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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good.

Good: This meant people were safe and protected from avoidable harm.

We rated Safe as Good. The environment was clean and equipment was well maintained and was safe for use and that staff were trained to use equipment.

Medicines and medical gases were managed and stored correctly

Staff had received safeguarding training and staff we spoke to knew how to raise concerns and those we spoke to knew who the Freedom to Speak up Guardian was.

Staff described a culture where they could raise concerns, and they learnt lessons from incidents.

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.

Patients told us they felt safe and did not have any concerns.

Staff identified, reported and managed incidents in line with the provider’s incident reporting policy. Staff told us they were encouraged to raise concerns and could easily access the electronic incident reporting system.

Managers shared incidents with staff at team meetings. We reviewed theatre and ward team meeting minutes, which showed incidents had been recorded and discussed. The minutes documented how lessons learnt had resulted in improvements being made, the ward team had reviewed fall data and introduced a “call don’t fall” poster in each room to prevent falls.

Staff had reported one never event at the hospital in the 12 months before our assessment. A never event is a serious, wholly preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers. The service reported this appropriately to the CQC and completed a duty of candour with those involved. Leads had undertaken an investigation which identified key actions with theatre staff.

Senior leaders told us they had a positive reporting culture. This was corroborated by staff we spoke with during the assessment. We observed the multidisciplinary patient safety group discussing incidents and concerns. The hospital adhered to NHS England’s Patient Safety Incident Response Framework (PSIRF). Staff reported a high number of patient safety events to evidence Learning from Patient Safety Events (LFPSE) platform. This is a national system where patient safety concerns are reported.

Staff completed incident records appropriately and put actions in place to aid learning and improvement. Lessons learned and shared from safety incidents resulted in changes which improved care for others.

Staff followed the provider’s duty of candour policy for any incidents rated moderate harm and above. The duty of candour is a regulatory duty requiring openness and transparency with patients if their treatment causes or has the potential to cause harm or distress. Senior staff had received training in duty of candour and could describe how this had been used.

The service work 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’s referral and admission processes ensured all essential information about the patient was received. This helped staff determine if the patient’s needs could safely be met.

Patients were low risk and their needs could be met by the healthcare provider.

The pre-screening of surgical patients in the outpatients department ensured patients were referred elsewhere if they required more complex care. Please see our outpatient’s report section for further details.

The service had daily safety huddles which included the head of clinical services. The team discussed serious incidents, equipment issues, patient risk, safeguarding, discharges and staffing levels.

The hospital’s leadership team worked in collaboration with the local health board, its members and the integrated care board (ICB).

The system for transferring patients was efficient. The service had supported the local trust’s elective activity. During our assessment, most hospital surgery for hips and knees was provided for NHS patients.

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.

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 hospital’s latest compliance for all safeguarding level 1 and 2 modules for adults and children was above 90%. This meant surgery 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 understood how and when to make a safeguarding referral or alert and who to inform if they had concerns. They knew how to contact and access support from their provider and local authority safeguarding teams. The provider’s safeguarding policy instructed staff how to identify and report any safeguarding concerns. The staff we asked were aware of the provider’s safeguarding policy and how to escalate concerns.

Hospital and service 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 staff 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 head of clinical services was the safeguarding lead. They had completed level 4 safeguarding training for children and adults. The safeguarding lead gave examples where they had consulted on safeguarding concerns. Staff knew how to access them for support and advice.

The safeguarding lead worked with the local safeguarding board and integrated care board. They also had access to the local mental health trust and acute trust where they could seek advice.

All staff were trained to the appropriate level in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

Description: We 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.

3. 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 understood how to manage people’s risks during an emergency. All used the National Early Warning Score (NEWS) following surgery. We observed staff carrying out routine observations during and following treatment.

The service had exclusion criteria which identified people with complex needs who could not be admitted for treatment. The hospital had relevant policies and service level agreements in place. This included an agreement with the nearest NHS hospitals for emergency blood supplies and the transfer of deteriorating patients.

