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

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from abuse and avoidable harm.

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 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.

OPD staff knew what incidents to report and how to report them. They adhered to NHS England’s Patient Safety Incident Response Framework (PSIRF). We reviewed reported incidents and themes within OPD. We identified no significant or recurring concerns. The only issues noted were isolated areas of suspected wound infection and occasional delays in clinic start times due to consultants running late. Leads took appropriate actions in response to safety incidents.

OPD staff had a good reporting culture where they felt safe and encouraged to report incidents, concerns, near misses, and feedback. The service had reported 123 incidents on the provider’s incident reporting system in the 12 months from January to December 2025. Of these, 15 were classified as low, non-permanent harm, three as ‘near misses’ and the rest as ‘no harm’. The month with the most reported OPD incidents was September 2025 with 17.

Staff responded to incidents and events appropriately. They could evidence learning and actions taken to prevent future recurrence. We reviewed a patient safety incident involving respiratory complications in February 2025. This included an After-Action Review (AAR) report with improvement plans around communication and better allergy alerts and identification.

Staff received feedback from incident investigations, both internal and external to the service. We also heard an example of a patient safety incident involving an outpatient cancellation. This was caused by a failure to refer a patient for an anaesthetic review. Leads reviewed this in line with PSIRF principles using a proportionate AAR. All staff directly involved in the pathway participated in the AAR. There was evidence changes had been made after feedback. They identified key learning points around referral triggers, clarity of responsibility, and communication between teams. Staff agreed actions to prevent recurrence.

Separately, this patient’s feedback regarding their care prompted a case-based reflection. This considered both clinical and communication aspects of the outpatient pathway. The reflection reinforced the importance of timely escalation, clear explanations to patients, and shared decision-making. Managers debriefed and supported staff after severe or distressing incidents. Leads shared this learning with the wider team to support improvement.

Staff raised concerns and reported incidents and near misses in line with the service’s policy. OPD staff understood and adhered to the provider’s duty of candour (DoC) and being open policy. They were open and transparent when things went wrong. We reviewed apology letters to patients informing and involving them in learning reviews. The department displayed relevant DoC posters to prompt staff and patients with key points to remember.

OPD staff heard about patient safety updates from NHS England’s national patient safety team. Key messages were shared, for example around progress implementing Martha’s Rule.

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 worked to improve pathways and continuity of care for outpatients. Nursing staff clearly understood and outlined the outpatient’s pathway. They completed and reviewed a health questionnaire in full with patients. All criteria was addressed such as risk of falls, venous thromboembolism (VTE), pressure area care, moving and handling, and smoking and alcohol intake. The service audited these questionnaires and found 100% were completed in the last quarter of 2025.

Patient notes were comprehensive, and all OPD staff could access them easily. Nursing and clinical staff used an electronic patient records (EPR) system they told us was user friendly.

All outpatient medical records were electronic and always available for clinics. In the rare event they were not, staff reported the lack of available records as patient safety incidents through the incident system. Leads reviewed these under PSIRF.

Records were stored securely. We reviewed six sets of outpatient medical records these were all completed comprehensively. All patients were prompted to inform staff if their details had changed so they could update their medical records.

Staff used the provider’s secure online healthcare portal to access and update patient notes. This was purpose-built so patients could view and manage upcoming appointments, update personal and medical details, and access files and important documents anytime.

OPD leads ensured service sustainability and business continuity. This was done through proactive workforce planning, flexible clinic models, risk-based oversight, and active engagement with finance and operational teams. They managed lost contracts, such as endoscopy or colonoscopy, by redistributing activity, prioritising patients, and using contingency measures. An example was their flexible cystoscopy lists shortly before our assessment.

Outpatient services accepted patients based on clinical appropriateness. Staff followed the NHS pre-assessment policy as per guidelines. Their admission, inclusion, and exclusion criteria were clearly defined. It was in alignment with the hospital’s latest statement of purpose and the NHS e-Referral Service (eRS) Directory of Services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

OPD staff received and kept up to date with training specific for their role on how to recognise and report abuse. Registered nursing staff were safeguarding trained to level 3 for adults and level 2 for children. Support workers were trained to level 2 for both adults and children. The Head of OPD was trained on Safeguarding Adults and Children level 3 through the provider’s learning pool.

During our assessment, OPD compliance for all safeguarding level 1 and 2 modules for adults and children were above 90%. This meant OPD staff overall were equipped with the required knowledge and skills to identify, respond to, and escalate safeguarding concerns appropriately.

However, safeguarding adults level 3 training compliance for the hospital’s registered clinical staff was 86.8%. This did not meet the provider target of 90%.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They had contact details for local authority safeguarding teams.

We saw examples of complaint response letters to outpatients where staff had recorded events as potential safeguarding incidents. This ensured they maintained the relevant governance to maintain a safe environment for patients.

Hospital and OPD leads were committed to ensuring all staff were thoroughly trained in identifying risks to patient safety. Staff covered female genital mutilation (FGM) guidelines as part of their safeguarding training.

All eligible OPD employees were compliant with disclosure and barring service (DBS) checks. They held a valid DBS check appropriate to their role and level of patient contact.

