided by an external company.

The service made sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough radiography and support staff to keep patients safe. Consultant radiologists were employed by the local NHS Trust. We reviewed a sample of practicing privileges which met the required employment checks. The service always had access to a consultant radiologist for advice. This meant patients could have timely interventions.

The manager could adjust staffing levels daily according to patient needs. The diagnostic manager reviewed the planned activity through the hospital scheduling meeting. They ensured the department had appropriately trained staff.

Most mandatory training met the provider’s target compliance. Only a few subject areas were below this target. The diagnostics manager and head of training monitored mandatory training. They ensured non-compliant staff booked onto the next available training dates.

Staff told us their mandatory training was comprehensive. This met the needs of patients and staff.

All staff received and completed training specific to their role, including bank staff. For example, they had received and documented training on equipment used in the department. Staff received annual appraisals and could access the appropriate professional development identified, and only one staff member’s appraisal was overdue, they also had team meetings and 1:1s with the manager.

Managers gave all new staff a full induction tailored to their role before they started work. All staff had completed an induction programme

The service assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The waiting areas and furnishings were visibly clean, suitable and well-maintained. Chairs were fabric, visibly clean and were steam cleaned by the housekeeping team.

We saw cleaning audits were completed.

Cleaning records were up to date and proved all areas were cleaned regularly. Equipment had ‘I am clean’ tags were attached.

Staff followed infection control principles, including the use of protective personal equipment (PPE). Staff were bare below the elbows and washed their hands between any care and treatment episodes.

Cleaning materials and documents met Control of Substances Hazardous to Human Health (COSHH) regulations and were stored correctly.

Spillage kits were in date and decontamination procedures were in place

The service made sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff stored and managed all medicines and prescribing documents safely. We saw they were in date and stored correctly.

Temperatures were recorded daily in areas where medicines were stored and the readings consistently remained in line with the required guidance.