The hospital had an advanced life support-trained Resident Medical Officer onsite 24 hours a day. They were well supported within the hospital by the senior management team.

All eligible hospital staff had completed advanced life support (ALS). 94% had intermediate life support (ILS) or were booked onto the course.

However, only 68% of eligible staff had completed basic life support (BLS) training. This was below the provider’s target compliance, however the education lead had oversight of training and sessions were planned and staff reminded to book on places. This meant we could not ensure all staff knew how to respond appropriately to medical emergencies or in the event patients deteriorated.

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. For example, the theatre environment imaging equipment met the IR(ME)R guidance. Specialist equipment for theatres was checked and serviced.

The facilities department ensured the building was maintained. Leaders had a planned improvement programme to improve the theatre doors over the planned closure period.

The department was a safe environment as staff controlled potential risks and undertook protocol measures. Ward and theatre environments were clean and tidy; equipment had been checked and serviced. We saw evidence that health and safety checks, including legionella were in place and completed as per the hospital policy.

There was a service level agreement for sterilising services, and staff ensured that equipment was available for theatre lists. Orthopaedic equipment had been replaced following a successful business case.

The service make 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.

3. 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.

Patients told us there were enough staff during and after their procedures and they provided safe care and treatment. They spoke positively about how staff communicated and interacted with them. Staff responded quickly when patients requested assistance.

We saw staff were available throughout the day to respond to patients promptly.

We observed staff’s positive interactions with patients and worked with the multidisciplinary team to deliver patient care. All staff engagement we observed onsite was positive, friendly and encouraging.

The service had enough medical staff to keep patients safe. Surgical procedures were carried out by a team of consultant surgeons and anaesthetists. Most were employed by other organisations (usually in the NHS) in substantive posts and had practising privileges at St Hughs Hospital. The process for review of practising privileges ensured consultants were practicing within their scope.

Staff received and completed training specific to their role, including bank staff. They completed mandatory e-learning annually. Staff we asked had completed all their mandatory and refresher training.

The provider trust’s target for mandatory training was 90% and they had a training needs analysis in place.

Managers provided staff with clinical supervision (meetings to discuss care management, to reflect on and learn from practice, and for personal support and professional development). They had an appraisal of their work performance where they could identify learning and development requirements. We saw evidence of reflections of staff for their revalidation of registration.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the patient group. Staff received annual appraisals and the service monitored compliance. Managers ensured staff had access to regular team meetings.

Managers told us how they had dealt with poor staff performance promptly and effectively.

The service recorded and monitored when doctors and consultants working under practicing privileges had completed appraisals with their own organisations (usually an NHS trust).

The provider’s recruitment policy outlined the recruitment and fit and proper person checks. These were carried out for new staff, including bank staff. We reviewed 10 staff recruitment files. Managers had carried out appropriate recruitment and pre-employment checks. Staff recruitment files showed appropriate recruitment and pre-employment checks had been carried out. Staff’s disclosure and barring service (DBS) checks were renewed every three years as per policy. Human resources monitored DBS checks with a tracker to alert them when registration or DBS required a renewal.

The service had a consistent workforce in place with minimal turnover and sickness.

The ward operated a 1:6 nurse to patient ratio although they said this was usually a lower patient ratio. Shifts could be flexed to meet the service needs, and they had introduced a twilight shift which gave additional cover for patients recovering from theatre.

The service had improved mandatory training compliance since our last inspection. A dedicated education lead delivered onsite training opportunities for staff. Managers monitored all, modules which did not meet the provider trust’s 90% target compliance.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. The hospital had a dedicated education lead in-house. Staff were very complimentary about the bespoke training provided to them. The lead worked with the local trust which enabled training to be shared. They had recently held a joint conference on sepsis management and received positive staff feedback.