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. All staff we asked knew the procedure if someone collapsed or suffered a cardiac arrest. They would start life support then call 999. Relevant staff were trained to use live-saving equipment. OPD had their own tagged resuscitation trolley located in the department. We reviewed staff’s daily trolley checklists and contents. Nurses also completed monthly checks. They highlighted expiry dates or drugs and ordered new stock when needed. All stock was in-date and ready for use. No equipment or dates had been missed.

Staff knew about and dealt with any specific risk issues. They individually assessed all patients to ensure a safe and appropriate clinical environment. Nursing and support staff completed appropriate risk assessments for patients.

OPD teams received essential learning, for example around sepsis. During our assessment hospital staff’s overall training compliance in the sepsis two yearly module was above 90%. This met the provider target. The clinical educator visited the department to offer learning sessions on several occasions. These entailed updates on sepsis awareness and best practices. Staff also received guidance on their screening tool to identify and respond to potential cases. These visits ensured OPD staff were fully informed and confident in recognising and managing sepsis.

All staff understood the department’s eligibility criteria. They would confirm any discrepancies with their managers. Nursing staff clearly confirmed any exclusion criteria with patients to filter out avoidable risks such as sleep apnoea, or body mass index (BMI) with or without comorbidities.

Staff routinely updated risk assessments, and reviewed incidents through hospital governance meetings. Hospital and service leads were reviewing how they could implement Martha’s Rule after recent similar incidents involving surgery. This is a patient safety initiative in England that gives patients and their families the right to a rapid, independent review by a critical care team. This aims to prevent missed opportunities to treat patients who are deteriorating.

Shift changes and handovers included all relevant key information to keep patients safe.

However, we heard GPs occasionally referred patients unsuitable for treatment.

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. The hospital had clear signage and directions to the outpatient’s department. This meant all visiting and first-time patients knew where to arrive and park. We heard from ‘you said, we did’ feedback this resulted in fewer late arrivals and reduced stress.

Staff ensured the department was a safe environment by controlling potential risks and taking several measures. For example, all clinic doors were digi-locked, which only staff could access. Toilets had pull cords and assistance buttons accessible to people with mobility issues. Electrical equipment such as echocardiogram (ECG) machines had been safety checked within the last year.

Staff knew fire procedures and how to direct patients and other visitors to safely exit the premises. Fire safety equipment was tested, in-date and located near the fire doors and alarm system. All staff undertook e-learning and face to face fire safety training annually. Fire drill scenarios were completed bi-annually to ensure compliance with the fire safety processes. We reviewed the last three scenarios and latest fire incident. Staff carried out all evacuation procedures as per policy.

The service had enough suitable equipment to help staff safely care for people. A first aid kit and eye wash station was positioned centrally in the department. These were tagged with a list of trained first aiders.

Staff carried out regular safety checks of specialist OPD equipment. OPD teams maintained a centralised inventory of essential equipment such as ECG machines, defibrillators and urology machines. When a plaster of paris cast saw failed to function appropriately, staff contacted the medical supplies contractor. They issued a replacement head and raised a purchase order for a new head. Staff also completed maintenance schedules to ensure equipment was functional and ready for use.

Porters disposed of clinical waste promptly and safely. Bins were locked and not overfilled. OPD support staff undertook monthly sharp bin audits. We reviewed these last three audits from October to December 2025. November’s results showed consultants left a couple of bins full and unchanged with the lid unshut. The IPC lead took immediate actions to address areas for improvement.

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 nursing and support staff to keep outpatients safe. We reviewed staff rosters for the three months preceding our assessment (October–December 2025) and found that all shifts were fully staffed. This meant the number of nurses and HCAs matched those planned.

The manager could adjust staffing levels daily according to patient needs. They used a staffing tool which gave them an overview of safe staffing levels. Leads usually planned staffing six weeks in advance. They reviewed and amended rotas as required in response to changes in activity, demand, or staffing availability. Rotas were based on an agreed, standard clinic timetable.

Staff could take time off in lieu (TOIL) when clinics finished early and all housekeeping duties were complete. This supported their morale and wellbeing. Staff could accrue TOIL when supporting service pressures. This provided extra flexibility while maintaining safe staffing levels.

Managers gave all new staff a full induction tailored to their role and completed a checklist before they started work. OPD leads gave all new starters corporate induction and employee handbooks.

The service had a low vacancy and turnover rate. Managers could access extra nursing and support staff. OPD had a pool of bank staff who managers could contact when they needed extra cover. Bank staff we spoke to were offered regular shifts. They knew the consultants in clinic well and had good working relations.

However, bank and OT usage by hours had increased in September 2025. This was up 14.72 hours overall compared to August due to increased staff sickness. The department did not use any agency staff.

Staff received and completed training specific to their role, including bank staff. OPD staff completed mandatory e-learning annually. Staff we asked had completed all their mandatory and refresher training. Outpatients mandatory training compliance in September 2025 was 90.8%. Staff compliance was high across all modules. For example, 96.6% of hospital staff had completed the statutory Oliver McGowan training on learning disability and autism. This met the provider target.