Managers provided new staff with appropriate induction (using the care certificate standards as the benchmark for healthcare assistants). All staff, including bank and agency staff received a full induction tailored to their role before they started work. We saw the completed induction checklists in the files we reviewed.

Medical staff practiced under the practicing privileges policy and there was a tracker in place to ensure they had all employment requirements. We reviewed 10 medical staff files whilst on site. Medical staff had appraisals at their primary employing trust, and the sign off would review their compliance with mandatory training. However, this was not transferred onto a database and we could not locate a comprehensive list of all their necessary training records to be signed off. The hospital requested these whilst we were on site and planned to review the recording system.

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.

All ward areas were clean, had required furnishings and were well-maintained. Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Patients told us the premises and equipment were visibly clean and tidy. They had no concerns relating to environmental cleanliness.

All staff had received training in infection prevention and control (IPC) and hand hygiene. They followed the provider’s IPC policies. These guided staff on processes and practices such as hand hygiene, cleaning of the perioperative environment and isolating patients with known or suspected infections.

Cleaning records were up to date and demonstrated ward areas were cleaned regularly. The service’s cleaning audits were held centrally. An accreditation scheme was in place. Clinical areas met the maximum star rating for cleanliness.

The service had an experienced IPC lead who oversaw infection control processes and provided support and training for staff. They monitored surgical site infections, antimicrobial prescribing and the infection control audits.

The hospital had a service level agreement with microbiology at the local NHS trust and followed their protocols.

All ward and theatre areas were visibly clean and had suitable, well-maintained furnishings. For example, fabric chairs in the waiting area were steam cleaned. Clean linen was appropriately stored and segregated in dedicated storage areas. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and decontaminating equipment.

Patients were cared for in individual rooms and had ensuite bathrooms. There was a seated bay with reclining chairs for patients who were fit to sit following surgery, this had a bathroom area within it.

Staff screened patients for infections such as Methicillin-resistant Staphylococcus Aureus (MRSA). The service had isolation rooms to support the management of cross infection risks. Leaders had reported no cases of MRSA in the 12 months before our assessment.

We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care.

Staff could access enough handwash basins and hand gels. Patients and visitors were encouraged to wash their hands. The ward entrance had a clear notice to remind visitors to wash their hands and not visit if they had symptoms of infection such as vomiting.

Theatre staff adhered to gowning procedures during surgery.

Leaders undertook audits to minimise risks of surgical site infections. The theatre audit for asepsis and scrub audits had achieved 100%. The infection control lead reviewed and audited their use of antimicrobials as prophylactic treatment to surgery. Audit results indicated the service had met the requirements.

The service conducted surveillance of surgical site infections (SSI’s). All incidents were reported and investigated to identify improvements. The service had reported 37 SSI’s from December 2024 to December 2025. Eight patients were confirmed as infected. These varied by month and consultant.

All specialities demonstrated active surveillance and reporting of surgical site infections. Reports detailed documentation of patient identifiers, infection types, treatments, and outcomes.

Clinical waste was disposed of correctly, promptly and safely.

The service make 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.

Medicines were stored, prescribed and administered correctly. The hospital had no pharmacy onsite. Instead, the service had a service level agreement with the local mental health trust. Their pharmacist was onsite twice a week, and a pharmacy technician was onsite other days. The pharmacist ensured medications were in date. The service undertook controlled drug checks three times a day. They were always available to offer the clinical team advice.

The pharmacist participated in medicines audits. They undertook a programme of regular medicines audits to ensure staff followed hospital policy in practice. Prescription stationery was securely managed. Medicines including controlled drugs were stored safely and securely at appropriate temperatures.

Medicines administration records were clearly presented and up to date. Upon discharge staff gave patients verbal and written information about what to do. They had contacts if they were unsure how to take their medicines or manage any side-effects. Staff send discharge letters to patient’s GPs so records could be kept up to date.

Staff followed good practice in medicines management in line with national guidance. This entailed transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and use of covert medication.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.