However, five staff members and one bank staff new starter were below the 90% provider trust target compliance. Leads monitored staff training records. They alerted staff when they needed to update their training.

Staff told us their mandatory training was comprehensive and met the needs of patients and staff. The advanced life support (ALS) trained clinical educator provided in-house training. OPD staff commended them and were well supported.

All eligible staff were booked onto or had completed the face-to-face intermediate life support (ILS) module. We heard ILS training content had significantly improved since the clinical educator’s bespoke involvement. Staff told us this module was now more relevant and beneficial to their role. The clinical educator worked hard to line up appropriate training. They had good educational links with the local acute trust to orientate training opportunities.

Staff had opportunities for further training and upskilling. For example, plaster of Paris cast removal training was scheduled for six OPD team members in January 2026. This was in response to an identified risk which was on the service’s risk register. Lower limb surgeons would remove outpatients’ plaster casts until these staff were competent. Staff nurses had attended relevant courses when their roles were extended. For example, in venepuncture.

Staff had opportunities for cross-learning in-house from the provider’s other services. For example, in meeting the need of people with dementia. Staff had varied experience from different background settings. Staff could access and complete NHS modules from e-learning for healthcare (eLFH) as part of their learning pool. During our assessment, the provider’s head of nursing was reviewing all staff’s clinical competencies in development.

The provider was adopting a blended learning approach. This was in response to learning and development staff survey feedback. Trainers helped roll this out across all staff groups. This meant many sessions combined e-learning, online webinars and face to face practical training.

However, the department had no formal competency suite of skills. Lower grade staff had a lack of training or development opportunities. Managers repeatedly refused their continuous professional development (CPD) requests at appraisal over several years. This sometimes put their working conditions at risk of being unsafe. For example, if staff were not given sufficient background medical information to always keep patients safe.

Managers supported all staff to develop through yearly appraisals of their work. We saw appraisal compliance was 11 out of 14 for September 2025. Nursing leads had booked all eligible clinical supervision in August and September 2025. Leads maintained a spreadsheet of all staff’s qualifications and record of learning certificates to ensure they were competent.

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.

Clinical areas were clean, tidy and uncluttered with suitable and well-maintained furnishings.

The service had an infection prevention control (IPC) lead for the hospital. They kept up to date with latest infection rates and related issues, whilst undertaking audits.

However, the lead felt they were not given enough protected hours to fulfil IPC responsibilities.

Cleaning records were up to date and proved all areas were cleaned regularly. Staff completed daily and weekly cleaning rotas which allocated specific equipment. They cleaned rooms after clinics ended, and in-between patients when needed. We saw four- and five-star cleanliness ratings in OPD areas with expiry dates. The service’s cleaning summary and tasks with their commitment to cleanliness was displayed. All disposable curtains were in date.

Staff carried out enhanced cleaning protocols within OPD treatment rooms. Staff documented and monitored all cleaning activities to ensure compliance with healthcare hygiene standards.

OPD staff participated in November 2025’s global antimicrobial stewardship (AMS) week as part of their (North East and Yorkshire) regional AMS. Antibiotic guardian quiz sheets, drug-resistant infections and penicillin allergy factsheets were laid out in waiting areas.

Staff had access to sufficient and suitable protective personal equipment (PPE). They followed infection control principles including the use of PPE. We observed OPD nurses and support staff donning and doffing suitable PPE for any patient treatment. They cleaned their hands between patients and all episodes of care. Staff used available hand gel dispensers along the central corridor and throughout the department.

Staff cleaned equipment after patient contact. They labelled equipment to show when it was last cleaned.

We saw cleaning materials and documents met control of substances hazardous to health (COSHH) regulations. These UK regulations are designed to protect workers from health risks associated with hazardous substances. They were stored safely and securely in a locked cabinet.

However, during our assessment ODP had a lack of housekeeping. We did not see any housekeeping staff cleaning or present in the department during our two-day assessment. This was an identified moderate risk on the service’s risk register with controls in place. For example, in September 2025 the IPC lead and OPD manager discussed and agreed to increase the frequency of audit cleanliness until the issue was resolved. Meanwhile OPD staff completed daily deep cleans between them.

The service ensured medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed systems and processes to prescribe and administer medicines safely.

Staff reviewed each patient’s medicines regularly. They provided advice to patients and carers about their medicines. OPD staff could access a pharmacist onsite daily. The pharmacist recorded morning and afternoon ambient room temperature checks, and daily fridge checks for medicines throughout the department. They reported any issues to the estates and facilities manager.

Staff completed medicine records accurately and kept them up to date. OPD nurses inputted all patient’s medicine details onto a secure system.

Staff checked patients had the correct medicines early in their pathway, and when they moved between services.

Staff stored and managed all medicines and prescribing documents safely. We checked the medicines cabinet and several medicines. All were appropriately stored and in date. The pharmacist made daily rounds and kept the cabinet well stocked. They never had delays obtaining medicines. The door listed all medicines and their expiry dates for staff’s easy reference.

The department stored no controlled drugs.

However, the hospital’s clinical staff training compliance for medical gases training was 75.5%. This did not meet provider target and was the lowest compliance of any module.